Four tips for building psychological resilience

Life is often stressful. These stresses can come in all shapes and sizes, from the burden of financial debt to the hassle of a fender-bender; from the heartache of a sick parent to the irritation of a late train. The bottom line is that whatever form it comes in, we can’t avoid stress. So what can we do about it? One obvious suggestion is to reduce the amount we’re exposed to: pay that bill a.s.a.p. and be careful to avoid other cars when parking in multi-storey car parks. This is good advice, but the reality is that not all stress can be avoided. For these types of stresses, it can help to increase our capacity to cope: our ‘psychological resilience’. But how can we do this? Here, I offer four tips based on research I have conducted into the factors that confer resilience.

1. Know your strengths: build your confidence. My research has shown that having high self-esteem helps people be resilient to stressful events. In a previous blog post, I outline one evidence-based technique for building self-esteem. Briefly, this works by encouraging you to consider your personal ‘strengths’ and then getting you to think of specific pieces of evidence which show that you have this strength. For example, if your strength is that you’re a good listener, a piece of evidence might be that a friend from work confided to you about their recent break-up last week. 

First though, you have to be willing to allow yourself to do this. When I deliver resilience training, many people I speak with are embarrassed to acknowledge the things they’re good at, for fear of appearing egotistical or narcissistic. This belief is both misleading and detrimental, as some individuals who are highly narcissistic in fact report low levels of underlying self-esteem. The reality is that knowing your strengths can help you to build a quiet confidence that will improve the way you work, and will not make you appear egotistical.

resilience

2. Learn to let yourself off the hook. Being a perfectionist is one of the worst things you can do for your mental health. It’s linked with higher levels of depression, anxiety and self-harm and it’s terrible for psychological resilience. What this tells us is that reducing our perfectionism could boost our psychological wellbeing and levels of resilience. There are misconceptions around perfectionism though, with people sometimes fearing that being less perfectionistic could make them less effective or high achieving. This isn’t the case. Perfectionism is about rigidity: it’s when people push themselves hard, no matter what. Being less perfectionistic involves self-awareness. It’s about knowing when to strive and push forward, and when to let yourself off the hook. If you’re a fitness enthusiast, this might involve knowing when it’s time to take a couple of days off training. If you’re a dedicated student, it might be knowing when it’s time take the afternoon off revision to see friends. For detailed suggestions on tackling perfectionism, see my previous blog post.

3. Focus on the future. When the present is no fun, it’s important to have things to look forward to, and research shows that having hope for the future can help us be more resilient. These don’t have to be big things, but they need to be clear in your mind. For example, you might enjoy going for a coffee and reading the paper, going for a walk in a park, or reading books. This practice is often incorporated into cognitive-behaviour therapy (CBT), and is called ‘pleasant event scheduling’. A recent study which tested the impact of pleasant event scheduling when done in isolation, without any of the other aspects of CBT, found it was effective in reducing risk of depressed mood. It’s not rocket science though – you can easily do this yourself by making a list of things you’d like to do and then scheduling these in your diary.

resilience

4. Don’t beat yourself up when things go wrong. There are three main ways that we explain negative events in our lives. First is how much we blame ourselves, compared with other people or the situation. Second is how permanent our explanations are: whether the problem that caused this one event is likely to keep on causing negative events in our future. Third is how all-encompassing are explanations are: whether this cause is going to make trouble in other areas of our life, as well. For example, if we were to fail an exam, we could think, “This is all down to my own general stupidity. I knew I’d never get through it”. This explanation is negative as we’re taking the blame entirely on ourselves. We’re also doing it in a permanent, all-encompassing way: if we’re stupid, it’s probably going to affect everything we do, forever.

The way we tend to explain events is habitual and it’s called ‘attributional style’. Resilient people explain events in a way that is more positive. In an exam failure situation, a resilient person would acknowledge any stress they’re under, or any other factors that could have affected their performance. Furthermore, they’ll do this in a way that doesn’t leak into other areas of their life and gives them hope for the future. In this example, a resilient person might think, “It was a stressful time with my mum being ill. I haven’t had to manage this kind of situation before, and the result was that I didn’t allow enough time to revise. I’ve learned for the future though: I know what I’ll do differently next time”. Not only will this person feel less bad about the exam failure, they’re also more likely to pass next time. It’s possible to change the way that you explain events with cognitive-behaviour therapy. For a do-it-yourself approach to improving your attributional style, I’d encourage you to ask yourself three questions when you know you’re beating yourself up about something:

