Counselling Psychology in the NHS

Counselling Psychology in the NHS

Frankland, Alan

Background

Counselling psychology is a relatively new profession in the United Kingdom. Although some of us with an academic background in psychology and working in counselling or psychotherapy have thought of ourselves as counselling psychologists for maybe 30 years, the discipline has only been recognised for about 20 years and formal qualifications were only established by the British Psychological Society 12 years ago. As a profession we have a lot in common with other psycho therapeutic psychologists across Europe, and counselling psychology is established in much of the English-speaking world, although in the USA it has more of a feel of educational guidance than in our history, which has more in common with therapeutic counselling and psychotherapy. There is also an overlap between counselling psychologists and counsellors and psychotherapists because many of us are, or have been, members of these professional groups. Essentially counselling psychology is differentiated from counselling or psychotherapy by the fact that we have an initial training in psychology, and see ourselves as reflexive practitioners deploying an evidence-based practice developed from within the discipline of psychology (Walsh et al, 2004).

Counselling psychologists working in the health service are generally professional psychologists chartered by the British Psychological Society (BPS) (or working towards registration), and, whether they have worked through a personally structured independent training or through specialist university courses, chartered counselling psychologists have a doctoral-level qualification which ensures that they have a diversity of psychological knowledge and theory relevant to practice and research, a variety of practice experiences and supervision, and an understanding of their personal and therapeutic experiences. This training gives rise to a number of demonstrable competencies or training outcomes so that when the NHS employs a chartered counselling psychologist they can be confident that they will have:

* developed an understanding of and the capacity to critically evaluate the diverse philosophical bases that underpin counselling psychology and to understand the cultural and spiritual traditions relevant to the discipline

* developed a critical understanding and capacity for skilled practice within one theoretical model of therapy, a working knowledge and competence within at least one other model and an appreciation of a range of therapeutic models

* developed the ability to demonstrate the continuing evolution of their initial psychological knowledge including lifecycle development, the impact of social and cultural contexts, psychopathology, psychopharmacology, testing and assessment procedures

* developed capacities for research and inquiry, generating and evaluating evidence using both qualitative and quantitative methodologies

* developed competencies in effective client work across more than one modality (individuals, couples, families etc) demonstrating the development and maintenance of a purposeful therapeutic alliance through a personally coherent and ethical way of working

* developed an understanding and facility in professional issues including supervision, CPD, organisational policy, legal responsibilities and the management of professional and organisational relationships

* developed a sound understanding of ethics and ethical decision making

* additionally, they will be actively and systematically engaged impersonal development to enhance their understanding of therapy and to encourage safe practice and the development of creativity and artistry in their work (BPS, 2004).

There are over 500 chartered counselling psychologists currently on the BPS register, of whom 270 currently work within the NHS. Nearly all counselling psychologists in training (600-plus) will undertake at least one substantial placement within the health service, with a proportion already being in NHS employment while training (James, 2005).

Perhaps because we are a new professional grouping counselling psychologists do not yet have access to salaried training in the way that clinical psychologists do. Some individuals are (partially) funded where trusts are able to provide employment and some funds from their training budgets. However, the majority fund themselves, by working part-time in a variety of activities, by using savings or capital (including selling or re-mortgaging their homes) or by taking out a career development loan. The willingness to self-fund through the equivalent of a three-year full-time training demonstrates the motivation and dedication of this workforce, especially when there was no guarantee (until quite recently) that chartered counselling psychologists would be offered NHS employment on the same terms as other chartered psychologists in the health service.

In the last few years things have changed considerably in this regard and now the NHS is clear that counselling psychologists represent a new and significant workforce. For this reason the profession is seeking commissioning for trainees, which would go some way towards meeting the anticipated demand for qualified psychologists in the health service. Representations have been made to government over the past two years outlining the modes of training, competencies, current numbers of trainees and where we make a contribution to the national service frameworks. This is supported in a briefing paper, A case for the Employment and Funded Training for Counselling Psychologists in the NHS (James, 2003). A second document shows their numbers in training in more detail: Applied Psychologists in Health and Social Care: Summary of the Available Workforce and Future Developments to Achieve the National Plan Workforce Requirements for Psychologists (BPS, 2004).

A major challenge for all psychology services in the next few years is to develop responses to the recent Department of Health report concerning widening access to psychological therapies within the NHS (NIMHE, 2004). Coupled with the increasing number of NICE clinical guidelines recommending psychological therapies for a range of common psychological disorders, the choice agenda, and the requirement to keep treatment times to below 18 weeks, it is likely that the demand for applied psychologists will be ever increasing. Meeting these demands is one of the ways in which counselling psychology will undoubtedly make an impact.

NHS settings

Primary care

Many counselling psychologists are employed within GP teams working with the more common mental health issues on a mostly short-term basis. They provide evidence-based psychological therapies for individuals and psycho-educational work relating to stress, smoking cessation and the management of physical illness.

Sandra is 35, and has been qualified as a counselling psychologist for two years, having previously trained and worked in another health service profession. She currently works in a busy university town providing services for a number of GPs who mostly refer clients with problems such as depression or acute anxiety as well as clients with psychosexual and psychosocial difficulties associated with childhood abuse. Sandra develops a relationship with her clients that enables her to undertake brief psychothérapeute work within a CBT frame.

