Clinical Psychology Matters

My Life and Times in Clinical Psychology

In the summer before my final year of my MA degree I applied for, and got, a summer studentship at Crichton Royal Hospital, which confirmed my choice of career. After completing my MA degree course I returned to start my Diploma in Clinical Psychology along with four others from across the UK. I loved every minute of my year there both educationally and socially. The age of psychometrics was on the wane and the age of psychological therapies was just beginning. We were encouraged and supported to involve ourselves in the new behavioural therapies. Mostly it was relaxation assisted desensitisation. But the door had been opened. Some, like aversion therapy, were questionable, and all of us drew the line at its application to homosexuality. What was and was not an illness was to become a recurrent issue, not just in the Course, but in clinical psychology generally.

The bulk of Adult Mental Health teaching was done during the second year of the Course in Glasgow at the Southern General Hospital and Gartnavel Royal Hospital, with Mental Handicap covered at Lennox Castle Hospital in a most uncomfortable week(or two?) of parades of patients like some kind of freak show, at the end of which we got a Certificate in Mental Deficiency. After the final exams, in June 1969, we dispersed into the world as, more or less, qualified Clinical Psychologists.

When we eventually got around to a reunion it was inevitable that it would be at the Crichton Campus, in a hotel in Johnston House, the very building we had been based in. We carried on where we left off 40 years before!

Having completed the Diploma Course, and with nothing very exciting on offer, my wife and I set off to Canada after I had an interview in Edinburgh with Graham Foulds, who was about to go to Western University, London, Ontario, as a visiting professor. In the first year I worked as a member of one of the consultant led psychiatric teams at London Psychiatric Hospital seeing both inpatients and outpatients. In the second year I worked in a psychoanalytic unit and a general practice Unit at St Joseph’s General Hospital. Clinical staff at Western University were very interested in Behaviour Therapy and I was surprised to be treated as an expert despite my lack of experience. North American psychological therapies at that time could largely be summed up in the ‘Gloria’ films, three approaches to psychotherapy, Albert Ellis, Carl Rogers and Fritz Perls, each working with a real patient for 20 minutes. Like CBT in the UK now, all was not right behind the scenes https://www.psychotherapy.net/blog/title/the-gloria-films-candid-answers-to-questions-therapists-ask-most

We thoroughly enjoyed our time there but never considered staying despite job offers. Another interview, with Frank McPherson in London, Ontario, and I had a job to come back to in Liff Hospital, Dundee. As it happened we both got jobs in the hospital and settled in Tayside, where we are still.

In Dundee I was fortunate to have Allan Presley as mentor for my basic grade apprenticeship year. Quiet, honest, caring and always ready to listen. I hope something of Allan rubbed off on me.

I learned early on that patients and I were doing much the same thing in trying to make sense of their problems, their situations and experiences. It therefore made sense to collaborate. These were the days of scientist-practitioner when every case was a single case experiment. I brought my special knowledge and the patients brought their special knowledge. We agreed a working hypothesis, tested it, reviewed the results and congratulated ourselves or revised the experiment. Formulation was all.

In my senior grade post I was again lucky in working with Dr John Scott and his staff in Murray Royal Hospital, Perth to develop a geriatric psychiatry service. The discharge rate from his ward was on par with the acute psychiatry ward, something unknown at the time. I suppose it would be called a problem oriented approach now. There were no community nurses, so ward nurses did that job as well. My main contribution was to change the ward from a traditional hospital environment to a ‘living’ environment by introducing compensating features like large faced clocks, and signs, colour coded areas/doors etc. and introducing activities throughout the day to engage the residents. There was some nurse management resistance on grounds like staff spending time with residents rather than doing the important jobs like tidying cupboards. Some staff found the environment too different and requested moves. Most threw themselves into changing the ward culture. The hospital administrator was supportive of the initiative and made finance available to provide equipment and crockery for afternoon teas, etc. I ran workshops for all ward staff including night staff (yes during the night!). An interesting side issue was that our observations told us that cleaners had high levels of interaction with residents. This was a problem for management and unions, and cleaners were advised to restrict their activities to cleaning. This resulted in a number of cleaners becoming nursing assistants so that they could legitimately continue to interact with residents. The atmosphere in the ward was totally altered with the mood and interest of both patients and staff improved. Given the opportunity, staff were increasingly creative on the activities front. I liked best the gaelic class provided by a patient who had been a teacher. When I left to become Tutor on the Aberdeen MSc Course on Clinical Psychology, the work was continued and extended by my colleague Peter Galliard.