  1. What range of factors contributed to this event? When things go wrong, they can rarely be pinned on just one thing. List all the things you know contributed to the event, to help yourself create a balanced perspective.
  2. What else has gone right recently? Think about other things that went to plan, no matter how small. This might be, for example, a friend’s birthday that you remembered, a work task that you completed well or a tricky conversation that you handled sensitively. It’s important to remember that this negative event doesn’t define you.
  3. What can you do to reduce the chance that a similar event will occur in future? Think about anything you’ve learned from this. Think about any actions you can take, whether this is personal (e.g., allowing more revision time in future) or external (e.g., asking for input from a tutor).

With all of these tips, it’s important to know that having good relationships with friends or family can help. Talking to others about stress you’re experiencing can help you to realise when it’s time to take action and can help you to change perspective. Have you ever moaned to a friend about a rough day at work, and appreciated it when they pointed out that it wasn’t all your fault? Well, that’s an example of them helping you to develop a more positive attributional style for that event. The take home message is: talk about it! It’s easier than trying to do it alone.

This article was originally posted on the Psychreg website on 14 June 2019.

Breaking bad news in healthcare: why we shoot the messenger

Breaking bad news is a cornerstone of healthcare delivery. From the doctor delivering blood test results in cancer services to the sonographer communicating the discovery of a pregnancy loss, healthcare professionals regularly find themselves in this challenging situation.

But why is it so challenging? In theory, the healthcare professional is simply the messenger: the person relaying information about an event they did not cause and had no influence over. The reality is nothing like this, though. Research tells us that healthcare professionals find these situations highly stressful, particularly when the news is unexpected or seems unusual or unjust. Some end up coping in unhelpful ways; distancing themselves from the patient by using technical language, delaying the communication of the news or avoiding it altogether and passing the task on to someone else. These coping tactics often backfire by creating a more negative experience for the patient and further increasing the stress the healthcare professional feels.

breaking bad news

A recent study has shed light on these conversations, identifying some of the underlying reasons for why these events are quite so difficult for healthcare professionals. This study conducted a series of 11 experiments, which together showed that:

  • After receiving bad news, people feel a need to try and ‘make sense’ of it
  • To help them ‘make sense’ of bad news, people dislike the person who told them, even if they clearly are not to blame for what has happened
  • People dislike the messenger even more if the news is unexpected, or if it is particularly unjust or unusual
  • The reason that people dislike those who tell them bad news is because they think these messengers have bad motives: they mean badly
  • This effect is reduced if recipients of bad news have reason to think the messenger has benevolent motives or means well

This study used a range of news delivery scenarios, including one where a person was told that they had not won a $2 bonus and another where their scheduled flight was running late. However, I think this study has important implications for healthcare settings for three main reasons:

  1. It brings a new perspective to why these events are so challenging for healthcare professionals. It’s not logical, but the truth is that patients will like professionals less when they deliver bad news, and consciously or subconsciously, professionals know this. Building good professional-patient relationships is a key part of healthcare delivery, and having to deliver bad news works against this.
  2. It highlights the situations where delivering bad and difficult news is going to be most challenging. Specifically, these are likely to be where the news is unexpected or where it is particularly unusual or unjust. I think that two key settings where staff should be better supported with this task are obstetric ultrasound and maternity services more broadly, as the news is often unexpected and paediatrics, where bad news could be more likely to be perceived as unusual and unjust. In these situations, the recipients of bad news may have to work harder to make sense of the information they have received, and as such, may be more likely to ‘shoot the messenger’.
  3. It offers a suggestion for how healthcare professionals can reduce the ‘shoot the messenger’ effect: namely, by communicating their benevolent intentions. For example, this could involve saying ‘I’m so sorry, I hoped to bring you better news than this. This must be so difficult for you to hear’. However, doing this requires professionals to be forthcoming and open. Unhelpfully, the impact of stress often has the opposite effect: it inhibits people, making them more careful and wary of saying ‘the wrong thing’; therefore increasing the chance that they’ll say very little. What this research shows is that by going against the natural instinct to say little in stressful situations, healthcare professionals can reduce the ‘shoot the messenger’ effect and help create a better experience for both themselves and their patients. It is also consistent with findings of a review I conducted which showed that training healthcare professionals in breaking bad news works: it enhances their confidence of how to manage these difficult situations and improves their skills.

