How are you doing? For me, early 2016 has been a time of challenge, transition and growth. While Creating Healthy Minds remains reassuringly consistent and stable, this has been in contrast with we’ve seen happen in much of public health care as the UK government continues to seek new ways to transform and improve services. Whilst the long term goals might be admirable, the short term experience of these transformations usually includes upheaval, disruption and stress to both service users and workforce. It becomes increasingly important for professionals within these environments, to be resourceful in finding ways of maintaining their own sense of stability and wellbeing, in order to continue functioning as useful people for those in need of help. This month, I’m delighted to introduce fellow art psychotherapist Beth Hoyes as guest writer. Her reflective summary below, expands on the theme of therapists’ self-care and is a worthwhile read for any professional working in public services in the current climate.
Take care for now,
Finding Ground in Shifting Sands: The importance of self-care amidst dismantling of services and in relation to self, systems and client groups.
Beth Hoyes, April 2016
I was wondering where to start with this piece as I am at the very end before I begin. It is difficult to get back in touch with the hope and liveliness where my experience started. As an Art Psychotherapist, I was inducted into a thriving Child and Adolescent Mental Health Services (CAMHS) Schools team within the National Health Service (NHS) in January 2013. CAMHS provides various assessments and interventions for children, families and young people experiencing emotional distress or mental health difficulties. The schools service comprised of several therapists with various backgrounds, including a large representation from Art Psychotherapy and Integrative Arts Therapies as well as Psychotherapies and Counselling. The service built links between mental health professionals working in the community and the central Child and Family Centre where multidisciplinary teams with a mix of specialisms such as psychiatry, psychotherapy, psychology and family therapy were based. The schools service was in a large East London borough and had grown significantly for 14 years, from starting with 1 practitioner in 2000 to 15 practitioners in 2014.
Each therapist would see four to five clients a day, many seeing up to 20 clients a week as well as parents and families. Schools therapists were supported through business meetings where current issues and developments within CAMHS and the team were discussed. We also had a line manager who oversaw our work in schools whilst liaising with schools and an administrator. A sub group of primary schools therapists and another of secondary schools therapists met monthly to discuss arising issues specific to age groups and settings in relation to systemic observations as well as individual cases and practicalities. We also had provision for booking slots to discuss cases within multidisciplinary team meetings held at the central CAMHS Child and Family Centre with a group of clinicians from different specialisms where joint work could be initiated if needed or where a case could be escalated if severe needs were identified. Group and individual supervision were also provided on a monthly basis. Many of these support systems were abruptly cut at various points throughout my second year in the service, never to be replaced. Like many things that were lost over the time I worked with the service there was little preparation or ceremony to each loss and in discussions within the team we often communicated a sense of limbs being suddenly severed with little acknowledgement of the value of what had been sacrificed.
During my first weeks there were already rumblings of changes within the service that were predicted to potentially erode it. A key pending change was the move of the schools therapy service away from targeted services – mainly delivered by specialised mental health practitioners – to universal services – primarily a physical health services domain under the management of nursing staff without a mental health background. The shift was mentioned with differing views within the team, some believing it was just another change in the constantly shifting landscape of the NHS but that the service would continue while others felt it was the start of more ominous things to come. For a long time very few of us truly believed that the service would be hit as severely with cuts as it was. In this paper I address the impact of the dismantling of the schools therapy service on myself and the team. The focus is on two strands, one being significant aspects of surviving the process in relation to self-care and the other being an insight into observing parallels of experiences within the systems and those brought by my client group. Within the parallels drawn; these are observations of reoccurring themes, which of course vary depending on the individual.
Shifting Sands and Drawing Parallels
During my induction I talked to the representative from the head management team when we were asked to share our thoughts, concerns and questions on starting in the borough. I mentioned the upcoming change and asked whether there would be an understanding of the needs of mental health services in the changeover to a physical health domain. She shrugged, saying ‘well all changes are difficult’ and moved on to the next person. This was my first encounter with being derailed by an answer to a question or communication. Many experiences followed of saying something plainly and getting a distracting answer in response or worse, no answer at all – both cases resulting in feeling powerless, invisible and unheard.
Here I feel it is important to draw a parallel to an experience that is often brought to sessions by my clients who have come from a neglectful environment; when asking for a need to be met and either being met by a void or being given something to distract. It makes me think of very early relationships and the difficulties and trauma that can arise from being constantly unheard, disregarded or simply being given a different thing back that doesn’t meet the need. As an example; like being hungry and asking for food and being given a stethoscope. Prioritising the need of being truly heard and responded to has been such a key learning point for me and how important it is to receive this in your work setting. As well as keeping ears open to the individuality and uniqueness of each communication from clients in sessions. I experienced the tendency to develop learned helplessness and apathy if you are repetitively met with silence or abstract responses. In my case it was in the form of regularly unanswered emails, questions or unacknowledged concerns and comments.
