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My Reflections on My Journey to Clinical Psychology

My first day in a clinical role will live with me forever. I had been studying psychology for 3 years at this point & had all of these ideas in my mind about what a career in clinical psychology would like on the ground. I turned up armed with all these psychological theories & models, ready to apply them to make people ‘better’ & the world a better place. I had my pen & my notebook ready. I’d seen how therapy was done on the TV. I ‘knew’ what therapy should like. So naïve.

My first role was as a community neuropsychological support worker. I was supervised by psychology & occupational therapy colleagues to deliver brief mood assessments & interventions (CBT-based) & neuropsychological rehabilitation tasks. The first thing that struck me was how low & unmotivated the patients were, especially in contrast to my mood, which was ecstatic to have acquired such a great post & motivated to get going & put all I had learned into practice! The biopsychosocial picture of neuropsychological deficits & rehabilitation had largely been neglected in our teaching at university. We had been taught ‘this is the neurological deficit & this is how you treat it’, which seemed straightforward enough to me. Low mood, anxiety (as well as the environment, competing multi-disciplinary approaches & spouses) seemed to complicate this picture completely! I learned very quickly to contain my own thoughts & feelings to be congruent & aligned with the patient, & I learned to adopt holistic formulations of presenting issues!

The second thing that struck me, & probably one of my most important realisations of my career to this day, was how understandable & reasonable each person’s distress was. Here they are, at the start of their much longed for retirement, ready to finally travel the world, & now they find themselves wheelchair bound, speech-impaired & unsafe to be left alone due to severe anterograde amnesia. There was nothing irrational or faulty about their thinking or their distress. Suddenly all the models I had been taught (primarily traditional Cognitive Behavioural Therapy, psychodynamic & biological models) did not seem to fit the clinical picture.

The same realisations hit me over & over again in my next clinical roles in inpatient & outpatient mental health services. Patient after patient, the notes all read the same- ‘patient has a history of sexual abuse, parental neglect & maltreatment’ followed by a list longer than my sons list to Santa of different diagnoses; paranoid schizophrenia, bipolar disorder, schizotypal personality disorder, depression, borderline personality disorder, anti-social personality disorder. Further, the over representation of those from BAME communities, lower socio-economic groups & oppressed & marginalised groups was startling.

Again, at university we were taught about the ‘signs & symptoms of mental illness’. We were taught about a list of diagnoses & disorders. This made sense sat at a desk in the library or in a lecture hall. The professor made a compelling argument. And then I entered a clinical setting. The word ‘disorder’ just did not sit well with me at all. If a person has been abused by those they should feel safest with their whole life, then would it not make sense that they would constantly feel anxious, fearful & ‘paranoid’ of others intentions? This did not sound disordered to me at all; in fact this his sounded like a very useful, adaptive & effective function of the brain.

Working across physical & mental health settings, another prominent realisation was that the environment in which we live could very much help or hinder health & wellbeing. Our capitalist, individualistic & Christian society places such an emphasis on productivity, being a ‘good & productive citizen’, & on individual achievement at the expense of co-production & cooperation that we become disconnected from what we actually need to maintain our health. The very things that we need to maintain our emotional & physical health - physical activity, secure social connections & time in nature, which all produce serotonin, dopamine & oxytocin (the brains feel good chemicals)- are they very things such a society takes us away from. And ironically, this type of society takes us towards all the things that contribute to physical & mental ill health- a sedentary lifestyle, competitiveness, lack of safety & security in accessing resources (exams, schooling, job uncertainties), lack of connection with others, lowered opportunities to develop secure attachment with parents & lack of opportunity to connect with nature. Capitalist societies encourage a focus on status & accomplishment in terms of monetary & material success, convincing us this is what we need to be well & ‘happy, when ironically this focus deprives us of the things that we actually need.

Further, the structural & material inequalities facing many patients were obvious. Over crowding, unsafe neighbourhoods, victimisation of marginalised groups, lack of access to resources such as safe & secure housing, food, schooling etc were all clearly contributing factors when undertaking wellbeing assessments. However these factors were scarcely addressed in interventions, if addressed at all.

Throughout the services in which I worked, the dominant narratives reflected that of a British society- narratives that include the biomedical model of distress, ideas about distress & suffering being abnormal, ideas about being a productive citizen, ideas about parenting & the model family etc. It became apparent to me over & over again that these dominant narratives did not fit for the vast number of patients we saw. This was particularly the case with ‘revolving door patients’, which made me question- maybe, just maybe, it’s the treatment approach that’s the problem- not the patient.

These realisations started me on a journey that would shape my understandings of distress & ultimately my clinical practice throughout my career.

My ‘relevant experience’ path to clinical psychology, like so many others, reflects a varied journey. I worked in various clinical & research roles across a range of clinical & academic settings; as a research assistant at university & for the local NHS trust, as a health care assistant in forensic & mental health inpatient services, a support worker in learning disability services & community mental health services, as an assistant psychologist in pain management & physical health settings.