This was also the time I was using behaviour therapy for mood disorders and OCD. I was never convinced by the rationale of, and response to, desensitisation. Patients were also not convinced. I was more comfortable using exposure with an habituation explanation. So were patients, and results improved dramatically for anxiety/panic problems and OCD. I learned as much or more from patients during that time than from any books or journals. A few days at the Maudsley Hospital where I was made very welcome, allowed to attend case conferences, talk to patients and shadow staff, helped to confirm my belief that I was going in the right direction

I was a fan of Marks and Gelder for their very practical (but medical) attitude to exposure therapy. Still, I knew then that there was a better way. I knew that patients had to play a more active part in their therapy rather than it being controlled by therapists. And I knew that George Kelly’s rather abstrusely presented ideas, even when ‘translated’ by Bannister and Fransella, held the key. The development of the Cognitive Invalidation Approach may have been much easier and earlier if I had not successfully applied for the job of Tutor on the new Aberdeen M Sc in Clinical Psychology post, giving me three months to prepare for the new job, actually three new jobs.

Despite the pressure, the birth of the Aberdeen MSc Course in Clinical Psychology was much easier than I anticipated. Ron Blackburn had slightly more time to prepare and so much of the Course design was already well in hand. I had lots of concerns, being younger than the supervisors I was to organise and assess, and hardly older than the students. I needn’t have worried about the supervisors or students all of whom were eager to contribute to the success of the Course. This culture of mutual support and co-operation spread throughout the Clinical Psychology Service. I had always found teaching rewarding and this was especially so with the MSc Course. You teach people who teach you, and go on to teach others. Powerful stuff! The workshops worked, and supervisors not used to the format quickly adapted. The students, also new to the format, gave good feedback, particularly how the workshops better prepared them for placements, and added an extra dimension to the academic teaching, and we definitely had more fun.

When Roger Baker became my first recruit to the Clinical Service to be followed by Richard Blakey from Tayside I began to think there was the possibility of creating a quality service in Grampian. From being a difficult to recruit area Grampian quickly filled every vacancy. It was an exhilarating time both in the MSc Course and in the Grampian Clinical Psychology Service.

Bad Times

In 1981 Ron Blackburn moved to become Chief Psychologist at Park Lane Hospital, Liverpool. This was a prestigious post from which Ron went on to become research director and professor of clinical and forensic psychology at Liverpool University. The decision was taken by Aberdeen University not to replace the Head of Course post. With the support of the NHS psychologists we managed to keep the Course going for another 4 years, with me as Joint Head of Course with Harry McAllister. With increasingly less support from the University I reluctantly advised them that I could not continue without more University support. Six months after the Course closed the University changed its mind but by then I had had enough. I was instrumental in ensuring that clinical psychology training continued to be funded in Scotland, but with a more distributed organisation of an East Coast Course centred in Edinburgh, and a West Coast Course centred in Glasgow.

Very Good Times

The splitting of the Adult Psychology service into a Mental Health Clinical Psychology Service and a Community Clinical Psychology Service was not a change sought by the psychologists, but came about as part of a general reorganisation of Health Board structure For me and those others who found themselves relocated to the Community Service, it was most definitely a good time. As well as providing an area-wide service for primary care referrals, we provided consultancy services to many other disciplines and the voluntary services. A year survey of contact with 60 other departments and services showed 18 had been provided with teaching, 49 with consultations, and 3 with continuing supervision and support. These were in addition to more major involvement with the University Department of General Practice.

We became a very cohesive supportive group with systems in place for peer supervision, CPD, and self assessment. The department was well respected and played a central role in Community Health Services. We continued to attract and retain staff as before, well supported by management.

Throughout the 1980s I was able to further develop the cognitive invalidation approach to panic disorder, first by the reception it got from colleagues most of whom had adopted the approach in their own clinical work. Both Roger and Richard collaborated in the development. Indeed it was like having a team working continually on the project. As always the response of patients was the measure by which we assessed our progress. When I started using exposure based therapy I accompanied patients on each session and only gradually withdrew over many weekly sessions. Later I had the help of nurse therapists and clinical psychology assistants, who quickly became competent therapists with very little training. During the 80s therapist time had reduced to a few hours on average and most patients were doing their ‘therapy’ sessions in their own time, sometimes with help from family members who also quickly mastered their support role. And of course students on the MSc Course considered it all as normal. Throughout the late 80s, Roger and I presented the approach at a number of conferences and had a chapter in Current Issues in Clinical Psychology volume 2 Ed. E Karas. Finally, what I consider as the definitive account of the approach came out as a chapter in Roger’s Book, Panic Disorder, Theory, Research and Therapy.

