Category: Mental Health

Clinical Supervision and how it can support the work of non – specialist client facing workers

Fulfilling Lives South East

What is clinical supervision?

Clinical supervision isn’t new, having been used for many years in a variety of healthcare settings, including mental health. Clinical supervision is a formal mechanism through which individual and professional development occurs by the worker reflecting and learning with the supervisor. People who receive clinical supervision have jobs that are emotionally demanding, in the case the of the Fulfilling Lives South East (FLSE) project supporting people with significant trauma histories and/or multiple and complex needs (MCN).  

A key piece of learning from the FLSE Perspectives Project and Perspectives Project: Part 2 work was how statutory mental health professionals could support non-specialist client-facing workers to safely hold high levels of risk. This blog shares learning and aims to illustrate the important role that clinical supervision can play, or could play, in providing a form of mental health specialist support via the worker to clients with a coexisting condition. In building confidence and knowledge in workers to understand the complex nature of this client group, develop appropriate methods for risk taking and sharing risk, managing worker wellbeing, and navigating complex systems when advocating for clients.

In what ways can clinical supervision help non-specialist frontline workers?

  • Feeling connected

Working in a role providing support to clients experiencing MCN on a one-to-one basis can be an isolating experience for the worker. The danger of vicarious trauma is more likely in this type of role when in your day-to-day work you are surrounded by complex trauma. Not having a space where you can discuss feelings and emotions that the work might be bringing up for you is an unsustainable approach that will lead to workers having to take time off sick. Clinical supervision offers a space for workers to process the emotional aspect of the work and understand the interplay in the client worker relationship. Being able to talk about what comes up when supporting clients to recognise transference and how this can conflict with your own attachment styles is vitally important.

  • Confidence and knowledge

Clinical supervision equips non-specialist client-facing workers with a framework of language that gives knowledge and confidence when adjusting to different audiences and situations. It can help workers advocate for clients using language that statutory mental health workers will recognise and listen to, as well more authoritative robust language to explain the risks and consequences of not responding to the needs of the client.

Additionally, clinical supervision supports workers to facilitate and lead multi-agency meetings that illustrate to partners trauma understanding and this helps other agencies work in the same way, modelling what good can look like when a multidisciplined team approach is adopted to working with complex needs clients.

Another way in which workers’ development of communication is important, is learning through clinical supervision how to interpret the client’s language as well as gauging what language is appropriate to use in response to a variety of situations that can and will arise when supporting MCN clients.

  • Innovative, flexible, new approaches

Services can be risk averse which stifles creative approaches to working with MCN clients. Working with this client group requires new approaches and time to build the vital relationships that set the foundations for positive support work to take place. Training staff to have the confidence, knowledge, and skills to work in this way is key to working in a trauma informed way. Non-specialist client-facing workers having the opportunity to discussion innovative ideas in clinical supervision where thinking can be refined, and potential risks can be identified, and mitigation strategies can be worked though. Is incredibly valuable and reassuring for a worker to know that a specialist is endorsing their case planning and now leaving the worker exposed to holding the risk alone.

  • Wellbeing and burnout

While clinical supervision is not therapy, it can be used for times when workers are triggered and to think about why that may be. Sometimes these discussions do not happen with managers until the worker has to go off sick and the reason for absence must be disclosed. Clinical supervision offers a regular slot in a worker’s diary where the focus won’t be frontline operational priorities, rather a time to talk with someone who isn’t part of their day-to-day working life. This protected time affords the worker safety to disclose issues and feelings resulting from the nature of the intense client work. Any sense of uneasiness around disclosing feelings that may be perceived as weakness or make the worker feel shame is diminished by the containing space provided through clinical supervision.

  • Feeling valued

One of the main impacts that clinical supervision has is it gives a message to staff that the organisation genuinely cares about them and their work. Staff are aware that clinical supervision is something that professionals with specialist qualifications receive, so it sends a signal that the organisation is treating the vital work they do with seriousness. There is often a sense that non-specialist frontline workers are regarded as professionals with a small ‘p’. This kind of investment in staff is validating making workers feel that their role in the support system and the contribution they make is being rewarded by the organisation looking after their wellbeing and professional development.

Why we need to protect our workers?  