These roles enabled me to develop various transferable skills that were relevant to the broader role of the clinical psychologist such as how to build effective & constructive working relationships with the multi-disciplinary team, leadership & project management skills, data entry, management & analysis skills, flexible communication skills & report writing & note-keeping skills. They also enabled me to start developing crucial clinical skills such as containment, de-escalation & crisis management skills, the ability to ‘sit-with’ discomfort, self-awareness & self-management skills, brief therapeutic intervention skills & an appreciation of the role of the all important therapeutic relationship.

Many of my learning experiences that shape my current thinking & the clinical psychologist I am today were gained from these roles. I developed an understanding of different services, service pathways & the role of other health professionals within the multi-disciplinary team & the role of the clinical psychologist within such services. Most importantly, thy influenced my understandings of distress & the way I practice clinically. I came to appreciate the evolutionary & functional role of thoughts & emotions as well as the importance of systemic & wider ecological analysis, assessment & intervention in understanding these inner experiences. As a result I endeavour to avoid locating distress in the individual, always contextualising distress within the socio-political context. When offering intervention, whether with staff or patients, I always strive to explore top-down interventions as well as bottom-up ones, ensuring I do not become a maintaining factor in harmful social practices. This may include lobbying at government level, challenging unhelpful or unfair or unjust policies this may be informing policy development or addressing service structures. It may also include challenging unhelpful dominant social narratives such as austerity or biomedical understandings of distress.

Another key moment in my formation as a psychologist was undertaking training in Acceptance & Commitment Therapy (ACT). Not only did this model help me to make sense of my early career realisations & to frame them in a psychological model for clinical purposes, it also offered me a profound explanation in terms of how I made sense of my personal career journey when applying for clinical psychology training.

I, along with the patients, family & colleagues that I work with, live in a society that views happiness as the norm & anything that deviates outside of this as abnormal. The concept of unpleasant inner experiences such as distressing thoughts, feelings & physical sensations being inherent to our survival & a normal & understandable response to our experiences fit with my evolutionary psychology beliefs. Understanding thoughts & feelings not as something to change or challenge, but as a friendly ally scanning our environment for potential danger & threats, trying to keep us safe helped me to start changing my relationship to the more difficult thoughts I experienced. It also helped me support patients to learn to view their thoughts regarding their unchangeable situation such as a pain condition, diabetes or stroke in such a way, reducing the impact of these thoughts on their actions & their wellbeing. Learning to view inner experiences in this way, & viewing thoughts as just a thought, can be an empowering & liberating experience enabling us to choose which ones to listen to & which ones to let go.

The added dimension of values-based living within ACT also helped me at a time when I was feeling particularly hopeless & despondent with my career. I had applied several times for the clinical psychology doctorate & despite having many interviews I was just not able to acquire a place. I noted that the thoughts my mind was generating were very critical & reflected catastrophizing & all or nothing thinking styles. I constantly had thoughts such as ‘I am not good enough’, ‘I will never achieve a place’ & ‘if I don’t get a place then I was failure’.

Like so many others I had placed clinical psychology training on a pedestal & had become overwhelmed by all-or-nothing thoughts… I noted that I was so focused on the goal of attaining a place on clinical training that I had lost sight of the here and now, and all the amazing work I was already undertaking & achieving; key note speaker at a highly reputable conference, published papers, pioneering service development & offering psychological intervention… Actions I was already undertaking connected with my values such as to promote psychological thinking in others, to develop high quality psychologically-informed services, to help & support others. I started to reconnect with what was important to me, what gave me & my career purpose, what gave me satisfaction & joy in my daily life.

Connecting with these values instead of my goals & learning to live aligned to them was the first step to changing my attitude towards clinical psychology training. The second step was practicing mindfulness & thought defusion. Again, my thoughts were taking my focus to the future & to the ‘what if…’ scenarios are minds are set up to create in anticipation of potential danger. ‘What is I never gain a place on training…’ ‘What if I can’t think of answer to the interview questions…’ ‘What if my anxiety overwhelms me again…’ Each time I attached to & fused with these thoughts my anxiety increased & my connection with the present moment & all my current values-based actions weakened.

I started to move away from back & white / all or nothing thoughts. I started to see the grey areas. I stopped living in my head, fused & automatically believing the thoughts my mind generated- the stories about my experience. Instead I started to live connected to my actual experience, as lived through my direct senses with the world. I connected with my daily actions in the workplace linked to my values, the achievements I had already accomplished, the values-based actions I was already undertaking. Living in the here & now, connected to my values, rather than my goals, enabled me to feel enriched & reconnected with my purpose. Of course I continued to set goals along the way including obtaining a place on clinical psychology training, but removing my focus from these goals & gently shifting it on to my values reduced the sense of pressure & stress I felt, whilst enhanced my wellbeing on a daily basis.

So my closing words of wisdom to all aspiring psychologists are to resist fusing & buying into every social narrative you encounter & every thought you have regarding your career choice, to use every experience as a learning opportunity & to connect with your personal & career values. Live everyday in the moment, taking valued actions, & if you do set yourself goals, hold your focus loosely on these! And always contextualise experience.

Good luck!

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