The Concept of Psychological Safety: a proposal for a service philosophy In: Clinical Psychology Forum 186 pp 50-54 2008

Suzanne Conboy-Hill Economy of scale can result in depersonalisation of services. Evidence indicates that sound attachments are both therapeutic and humane. This article describes the proposed application of

attachment theory, through notions of psychological safety and the professional family, to a multidisciplinary clinical service for adults with learning disabilities.

The Guiding Mind in the organisation Large organisations have advantages associated with economy of scale in providing services but can easily lose sight of the individual in the process. When something goes wrong and victims embark on litigation, the guiding mind of the organisation is identified on the grounds that it is this that influences the culture within which employees and customers are kept safe. How much more valuable then to begin instead with a positive guiding mind by which to explicitly build in safety and well-being. Psychological Safety (Seager, 2006) is a concept arising from analytic psychotherapy that has the potential to provide the framework by which a positive guiding mind for services for vulnerable people can be developed.

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Health Economics and Therapeutic Practice Services of all kinds are under pressure to produce more for less, every discipline is being challenged to define its usefulness. Certainly there are therapeutic approaches that are more effective than others but the effectiveness of the majority is almost always underpinned by the relationship itself rather than the specific technique being used. Patients want different things from therapy, outcomes are not easy to define in complex cases, and sometimes a positive outcome for the client looks like something else altogether to an observer.

How then to think about being therapeutic? The concept of object attachment suggests that ego strength is formed and maintained by the experience of good or bad objects during childhood and that later resilience in the face of adversity is dependent not only on inner strength but on the consistency of positive childhood attachment objects. This means there are two points at which

psychological safety is threatened, the first when developmental conditions do not offer good primary attachment objects, and the second when a significant attachment is suddenly lost. Where psychological history itself is insecure, the likely effect is almost unimaginable.

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Considering the ways in which mental health services are organised and our response to risk, Seager (2006) outlined the typical scenario pertaining to suicidal behaviour. People are admitted as

in-patients until they are deemed well enough to be discharged and then returned to their physical and psychological environments. That a significant number of such people commit suicide at this point (King et al, 2001) seems to be surprising to clinicians and often triggers evaluations of risk and responsibility with an undercurrent of blame running through the process. That it should not be a surprise emerges from the appreciation that, in discharging people at the point of apparent wellness, we simultaneously break the significant attachments that have got them there and so leave those already vulnerable in a state of such desolation that suicide is their only answer.

The theoretical position is that, for people accessing mental health and learning disability services, staff teams comprise the significant attachment objects that contribute to maintaining a sense of wellbeing. Seager refers to this as the professional family and

describes it as comprising the whole team from managers to desk clerks, senior clinicians to volunteer assistants. The containment

derived from this family is rooted in the feeling of being held in mind, remembered, and known by a consistent and important group of people and this is what engenders a sense of safety.

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The Professional Family, Object Attachment and People with Learning Disability So how does this affect people with learning disability? Our clients have arguably some of the most disrupted childhood and adult attachments, unstable emotional environments and devaluing

experiences of any social group.

Many were institutionalised as

children and grew up in the bleak and unforgiving environment of a 2000 bed hospital. Today most live in community services which

are ostensibly better than before but still variable in their capacity to provide emotionally nurturing and stable relationships.

For people who are developmentally delayed through intellectual impairment and impoverished emotional histories, the situation is further complicated by the likelihood of impaired wholeness or adultness of the personality that is now struggling to cope with uncontaining social and emotional circumstances. As a consequence, some people may need complex therapeutic support in order to build the trust necessary to forming positive attachments, others may not understand what positive attachments are and need experience of positive dependency within a secure therapeutic relationship to begin to construct such notions.

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What is clear is that the professional family has a role over and above the individual clinical remit of its members. As Seager says, referring to suicide, When we define safety in terms of attachment and containment it is clear that it is . misleading and . dangerous to split off our own role and the part played by other relationships in the total care system .

Psychoanalytic thinking describes suicide as the ultimate act of someone who feels at the complete mercy of one or more bad objects and/or bereft of attachment to any sufficiently good object. People who feel worthless, disconnected, unloved and unvalued are at greatest risk of successful suicide attempts.

One man, his voice shrieking his distress, left a message on our answerphone to say that he had tried drinking bleach to no effect and so now he was going to eat loads and loads of chocolate. Funny? Momentarily. Tragic can there be any doubt? Why he thought chocolate would kill him, none of us could say but when it did not, he hanged himself in a public car park.

For people with learning disability, the tragedy is that what often keeps people alive is their own inability to escape the surveillance that pervades their lives. The dreadful conclusion is that people

with some of the fewest resources are condemned to live in the deepest misery through being unable orchestrate their own end.

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Thankfully, most of our clients get through life without such major trauma and, because many services do not retire them when they reach old age, we travel with them from adolescence to death. This gives us both the opportunity and the obligation to put in place a service system that is able to address issues of psychological safety. Teams comprising a diverse staff group are capable of providing the continuity of contact that underpins a service memory of people so that they always feel known and remembered. This is also an

enduring relationship that offers a narrative record bearing witness to their lives when often there is no-one else to do so. Making this explicit as a service philosophy would positively influence the function of the team and so its structure.