Very Bad Times

I had nothing against managers. Indeed I had found them generally very helpful. But ‘General Managers’ proved to be a different breed. You would think it would be obvious what could happen when you gave people who knew virtually nothing about the NHS complete authority to do what they liked with it. The business schools fashion at the time was for for top down management, which meant you brought in outside consultants to advise you what to do and how to do it. Then you delegated the next tier of managers to implement the required changes through a process of ‘cascading’ all the way down to the workers.

In practice it has resulted in a culture of fear and intimidation which is now rife throughout the NHS in Scotland, and the rest of the UK, as widely reported in the media . In the NHS throughout the UK there is a culture of bullying, and managing people out of a job through contrived actions designed to get rid of those who displease management.

https://www.theguardian.com/society/2016/oct/26/nhs-staff-bullying-culture-guardian-survey Recently NHS Scotland has had to issue a ”Bullying and Harassment Policy”. Clearly the problem is much wider than can be resolved by an HR policy review and is threatening to have a major effect on patient services, staff recruitment and retention, and budgets. While Governments are struggling to deal with the pandemic, it will be difficult to also deal with a crisis in management of the NHS, not to mention the failed service for “common mental health problems”.

A survey by the Tax Payer Alliance found that between 2015-16 and 2017-18, at least 915 settlement agreements were made between NHS trusts and former employees totalling £27,978,661. Many trusts, including Grampian failed to provide the detailed information requested. Scotland had the highest average payment.

For Grampian Adult Clinical Psychology the next reorganisation meant recombining the Mental Health and Community Departments, not a problem in itself unless you were aware that some had fears that GPs may value psychology more than other services and this could have a negative effect on the internal market about to be established. What if Mental Health could agree with Social Work that NHS mental health services would only be available to those with psychoses, and offloaded the rest to the voluntary sector. That might work. And might have if the GPs had not prevented it.

By then reorganisation had become more of a continuous state, and for me things were beginning to get personal. The next reorganisation of Adult Clinical Psychology returned the service to pre-Trethowan Report (1977) conditions. The psychology staff were again split, this time into two management units headed by Psychiatrists. The relationship was initially very strained as I argued for psychologists retaining professional independence. Fortunately my manager was at least willing to see how things worked out in practice. After a sticky start, things worked out very well indeed, with good professional cooperation in establishing cohesive multidisciplinary mental health teams well received by the General Practices served. Clinical psychologists retained professional independence.

My next challenge came in a letter from Human Resources to advise me that my Grade and salary were being reduced owing to change in responsibilities. The local full time union officer thought it likely that nothing could be done, but agreed he would support me if I wished to go to a Tribunal. I did, and he didn’t. After a wait of many months I attended the preliminary hearing to determine whether my case could be heard. The Trust was represented by a barrister, who put the case that following reorganisation I was no longer in a senior position and therefore my grade and salary could legitimately be reduced. The union officer said nothing so I asked the chairman if I could provide a copy of my contract which he passed to the advocate who read it through before apologising to the chairman, said she had been misinformed, and withdrew her case. The chairman informed us that he was taking the unusual step of recording that I had not been legally represented in case the NHS still wanted to proceed. A later meeting with ACAS lasted just long enough for Grampian Healthcare to confirm that it was prepared to reinstate my grade and salary, backdated.

This was only one of a number of extremely unpleasant interactions with various senior officers, one of whom asked me if I knew what he could do to me? I did. I was well aware of the regular disappearance of senior staff. Fortunately this was in front of a senior HR officer who called for a break, after which the person continued, as if nothing had happened, to tell me what the next plan was for Clinical Psychology. Oddly it led to me being in charge of the whole Area Psychology Service. I was warned by other senior managers to beware the trap of being given a new post which then disappeared in the next change.

By this point I had raised a formal grievance procedure against Grampian Healthcare for victimisation, personal harassment, and refusal to engage in the agreed grievance procedure. The agreed time for a response was something like 6 weeks which was drawn out to over a year.

Despite the political machinations and my personal trials, as a service we continued to be highly successful in cutting waiting times and increasing throughput, by committing to a system put forward by Richard Blakey, and at the cost of reducing research and consultancy work. Trust management refused to engage in consultation with Psychology preferring to manage by edict. I was lucky in that my manager did engage with the psychologists and quickly saw the advantages of having a (fully staffed) professionally independent psychology service within his unit. My colleagues in the other management unit were not so lucky. Nor were the patients and GPs served. Within the year there were no psychologists in that management unit. Still the Trust refused to engage with the psychologists.