The current headwinds buffeting third sector healthcare settings are some of the most difficult we have faced. The system is more stretched than ever, the number of people requiring support continues to grow as the level of complexity people are presenting with increases. Coupled with staff shortages and reduced funding the sector is producing a workforce that is stressed, under pressure and poorly supported. Of course, the Covid-19 pandemic has amplified these long-standing issues in the system, while at the same time creating an opportunity to embed clinical supervision in the sector. Giving meaningful professional support and development to non-specialist client-facing workers would be a decisive and welcome contribution to the system.

To read more about how clinical supervision can benefit client-facing workers providing intensive support to clients with MCN, please read ‘The effectiveness of clinical supervision for workers supporting people experiencing multiple disadvantage’. Written by Juliet Hough, and independent researcher, published on the FLSE website in January 2021, the research found that the provision of regular one-to-one clinical supervision was highly beneficial to workers and to the FLSE programme. It was critical to workers trauma informed practice, and in supporting their well-being in the following areas: Increased workers’ understanding and skills around providing trauma informed care, helped workers to successfully advocate for support from other services, helped to protect staff from burnout and compassion fatigue, reduced sickness absence and staff turnover, benefited the people being supported

For further reading about how clinical supervision can play a vital role in our wider communities, please read an academic paper, ‘Could clinical supervision help us to support increasingly complex needs in the community?’ The paper is a collaboration between Kerry Dowding, FLSE Research and Evaluation Officer, and, Juliet Hough, an independent researcher. First published online 15th February 2022, this paper presents qualitative research exploring the benefits of clinical supervision for workers supporting people experiencing multiple disadvantages. The paper illustrates how clinical supervision supported worker wellbeing, lessened compassion fatigue, and created space for workers to think creatively, manage risk and develop trauma-informed and reflective practice.

Locally, the FLSE team have taken a deep dive into the ways in which clinical supervision has supported our Practice Development team as they trial new ways to engage with people experiencing MCN. We wanted to see to what extent clinical supervision could provide a form of specialist mental health support to clients, via the practice development workers. Read more here https://www.bht.org.uk/wp-content/uploads/2022/06/PP_clinicalsup_FINAL_21062022.pdf

Authors:

Alan Wallace, Systems Change Officer

For further information about Fulfilling Lives work in this area, please contact:

Alan.Wallace@bht.org.uk

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Open letter to MP Maria Caulfield re. The ‘Women’s Health Strategy: Our Vision’

Fulfilling Lives South East1 Comment

In 2021, the government called for input on the Women’s Health Strategy with the following key themes:

We fed into this consultation with experts by experience, front line workers, the service user engagement team as well as the systems change team.

In January 2022, the new Vision for the Women’s Health Strategy has been published and we are pleased to see a local Member of Parliament- MP Maria Caulfield, leading this initiative.

We now are keen to share our reflections on the recent Vision for the Women’s Health Strategy for England by publishing the letter we have sent to MP Maria Caulfield in response to the publication on the 7th March 2022. And we hope to get an opportunity to discuss this further.

Open letter from Fulfilling Lives South East to the ‘Women’s Health Strategy: Our Vision’ publication

Subject: Women’s Health Strategy: Our Vision 

Date: 07/03/2022

Contributors:
Kate Jones, Engagement and Co-production Worker
MichaelaRossmann, Systems Change Officer michaela.rossmann@sefulfillinglives.org.uk
Rebecca Rieley, Systems Change Lead- rebecca.rieley@sefulfillinglives.org.uk

Sue Westwood, Expert by Experience
Victoria Hensley, Engagement and Co-production Worker
Contact details: Rebecca Rieley & Michaela Rossmann, Fulfilling Lives South East – BHT Sussex,144 London Road, Brighton, Sussex, BN1 4PH

Dear Maria Caulfield,

We are a local charitable project who are keen to share our reflections on the recent Women’s Health Strategy and are pleased to see a local Member of Parliament leading this initiative.

  1. OVERVIEW OF FULFILLING LIVES SOUTH EAST PARTNERSHIP

The Fulfilling Lives South East (FLSE) Project started in 2014 and is funded until July 2022 by the National Lottery Community Fund, and operates in Brighton and Hove and East Sussex, as one of 12 projects across England. 

We are funded to:   

(a) provide intensive support for people experiencing multiple disadvantage,   

(b) involve people with lived experience of multiple disadvantage at all levels and,   

(c) challenge and change systems that negatively affect people facing multiple disadvantage.  