How to become a psychological therapist without completing an undergraduate psychology degree

It’s not unusual to choose to become a psychological therapist later in life, perhaps as a second career. For example, in 2017, 395 of the applications to the UK Doctorate in Clinical Psychology came from candidates aged over 35. However, most training courses in psychological therapy require an undergraduate psychology degree. What are your options if you don’t have this? Here I offer three routes you might want to consider, depending on your current situation.

  1. You have an undergraduate degree in something else? Do a psychology conversion course

If you have an undergraduate degree in any other area, you can ‘convert’ your degree by completing a psychology conversion diploma (PGDip) or MSc course.

The key thing is to check that your chosen course is accredited by the British Psychological Society (BPS) and will provide you with Graduate Basis for Chartered Membership (GBC). The BPS currently lists 171 such courses nationally. The entry requirements for these vary, so it’s worth checking these on their websites and contacting them directly with any queries you might have. Two to consider are:

  1. Birkbeck, London’s ‘evening university’. Birkbeck offers two accredited psychology conversion courses, the Postgraduate Diploma and the Psychology MSc, both of which are designed for candidates with an undergraduate degree in another area. Both courses can be completed in a year full-time or two years part-time and involve attending lectures 4 or 2 evenings a week. I spoke to the admissions tutor, Dr Eddy J Davelaar, who is a Reader in Cognitive Science about Birkbeck’s entry requirements. He said “While the course is designed for non-psychology graduates, it is a postgraduate course. A certain level of pre-existing knowledge in research methods is needed. Where applicants have no such background, they may be made a conditional offer dependent upon their passing an online entrance exam in research methods. They will need to pass at 60% (if applying to study full-time) or at 50% (if applying to study part-time)”. However, if this is you: don’t panic. Birkbeck will assist you in identifying relevant courses (online or at the university) or practice materials to help you prepare for the entrance exam.john-schnobrich-520019-unsplash
  2. If you’re looking for a distance learning course, check out the MSc/PgDip Psychology (Conversion) courses offered by Manchester Metropolitan University. These can be completed in 12 months full-time or around 2 years part-time (21 months for the PgDip; 24 months for the MSc). These courses are taught entirely online, requiring no attendance at the Manchester campus. In terms of entry requirements, pre-existing psychology credits are needed for the PgDip route but not for the MSc. Further guidance on the qualities the course looks for in prospective candidates are outlined on their website and include commitment and motivations, IT skills and the ability to study independently.

Once you have your conversion degree, you can choose to pursue any psychology career which appeals to you, such as Clinical Psychology, Counselling Psychology or Forensic Psychology. Each of these requires further study, but there are opportunities for paid employment and development within these training routes. For example, once you have your degree, you can apply for Assistant Psychologist roles within the NHS which are usually appointed at Band 4 or Band 5 and provide further experience for subsequent psychology career specialties. Sign up to jobs.nhs.uk for alerts. You can also apply for research assistant posts at universities, which offer paid experience for psychology graduates interested in pursuing research-related careers. Sign up to jobs.ac.uk for updates. For further info on therapy-related psychology careers, see my previous blog.

  1. You have a background in mental health from a non-psychology discipline? Train in Cognitive Behaviour Therapy

An alternative to traditional psychology specialisms is to train as a Cognitive Behaviour Therapist. Cognitive Behaviour Therapy is an evidence-based, goal-oriented, time limited therapy. It is the most commonly delivered therapy in the NHS and the main focus of the Increasing Access to Psychology Therapies (IAPT) initiative, which delivers psychological therapies in primary care settings.

Perhaps the most interesting thing about this route is that it isn’t accredited by the BPS, but by the British Association for Behavioural and Cognitive Psychotherapies (BABCP). As such, you don’t need a psychology degree to start training. Instead, you need to have a background in one of the listed ‘Core Professions’, which include Mental Health Nursing, Occupational Therapy and Social Work, amongst others. If you have one of these core professions, you already hold the basic entry requirement for further training to become an accredited CBT therapist.

If you are choosing to self-fund your CBT training, check out the BABCP list of accredited ‘Level 2’ courses. Completing one of these will make you eligible for registration as a CBT Therapist and able to apply for Band 7 CBT posts in the NHS. Courses are 1 or 2 years long and involve supervised CBT practice on placement and attending teaching at university. You can apply directly to universities such as Birmingham and Bucks New University. Entry requirements vary between courses, but most stipulate that 2 years’ experience of working in mental health is a pre-requisite. Self-funded applicants are expected to have a pre-arranged placement where they can undertake supervised CBT practice to gain the relevant experience they need. At Birmingham, this is stipulated as 3 days a week for a year. At New Bucks, this is stipulated as 200 hours in total.