For around four years I had been working twelve hour days trying to maintain what had been one of the best services in the country, able to recruit and retain staff, highly valued by most of our medical colleagues, GPs, patients and community services. As I watched senior staff disappear ‘like sna’ affa dyke’ as they would say in Grampian, any hope went with them. When I opened the next letter from HR telling me of the latest plan for psychology I knew it was pointless trying to continue. I told my manager and my secretary that I was leaving immediately and did not expect to be back. The situation had finally caught up with me.

My first act was to arrange to see my GP as I was aware that I was no longer fit to be seeing patients, or to meet the other requirements of my job. We both recognised that my condition was work stress related, and that work stress would continue for some time as there was still an outstanding grievance process to go through. I was signed off long term.

Trying to sort out my feelings at that time was difficult because there were so many. I felt exhausted, both mentally and physically. But for a while the strongest feeling was of failure, and letting people down, particularly the few patients who needed long term support. I didn’t consider myself ill, but I certainly was not well.

For a long time I withdrew from almost every kind of activity, social, hobbies, political, but continued with work related things like patient leaflets. I tried to write my magnum opus, the definitive critique of CBT, but after numerous starts I had to acknowledge temporary defeat due to lack of concentration. My wife and son had turned their hobbies into a career while I turned my career into a hobby, except I wasn’t enjoying it, or much else, and I had little time for jokes.

I was aware that my lack of energy was due to continuous over arousal/hypervigilance. The slightest difficulty with a task would lead to extreme frustration and the never far away feelings of failure. There was of course anger about my situation but this was, surprisingly, well down the list.

Anxiety feelings came later. We had good friends who would not allow me to ‘hibernate’, but socialising was the one activity which sent my arousal into overdrive and caused more than a few panic attacks. A couple of times this led to self medication in the Scottish tradition. Fortunately friends were very tolerant and my wife was not. I forced myself to learn to tolerate difficult situations and feelings. By the time I felt able to pay a visit to the hospital I was still experiencing over-arousal but the panic attacks remained below the surface. It was of course something I had to go through, and marked a milestone in my ‘recovery’.

When it came to the grievance meeting, as before with the ACAS meeting, there was no attempt by Trust management to dispute my grievance claims and the arbitrator moved quickly on to say that as the situation was not sustainable the only option was for the Trust to agree a settlement with me. He did make it clear to the Trust that I should continue to be paid until the settlement was reached. There appeared to be no consideration of sanctioning those Trust managers whose behaviour had led to the grievances. Rather than put an end to the matter I was to learn that this was only the beginning. I thought that the Trust would wish to complete the settlement agreement as soon as possible to avoid the continuing cost of my salary, but over the next year it became clear that there was no urgency.

My union refused to provide support on the basis “that there was no record of me being a member of the union”, despite me sending them details of my membership, record of regular payments, and of my shop steward status. I complained to the head of the union and in return received two letters on the same day, one from the head of the union saying that since I was not a member they were unable to help, and the other a circular addressed to me in my capacity as shop steward, with details of their new whistle blower protection policy. I was on my own again. Heaven help the whistle-blowers!

Despite being again abandoned(again) by my own union, I was supported throughout my ordeal by a full time officer of another health service union who had a part-time Trust post as Employee Ombudsman. This support was very much appreciated but it gave no access to legal advice. I therefore consulted our family solicitor who told me he was not an employment law specialist but he could give me information on the kind of settlement amount which would be appropriate in my circumstance. I put this forward to the HR negotiator at the settlement meeting a few weeks later and was told it would be responded to in time. Time passed with no further communication from the Trust other than a phone call which the person making the call, himself a senior manager, told me he was instructed to make, to ask me how I would pay my mortgage if the Trust decided to dismiss me. I will not give further information to avoid embarrassment to this person who had kindly offered to mediate in my negotiations with the trust.

My next communication, months later, from the Trust was to inform me that it was ready to engage in final negotiations about my settlement, and I would need to get myself a solicitor in Aberdeen, paid for by the Trust. I did receive a number of letters from the solicitor whom I engaged to deal with the Trust, giving me details of offers which the Trust was prepared to make. Each time I instructed him to reject these. Eventually I was presented with what was described as a final offer from the Trust which was only available for acceptance within the next 24 hours. I deliberately allowed the time to expire. When I was told the Trust needed a response from me I told the solicitor to tell the Trust that I would see them in court. Some hours later he informed me that the Trust had agreed to meet my original demand.

There were other incidents and issues which I cannot report but which caused me more stress. However it did bring six years of hell for me and my family to a not very satisfactory end.

It was at this point that I felt anger most, at the idea that the NHS, particularly a Mental Health Unit management, could not only persecute individuals they didn’t like for some reason, or no reason, but that, in the process, they were prepared to destroy a first class patient service which had taken staff years to develop. And all without scrutiny by government.