We have highlighted six themes that have arisen from our work to date and within each theme we have further identified several Commitments for Change – changes that we believe will help improve support systems and services for people with multiple and complex needs.    

One of our core themes of our  Manifesto for Change is addressing Health Inequalities. 

  1. MULTIPLE AND COMPLEX NEEDS (‘MCN’)

Multiple and complex needs (MCN) are persistent, problematic and interrelated health and social care needs which impact an individual’s life and their ability to function in society.  They are likely to include; repeat street homelessness, mental, psychological and physical health problems, drug and/or alcohol dependency, and offending behaviour. People with MCN are more likely to experience violence and abuse, including domestic violence, live in poverty and have experienced trauma in childhood and throughout their lives.

  1. OUR RECOMMENDATIONS

How we are feeding into the Women’s Health Strategy- Consultation: 

FLSE has fed into the open call for evidence for the Women’s Health Strategy as a collaboration between the Systems Change Team and the Service User Involvement team. Together, we have used case studies, experts by experience and data from our project to inform the below recommendations:

A) Women’s Voices:

FLSE would like to see the healthcare system change to a more inclusive, trauma informed and collaborative system, where women don’t feel stigmatised when seeing professionals. Ideally, specific women’s only spaces are created so that taboos (such as sex work) and re-traumatising experiences are minimised. We would also like to be given a choice of being seen by female professionals instead of male professionals.

Our experts by experience feel that being listened to by a professional is crucial, but there’s a difference between being listened to and actually being heard.

Women experiencing MCN feel underrepresented and sometimes ignored or belittled. There are currently lots of gaps and barriers when trying to provide a person-centred health service. 

In contrast to the 96.9% of women who shared their own experience via the online consultation, our client group also faces digital exclusion and we feel that their voice has been left out.

We are happy to see the acknowledgement of stigma and taboo in the new Vision document but we strongly feel that trauma informed training needs to be rolled out across the healthcare system, not only in connection with Violence Against Women and Girls specific services/aspects of the healthcare system.

B) Healthcare Policies and Services:

Our clients and experts by experience would like to see a more flexible appointment system and walk-in clinics for women experiencing MCN. One of our experts points out that ‘GP surgeries should ditch using Covid as an excuse for failing of health services. We need a new approach and start again.’ The real issue for our clients is accessibility. This can’t be overlooked. If you can’t get through the GP’s door, then health outcomes won’t be improved.

We appreciate that ‘Ensuring equitable access to services and reducing disparities in health outcomes’ between women is now on the government’s radar and geographic disparity and women with disabilities are mentioned.

We are, however, concerned that women experiencing MCN, or multiple disadvantages, have not been named as a population category itself. It is often difficult for our clients to make appointments with GP surgeries by a certain time and day, which is exacerbated by feelings of not deserving help. In our experience, especially in Eastbourne since the closure of the walk-in clinic, it is extremely difficult to get through to GP surgeries, and if so, many of our experts by experience report difficulties ‘getting past’ receptionists who can appear to act as gatekeepers.

We welcome the life course approach of the vision document but feel that links between services are missing, especially when it comes to some of the potential links between the Mental Health Act, Mental Capacity Act, the VAWG Strategy and the Women’s Health strategy. We would like to see resource being directed to link us these strategies at a national level.

Our recently published mortality report shows that our clients experience on average at least 7 long-term health conditions which can lead to early deaths. We need policies that are fit for purpose and interconnected. We also call for a joined-up approach between support services within primary and secondary healthcare but also the third sector.

C) Information and Education

In our experience, women experiencing MCN are linked in with a variety of systems and services: the prison system, alcohol and substance misuse services, adult social care, domestic abuse and the physical and mental health services. The one commonality though is women are left feeling that these systems operate in isolation and information is not being shared.

This is two-fold:

  • Information about the clients is not being shared across services effectively and our clients need to consistently repeat their stories which can be re-traumatising;
  • Health information is not being shared between services and systems. Trusted relationships, such as key workers, might be outside of the clinical healthcare system but are crucial to provide support, information and education to clients.

