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Protecting therapeutic space in a recession

Protecting therapeutic space in a recession

In the right environment, where reflection and good practice are supported, it is possible for people to work together to protect the therapeutic space for patients, even in today’s gruelling economic climate.

Jessica Woolliscroft reflects upon how socioeconomic pressures affect psychotherapy services and how these impacts can be cushioned by holding on to key social and ethical values.

Richard Blackwell, a psychoanalytic psychotherapist with the Medical Foundation for the Care of Victims of Torture, has written that there are six forces that intrude into therapeutic space and which have the potential to destroy it.  These forces are economic, cultural, political, religious, interpersonal and intrapersonal (Blackwell, 2007). The role of the psychotherapist is to maintain the therapeutic reflective space for the patient in the face of all these pressures, so the patient can better understand his/her life.

In order for psychotherapists to hold the therapeutic space they need specific supports built in to their working environment. These are described by Sandra Bloom in her book ‘Creating Sanctuary’ as ‘psychological, social and moral safety’(Bloom, 1997).

NHS Trusts are complex and unpredictable service delivery systems (Pawson, Greenhalgh, Harvey, & Walshe, 2005) in which managers are under constant pressure to prove to PCT commissioners and government that they can deliver value for money through efficiency savings.  New government initiatives (IAPT) and their consequent league tables, performance measures, regulations and inspections come with some money attached, but not enough, so services have to be constantly reconfigured to meet new targets. Psychological therapists, whose traditional roles are to allow self exploration in the service of healing can find themselves in a culture clash with those whose role requires them to define health criteria and ration access to services. Economic pressure is heightening these cultural/philosophical differences (Lees & Freshwater, 2005). Under these economic and cultural pressures, rapid changes are  being introduced, old established ways of working are questioned, anxieties rise and strong group allegiances are formed, strong authoritarian leadership becomes more highly valued and power is protected by rewarding unquestioning obedience and  informed discussion or debate can be reframed as dissent (Bloom, 2005).

In these highly stressed and political organisational dynamics, when a staff member asks questions this can be experienced by the organisation as an anxiety provoking threat. C.Fred Alford, on interviewing whistleblowers, discovered that even if they followed policies to the letter in raising their concerns, they were just as likely to be disciplined or sacked as staff that had gone outside the organisation (Alford, 2001). He also discovered that in every case the person concerned had to be reframed as an outsider and pushed to the outskirts of the organisation to convey clearly that such questioning is taboo. Alford found that the majority of staff, as a consequence, will not raise concerns or ask questions or report problems because, even if they are afraid that what is happening is not ethical, it is just not worth the price to be paid for exposing it. Instead most members of organisations will carry on as if everything is normal. Alford called this behaviour ‘doubling’ and it explains why certain teams or parts of organisations, after serious incidents take place, can be found to be highly dysfunctional.

It is important to understand that this is about interpersonal and group dynamics and is not conscious in most cases, but staff will form strong in-groups and out-groups to protect their interests. Lastly, intrapersonal forces are those which exist in individual personalities. Some staff respond to stress by becoming quieter, more withdrawn, and more compliant. If the predominant culture makes it unsafe to talk about problems, problems go underground and some staff will develop physical illnesses because they are somatising their worries. Somatisation occurs when a person cannot allow themselves to know what they think and feel because it is too threatening. Other personalities respond by becoming more controlling. In some situations this behaviour may be rewarded if it fits the organisation’s project to effect change…the new broom.

Lastly, evidence –based research has come up with five specific guidelines for the rebuilding and recovery of communities after trauma (Hobfoll, et al., 2007).  These could just as well be applied to a team or to individuals in stressful situations. They are:

Creating safety,
Instilling calm,
Building community and individual efficacy,
Safeguarding community cohesion and
Hope.

In the right environment, where reflection and good practice are supported, it is possible for people to work together to protect the therapeutic space for patients, even in today’s gruelling economic climate.

Jessica Woolliscroft is a psychotherapist, trauma therapist and supervisor working within the NHS and in private practice at The Hope Street Centre.

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