Adult mental health

It is probably the case that a large part of the NHS counselling psychology workforce is based within the adult mental health services, predominately in community mental health teams (CMHT). Counselling psychologists employed within a CMHT work as part of a multi-disciplinary team alongside a variety of other professions: clinical psychologists, community psychiatric nurses, occupational therapists, social workers and psychiatrists. The brief for this type of work is that of addressing the needs of clients with a range of mental health disorders such as psychosis or clinical depression, anxiety and other affective disorders. Although the counselling psychologists in this arena communicate with their colleagues in the language of the medical model, they prefer to develop their case formulation within a more phenomenological approach.

Anya works on the edge of a large city. She is in her mid-thirties and has been qualified for about five years. She not only carries a busy caseload of clients with an SMI (providing short to medium-term psychological therapy using CB T and CAT as appropriate for her clients ‘ needs) within the CMHT, but also represents psychology on the risk management team within her borough. Anya also supervises newly qualified counselling psychologists and trainees.

Inpatient services

Counselling psychologists work innovatively within inpatient services to provide psychological input to some of the most challenging and demanding of mental health patients. This work ranges from very brief five to 10-minute therapeutic encounters within the ward milieu to different kinds of group work and ongoing individual therapy which can follow users out into the community.

Ranjit (40-something and qualified for seven years) is a consultant counselling psychologist working from a psychodynamic perspective who is responsible for the psychotherapeutic input into the inpatient units in a large urban mental health trust. This work entails providing some psychological therapy and managing and developing a team of more junior therapists working on the wards. Ranjit has responsibilities at middle management level requiring the development of strategies and policies for local implementation and is a member of the local implementation team.

Specialist services

Counselling psychologists within the health service also work in specialist services such as eating disorders, child and family, services for older adults, services for those with learning disabilities, and substance misuse and dual diagnosis services, among others.

For example, Yvonne (one of the authors of this paper) is a consultant counselling psychologist in NRLMHT, a large mental health trust covering four London boroughs. Now in her late forties, counselling psychology is her second career, which is not uncommon in our profession. Her work encompasses a small specialist caseload of clients with a dual diagnosis (substance misuse with SMI). Because she is the professional lead for counselling psychology as well as the lead psychologist for dual diagnosis for the trust, much of her time is given to policy and staff development and strategic issues.

Douglas, who is 50-plus, is also a career changer; he is on his third successful career. He qualified quite recently in counselling psychology and is now working as a member of an innovative pilot scheme for clients with personality disorder and substance misuse issues. His work entails carrying a small caseload for short-term case management, in addition to providing dialectical behaviour therapy, both individual and group. Douglas contributes, alongside other psychologists and therapists in his service, to the training and development of other professionals from a variety of disciplines.

These vignettes illustrate the work of some counselling psychologists; although anonymised they are drawn from life. We could also have written about colleagues who work with patients with eating disorders, both in in-patient and community settings; in refugee services; rehabilitation services; assertive outreach; home treatment services; and longer term psychotherapy with adults, adolescents and children. We also know of other counselling psychologists who work in pain management, physical health, and forensic services within the NHS. Even this list is not exhaustive. It seems that wherever the NHS provides psychological services, counselling psychologists may be found working alongside other chartered psychologists and health service professionals.

Conclusions

Although quite a large proportion of counselling psychologists are now working in the NHS at all grades from assistants and trainees to consultants, achieving this has been (and occasionally continues to be) something of a struggle. Counselling psychologists tend to favour models of practice and ways of thinking about mental illness that de-emphasise the medical model that underpins much of NHS practice. For this reason they may, at times, seem at odds with colleagues in related branches of applied psychology and other NHS professions in the system, and have had to demonstrate that they do have something appropriate and worthwhile to offer while also showing that they are not a threat. Since part of the fundamental essence of counselling psychology is about negotiating between various models and ways of seeing the world, it is to be expected that we will continue to manage this complexity with skill and tact.

Like the NHS, counselling psychology is actively evolving and it is anticipated that as a profession we will continue to make innovative and fruitful contributions to the achievement of service objectives and the well being of our colleagues and clients.

References

British Psychological Society (2004) Regulations and Syllabus for the Qualification in Counselling Psychology 2004. Leicester: The British Psychological Society.

Deparment of Health H (2000) The NHS Plan: A Plan for Investment, a Plan for Reform. London: DH.

James PE (2003). A Case for the Employment and Funded Training for Counselling Psychologists in the NHS. Discussion paper. Leicester: The British Psychological Society.

James PE (2005) Personal communication.

NIMHE (2004) Organising and Delivering Psychological Therapies. London: Department of Health.

Walsh YS, Frankland AM & Cross M (2004) Qualifying and working as a counselling psychologist in the United Kingdom. Counselling Psychology Quarterly 17 (3) 317-328.

Alan Frankland

Consultant Counselling Psychologist

NELMHT

Yvonne Walsh

Consultant Counselling Psychologist

NELMHT

Copyright Pavilion Publishing (Brighton) Ltd. Sep 2005

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