When our Line Manager was replaced with two Managers from nursing backgrounds in the move to universal services, we found ourselves on a ship without a captain, or rather, a ship with two captains who were unsure if they wanted to sail and had never sailed our kind of ship before. The differences between outlooks became more entrenched in silence and roadblocks as more decisions on the course of the service needed to be made. The decisions were mainly linked to resources and finances. In particular there was the view that our work should be funded entirely by schools’ payments. However, many children, young people and families who were offered preventative therapeutic interventions by the schools therapy service, would otherwise have needed further involvement from the NHS (National Health Service), local government or other CAMHS professionals. The schools therapy service was one of the few that brought money into the NHS. There was also the value of accessibility and good attendance of sessions due to being based in the familiar setting of schools. These observations were voiced by the team but we were told that the service could only continue if fully financed by schools. Eventually, it was the sudden high increase in charges alongside a lack of communication that prompted the vast majority of schools not to renew their contracts.
I was increasingly aware of my thoughts and concerns falling on ‘deaf ears’ and had a deep desire for mine and my clients’ needs to be understood. Our communication for a need for certainty, stability and clarity was met by increasing suggestions for sudden different directions for the service into shorter more flexible work or new systems with no definite route. It felt very innate and primitive to need to know what was happening to our service, our clients and our livelihoods. The importance of a sense of knowing and being known in the working base where you start from became more apparent as it slipped away, especially with the complexities of the work we were managing as therapists.
In reflecting on this I draw a parallel with the experience of going from being ‘known’ in a familiar setting with families and then being abruptly expected to manage going into a setting of being ‘unknown’. In particular I am reminded of the children I work with who have experienced several foster homes after being removed from their families. It also seemed to resonate with the shift for children from primary to secondary school and the huge steps that this entails from usually structured environments with the same teacher to a large setting with changing schedules and people. In this regard a strong feature of the schools therapy service were the links between primary and secondary schools therapists for children in transition.
The anchoring aspects of our environment became significant in staying connected and enduring. Two groups that remained constant throughout my time in the service were the primary and secondary school group meetings, which helped us to address the complex dynamics, experiences and the parallels to our work with clients. These meetings enabled us to stay reflective and active rather than becoming apathetic or despondent. They were also a space for the humanness of our experience and the emotional impact on ourselves and clients in an otherwise increasingly mechanical process. This also allowed us to stay in tune with the sadness and anger around the loss of a fruitful service, meaning that in turn we were more able to acknowledge the need for the emotional experiences of endings to be worked through with clients as the service’s survival became increasingly unlikely. I accessed both group meetings in my time with the service and found them both to be integral for staying afloat in the ever changing sea that I found myself in.
A book that was helpful in providing a frame for the experiences within the service was The Unconscious at Work by Obholzer and Zagier Roberts, which uses various psychoanalytic, open systems and group theories as a background for exploring the patterns and stresses in human services (Obholzer and Zagier 1994). Having a bird’s eye view on the dynamics within systems was a steadying force at times. Another constancy was my private Art Psychotherapy supervision sessions which helped me to have some important outside perspectives at times. This reminded me of when a young person might choose to create some distance between themselves and a harmful family situation where they are taken advantage of, neglected or abused. There is still a sense of belonging and of roots but also an acknowledgement of needing a healthy distance to be able to open themselves to new relationships that are more nourishing. External supervision provided a way of looking outwards and observing from a safe distance through keeping insight flowing where it would have been easy to internalise the sense of failure and maltreatment in relation to self-worth. I was also lucky to have reflective and responsive NHS supervisors. Retrospectively and in going forward, the underpinning supportive element for me was being part of a community within the schools therapy team and a young people’s therapy service team on the same clinical base. Staying connected rather than becoming isolated in the form of the professional forums but also in camaraderie.
I am reluctant to let my experience slip off the edge of the map like unfortunate ships on old illustrations of the world, hence I am marking it and not letting it vanish into obscurity like many before. I have carried so much with me from my time in the service, both heart-breaking and encouraging. Through following the threads of the two main themes of looking after oneself as a therapist and human in unstable environments and exploring insights into parallels of themes within the client groups, I have shared my experiences of the dismantling of a schools therapy service.
In the aftermath of the service’s disintegrating transformation, some of the schools we had worked with hired their therapists directly. My colleague started weaving a plan for a monthly group meeting to continue independently where those of us still working in this way in the borough could meet to continue supporting and learning from each other. We have been chopped at and uprooted but are now starting to grow brave new foundations. Networks and the importance of maintaining relationships remain integral to me in managing the intensity of the current environment for many therapists and health professionals. I have learnt a great deal about needing to pay more attention to those aspects of work that keep me well and in turn allow me to work effectively. In relation to self-care I am reminded of the flight advice of putting your air mask on before assisting others and it feels important to keep this in mind as I continue with my journey as an Art Psychotherapist. The need to be contained and valued in your work environment is often overlooked, but this experience has shown me that it is vital, especially when working with and containing the traumatic experiences of others. Although this is not always possible, there is potential to build our own spaces for containment where there is a lack, and find ways to stay grounded in shifting sands.
Obholzer, A and Zagier Roberts, V (1994) The Unconscious at Work: Individual and organisational stress in the human services.
Case, C. & Dalley, T. (1990) (eds). Working with Children in Art Therapy. London and New York: Routledge
First published on SA&T, http://www.socialarttherapy.com/camhs-2016.html