We appreciate that there is an acknowledgement of education and training for healthcare professionals on specific physical and mental health issues being needed in the Vision, but we would also like to see training on trauma informed approached and a less siloed approach between physical and mental health as well as the wider NHS services, adult social care and the third sector.

D) Health in the workplace

FLSE has employed a total of 41 individuals with lived experience of MCN, through its employment programme. You can read our findings from the employees’ perspective here and the employers’ point of view here.  

We would encourage greater attention on supporting the health and wellbeing of those with experiences of multiple and complex needs in the workplace and see this support as an enabling factor, helping people with lived experiences re-enter the workplace as well as supporting their health and wellbeing.

E) Research, evidence and data

Due to the high complexity of clients, we call for an open-ended, tailored and individualised approach. We believe that the healthcare system unfortunately is not always prepared to support women who experience multiple and complex needs or reach out and include them in research studies. FLSE would welcome a new, more collaborative and inclusive way of working to enhance the reach of research because historically women experiencing MCN have been under-represented in data and research.

Our project’s Research and Evaluation Officer has produced a toolkit to support researchers with practical advice and tips on applying the principles of trauma-informed practice to their research activities, specifically running focus groups, one-to-one interviews, and service observations. It is suitable for evaluators, researchers, service leads, commissioners, or anyone who would like to find out more about the experiences of people who may have been affected by trauma. This can be found here.

  1. OUR CONCLUSION AND BEST HOPES

In our experience, the key to providing better healthcare to women experiencing MCN is accessibility and flexibility. This is also supported by the King’s Fund ‘Interventions to tackle health inequalities need to reflect the complexity of how health inequalities are created and perpetuated, otherwise they could be ineffective or even counterproductive.’

FLSE is based in Brighton and East Sussex which means that our clients have worse health outcomes due to coastal inequalities, than in other areas as explained by Chief Medical Officer Prof.Chris Whitty’s annual report 2021.

Nonetheless, we hope that our contribution to the call for evidence for the Women’s Health Strategy will contribute to a better system for women experiencing multiple and complex needs.

That is why our best hopes for the Women’s Health Strategy are that:

  • Multiple and complex needs is recognised as a population category in itself, alongside disabilities and minorities.
  • There is recognition that some of the listed priorities (such as gynaecological health) can be traumatising or re-traumatising for women who have experienced certain forms of abuse and women experiencing/who have experienced MCN. As a result, high quality trauma informed training needs to be provided to all healthcare staff (incl.GP receptionists) and that the training includes the voices of lived experience.
  • The different strategies (such as VAWG, Mental Health Act, Mental Capacity Act) are linked together and find a systemic way to collaborate more efficiently.
  • The life course approach to include social determinants of health, as well as more joined up working, so that we move away from a focus on singular health issues, towards more joined up approaches to complex health conditions such as coexisting conditions mental ill health and substance use.

With kind regards,

The Fulfilling Lives South East team

Authors:

Michaela Rossmann, Systems Change Officer

Rebecca Rieley, Systems Change Lead

For further information about Fulfilling Lives work in this area, please contact:

rebecca.rieley@sefulfillinglives.org.uk  

michaela.rossmann@sefulfillinglives.org.uk

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Mental Health Act review- the Government’s responses and our feedback

Fulfilling Lives South East1 Comment

In April 2021, the Fulfilling Lives South East (FLSE) team responded to the government’s Mental Health Act review and published a blog detailing our responses and thoughts.

We called for:

  1. A commitment to invest in local mental health support services.
  2. The Advance Choice Document to include a Nominated Person instead of next of kin.
  3. To offer more advocacy support, ideally peer led, to help patients’ voices be heard.
  4. The new guiding principles of choice and autonomy, least restriction, therapeutic benefit and the person as an individual to be integrated in day-to-day work.
  5. Trauma informed practice training to be introduced to all staff members.
  6. MCN and co-existing conditions to be recognised as a specific category.

1,700 organisations and individuals UK wide submitted their responses to the government, and it is reassuring to see that the majority of responses reflect our recommendations and suggestions.

The government reflected on how this wide-scale review had generated useful learning: ‘In 2017 the government asked for an independent review of the Mental Health Act 1983 (MHA), to look at how it’s used and to suggest ways to improve it. The review’s final report said that the MHA does not always work as well as it should for patients, their families and their carers. We’re now proposing a wide range of changes to rebalance the MHA, to put patients at the centre of decisions about their own care and ensure everyone is treated equally.’