Finding an Evidence Base No-one has yet made the concept of psychological safety an explicit core value around which to design services so there is no outcome research and therefore no direct evidence of its efficacy. What we do know is that therapeutic communities have often adhered to a model of care that is a less formalised version of psychological safety and that this is perceived by patients as more humane than the traditional medical models (see Main 1957). We also know that, while doctors see their value in terms of a quick diagnosis which they believe should cause patients to like them, patients value a doctor who gives them time to tell their story, (make themselves

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known), and only then produces a diagnosis (Feldman 2006).

As

human beings we know that we prefer mostly to visit places where we are known than ones where we are always treated as strangers.

Finally, a recent study (Kennedy and Thomas, 2007) in which a mental health team developed a dialectical behaviour therapy (DBT) approach to their clients with borderline personality disorder showed how this saved an average of 11,962 per patient in emergency and inpatient admissions. sufficient? But was the DBT itself either necessary or

The description of what they did suggests that in fact

they had developed a mindful and psychologically safe service which contained and nurtured those vulnerable adults by giving them sustained, non-contingent contacts with people to whom they could attach.

The Proposal Brighton & Hove CLDT is a multi-disciplinary service within which philosophies of practice vary although all have a core of mindfulness that is not necessarily made explicit. This proposal, to establish a commitment to providing a psychologically safe environment in which vulnerable adults can make secure attachments to members of a professional family, is an attempt to place that core within a theoretical context. The defining values are these:

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 Psychological safety is about the total service ethos and the total experience of the service user. Psychological buildings safety is less about than containment containment in in

and

institutions

relationships. The greatest risk to psychological safety for all human beings is to be forgotten and not held in mind.

In practice this is a promise to service-users that they will be thought about in an empathic way by at least one other person in whom there is at least a basic level of trust and with whom there is reasonably regular contact, and that they will have connections to and continuity with other human beings, objects and places in a way that affords a sense of belonging, identity, shared meaning and purpose.

The aim is to provide that security for adults whose impaired intellectual function causes them to be life-long recipients of services.

Cost implications Attitude change costs little and, if initiated by the team itself, should lead to an improved service culture that actively values mutual support and collaboration.

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Work load implications There is no reason to assume that this would be labour intensive, rather it is about rethinking the meaning of therapeutic contact and professional roles. It has been our experience that, when placed in the context of trust and proper supervision, some of the most therapeutic experiences for clients have been delivered by preclinical assistant psychologists working as volunteers.

Seager (2006) makes the point that everyone, from manager to cleaner is part of this family and responsible for the ethos. In our service, the secretarial team exemplifies the model; not only do they welcome people with a warm smile and a cup of tea but they interface with distraught or angry clients and carers on the phone or in person and the ease with which we as clinicians can then follow up these matters is testimony to their capacity to contain and defuse under difficult circumstances.

As Seager (2006) says, therapy is much more than the formal therapy session, it is the culture of the service itself that allows for a style and mode of contact that meets the needs of the client and that the client finds therapeutic. The fact that so many of our

clients also need a form of adult parenting to enable them to carve out a lifestyle that brings them joy and affection, risk and

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excitement, and the stability to benefit from these lends strength to the argument that our provision must be flexible and containing enough to enable this. Our CLDT, as a multi-professional, multi-agency resource, is ideally placed to drive these principles into the heart of the local learning disability provision. Fingers crossed then

The man who committed suicide by hanging had been an inpatient for some months before this, resisting all attempts to discharge him by turning down the residential options offered. During this time he rarely complied with treatment, preferring to go fishing during the day and returning to the ward at night. But how do we understand treatment in this instance? To the ward staff it was being available to talk, to join groups, or to engage in occupational therapy but to him maybe it was just the sense of security he derived from being surrounded by people who would respond to his emergencies and not let him harm himself.

Affilation Sussex Partnership Trust Address Dr Suzanne Conboy-Hill, Consultant Clinical Psychologist for people with learning disabilities. Sussex Partnership Trust, 86 Denmark Villas, Hove, Sussex, BN3 3TY email [email protected],uk

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References

Feldman, S. (2006). What are Patients Looking for? Medscape General Medicine online article. 8, (3) 41.

Kennedy, F. and Thomas, S. (2007). A DBT service on the Isle of Wight. Clinical Psychology Forum. 171, 28-32.

King, E.A., Baldwin, D.S., Sinclair, J.M.A., Baker, N.G., Campbell, M.J. & Thompson, C. (2001). The Wessex Recent In-Patient Suicide Study. British Journal of Psychiatry. 178, 531-536.

Main, T. (1989). The Ailment. In Main, T. The Ailment and Other Psychoanalytic Essays. Free Association Books. London. work published 1957). (Original

Seager, M. (2006).

The Concept of Psychological Safety a

psychoanalytically informed contribution towards safe, sound & supportive mental health services. 20 (4) 266-280. Psychoanalytic Psychotherapy

Acknowledgment With huge thanks to Martin Seager for inspiring and guiding this paper.

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