In the NHS there is now a culture of intimidation, bullying, and managing people out of a job through contrived actions designed to get rid of those who displease management.

https://www.theguardian.com/society/2016/oct/26/nhs-staff-bullying-culture-guardian-survey

https://www.bbc.co.uk/news/uk-scotland-48764061.

A survey by the Tax Payer Alliance found that between 2015-16 and 2017-18, at least 915 settlement agreements were made between NHS trusts and former employees totalling £27,978,661. Many trusts, including Grampian failed to provide the detailed information requested. Scotland had the highest average payment. I guess, from the number of enquiries as to who had been advising me, that my settlement contributed substantially to that dreadful waste of public money.

Recently NHS Scotland has issued a ”Bullying and Harassment Policy”. Clearly the issue is much wider than can be resolved by an HR policy review and is threatening to have a major effect on patient services, staff recruitment and retention, and budgets. While Governments are struggling to deal with the pandemic, it will be difficult to also deal with a crisis in management of the NHS, and more specifically, with the major problems in the failed services for “common mental health problems”, The Matrix, and in England, IAPT.

Good times and better times; the ‘recovery’ phase.

The first change for the better was initiated by my wife’s increasing frustration with having me around the house interfering with her routines and activities. She reminded me daily that she was not retired, and more than once recommended that I get a hobby or “do something”. I had coached football for many years and had been thinking that I could look at extending this to coaching coaches. Having struggled with concentration I had to work up from 15 minutes a day reviewing the literature to an hour or so after a number of weeks. The literature was poor and I felt I could do better. I have now been coaching football coaches for many years with much success and enjoyment. Best times have been with the top women’s team in Scotland in the women’s Champion’s League. The process is not much different to clinical psychology – observation – plan of action – review results – if necessary, repeat. As with students the process is two way. I make them better players/coaches and they make me better at coaching them. Teaching’s teaching. Anyway that got me out of the house and out of my wife’s way.

The next step was pure serendipity and really got me out of the house – to the other side of the country. A psychologist who had worked with me many years before had to have an operation and a 3 month rehabilitation period and the service wanted cover for that time. This was the perfect opportunity, short enough for me to manage and long enough to find out how I coped. The culture of the Argyll mental health service could not have been more different to Grampian. The highland slightly anarchic attitude meant that they were not jumping to implement every new idea from NHS Scotland, but took time to evaluate whether it would improve the service. If not it was kept on the shelf in the knowledge that another one would be along shortly. At the same time there was a constant flow of progressive ideas coming from the front line staff, and no interdisciplinary rivalry. My work was appreciated both in the hospital and in the community, and I had no problems mixing with such genuinely friendly people. The time raced by. I later returned to Argyll on a 6 month locum contract which was extended to 2 years, and again later a further 3 month period extended to 14 months. In each case I stopped due to circumstances unrelated to work.

The contrast between Grampian and Argyll could not have been greater. Management was just as hierarchical, with a single person in overall authority, the Physician Superintendent (last one in the country). But where Grampian management created a culture of intimidation and fear, Argyll created a culture of support and encouragement, which showed in the enthusiasm and innovation of the staff. I have no doubt that who manages is more important than structure, and no doubt that no general manager could have achieved the quality of the Argyll and Bute service. I feel privileged to have been part of it.

For the last 2 years before retiring I opted to go local, and worked 3 sessions as part of an integrated primary care team serving a population of around 13,000 people. As with my two colleagues, (who were also ex-Grampian) I operated with no waiting list and patients were seen in the time it took to give notice of appointments. Other parts of the service had major problems in controlling waiting times.

While, naturally, I preferred the good times, there was much to learn from the difficult times, both personally and professionally. Personally I learned about my own limits and the costs of ignoring them. Professionally, my experience provided a different, more direct perspective on the normaI, but debilitating effect of work stress, which was a significant part of our clinical practice in Grampian, with farming families in conflict over farming for subsidies rather than food, bank staff being pressured to sell ‘products’ (often inappropriately) rather than provide services, teaching assistants being pressured to take teaching courses they were ill suited to, oil workers being subject to the frequent ups and downs of the industry, the comercialisation of universities, etc.

When I finally did retire from practice, in 2006, I tidied up a few projects preparing patient information leaflets on stress and panic disorders for use in mental health, primary care, and health promotion. These stressed the normality of stress disorders and mood disorders, and were alternatives to the ubiquitous CBT based material.

I would like to say that the paper which opens this website marks the final step on an almost career long personal campaign to take back Clinical Psychology from the current CBT imposter, but I’ll have to settle for it maybe being a first step.

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