Matt Hancock, Health and Social Care Secretary from January 2021 said in an oral statement to Parliament that ‘(…) this programme of transformation is ambitious and as we support mental health services now, so we must bring up to date the legislative framework also for the long term. The Mental Health Act was created so people who have severe mental illnesses and present a risk to themselves, or others, can be detained and treated. For their protection and the protection of those around them. But so much has changed since the act was put in place, nearly 40 years ago.’

Following the Consultation on the Bill between January and April 2021, the revised Act was released in October 2021.

Our Reflections

The FLSE team has since reviewed and reflected on this new content and would like to share our reflections below.

  • We welcome the introduction of the Advance Choice Document which focuses on facilitating patients’ recovery and patients with capacity to be able to refuse treatment, for their wishes to be respected and for the Mental Health Tribunal judge to give orders for treatments not to be given.  
    As set out in the White Paper, the government will take forward legislative changes to replace the Nearest Relative role with the Nominated Person role so that individuals can choose who represents them. 
  • Co-production and working with service users and carers is critical to the quality of advocacy services. 
    As set out in the White Paper, the government will take forward legislative changes to extend eligibility of Independent MH Advocate (IMHA) services to all mental health inpatients which means that their voices are being heard.
    The government will further explore with stakeholders the best way to improve the quality of IMHA services, whether through enhanced standards, accreditation, regulation, or increased training requirements. The government will continue to prioritise the development of culturally appropriate advocacy and work with stakeholders to ensure that ethnic minority backgrounds are considered as the reforms are implemented. 
  • The government is reviewing their position on the proposed time requirement for health and local authorities to deliver on directions made by the MHT, as a five-week timeframe might not be sufficient for those patients who require a complex care package. 
    We agree that there needs to be a focus on services in local communities (statutory and third sector alike) and for them to collaborate.
  • It is the government’s intention to take forward the proposals to increase the frequency of automatic referrals to the Tribunal as there have been concerns that some patients may never have access to a Tribunal hearing if automatic referrals are removed and that some patients “falling through the cracks.” 

There has been an acknowledgement that further development of the White Paper is needed when it comes to people with learning disabilities and autistic people and a commitment to discuss this further with an expert group. The need for appropriate community services was a common theme across responses to all of the learning disability and autism proposals. 

There are a number of areas that we believe remain unaddressed in the Act’s revisions:

  • We would very much like to get clarification on the type of training staff members will receive and how co-production is ensured across the system, not just advocacy services.
  • We are disappointed that ‘multiple and complex needs’ or ‘multiple disadvantages’ are not named and seen as a separate category in the MH Act.
  • It is also unclear what the commitment is to extra resources, funding and a timeline to implement these changes.

Reform

There is a commitment from the government to take the proposed changes further, which includes stakeholder engagement and individuals with lived experience saying that ‘The proposals made in the White Paper represent once in a generation reforms to the Mental Health Act (…). Our job is now to continue to develop a new Bill to reform the Mental Health Act. We have listened, we will continue to listen, and we will deliver on enacting mental health legislation fit for the 21st century – legislation which will provide for the protections and support for people with severe mental health needs, which will strengthen their voice, choice and rights, support the increased use of community alternatives to hospital, will limit the use of the Act for people with learning difficulties or autistic people, will improve support for offenders with acute mental disorders, and which will aim to address the racial disparities that have too long been part of the way the Act has been used.’

The Rt Hon Sajid Javid MP Secretary of State for Health and Social Care
The Rt Hon Robert Buckland MP Secretary of State for Justice


As it stands, there is no fixed timeline or secured funding to implement said changes, saying that ‘We intend to bring forward a Mental Health Bill, which will give effect to many of the changes we wish to make, when parliamentary time allows.’  We look forward to hearing more about concrete implementations of the White Paper soon.

The full government responses can be found here: 

Reforming the Mental Health Act – GOV.UK (www.gov.uk)

Authors:

Ian Harrison, Engagement and Coproduction Worker

Michaela Rossmann, Systems Change Officer

Rebecca Rieley, Systems Change Lead

For further information about Fulfilling Lives work in this area, please contact:

Rebecca Rieley, Systems Change Lead:

rebecca.rieley@sefulfillinglives.org.uk  

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