There is also the option to pursue paid training routes in CBT. For less experienced mental health professionals, this may initially involve training and working as a Psychological Wellbeing Practitioner (PWP) in Primary Care. These posts are usually appointed at Band 4 and promoted to Band 5 once training has been completed. PWPs deliver low-intensity CBT interventions, such as guided self-help and psychoeducation groups. To then train as a CBT therapist (termed ‘High Intensity Therapists’ or ‘HITs’), you apply directly to services for specific roles, rather than to universities. HITs train on a Band 6 and can apply for Band 7 roles once qualified. For training opportunities in both roles, search nhs.jobs.uk for ‘trainee’ positions.

you've got this

  1. Looking for a third way? Consider a career in counselling or psychotherapy

While the BPS is the accrediting body for psychological therapists and the BABCP is the accrediting body for Cognitive Behaviour Therapists, the BACP accredits counselling and psychotherapy courses. They all share similar letters, so beware of confusing them!

Counsellors can train in a range of therapy modalities, from Freud’s psychoanalysis to Roger’s person-centred (or ‘humanistic’) counselling. Once qualified, they can work independently, for the NHS or for third sector organisations. Training courses usually focus on one of these therapy modalities in particular, but the BACP suggests that counsellors may use a mix of techniques if they think a client would find this helpful.

Counselling training pathways exist separately from psychology or CBT training routes, and as such, no background in either of these is needed. Instead, the training involves 3 stages:

Stage 1: An introductory course lasting 8-12 weeks, usually run as evening courses at local Further Education colleges.

Stage 2: The Certificate in Counselling Skills, a year-long part-time course also usually run at local colleges.

Stage 3: The core practitioner training at diploma, undergraduate, postgraduate or doctorate level.

For Stage 1 and 2 courses, the BACP recommends contacting local colleges and education centres. However, for the core practitioner training, check their website for accredited courses. A wide variety of options are available, from weekend courses run by independent training centres to university-run MSc degrees. For an example of an independent training centre, see the South Manchester for Psychotherapy, which offers a 4-year, part-time Diploma in psychotherapy. For an example of university-run core practitioner training, see the University of Salford which runs both a postgraduate diploma and an MSc. These courses run part-time, with the diploma last 2 years and the MSc lasting 3 years.

This article was first posted on the Psychreg blog on 23rd May 2019.

Ten tips for aspiring Clinical Psychologists

The competition to become a Clinical Psychologist is fierce. In the UK, the constituent parts of the training are a three-year undergraduate degree which is accredited by the British Psychological Society (BPS), and a three-year taught Clinical Psychology doctorate. The doctorate is full-time; candidates are employed by the NHS and complete a series of six-month placements in addition to coursework and a research project.

Psychology undergraduate students self-fund their degrees and as such, courses have flexibility about the number of students they can enrol. Psychology is consistently the second most popular degree in the UK, with an estimated 13,000 graduating each year. However, until recently, the only places offered on the doctorate were NHS funded, and therefore carefully regulated. Between 2012 and 2018, doctorate courses enrolled around 590 students per year altogether; just 15% of the total number of applicants. While three courses now include self-funded places, these come with a price tag of £20k+ a year, putting them out of reach of most graduates. 

Here, I offer 10 tips for aspiring Clinical Psychologists:

1. Know the bottom-lineIf you are at the point of applying for the doctorate, look at the particular courses you are interested in on the Clearing House website. What are their non-negotiables? Many courses now stipulate that candidates must have a 2:1 or a score above 65% in their undergraduate degree. Others require that applicants have a year’s clinical experience supervised by a qualified psychological therapist. If you don’t meet their stipulations your application will be automatically excluded, even if it is otherwise strong.  It is therefore worth researching each course’s bottom-lines before you apply.

2. Look into placement-year degrees. Several universities including Aston, Bath and Leeds (where I am based) offer applicants the opportunity to undertake a placement year ‘in industry’ between the second and third year. This means that students can gain relevant clinical experiences which can help them to be competitive applicants for graduate jobs. These placements are overseen by the universities, helping to ensure that they provide students with more useful experiences than they may gain through general volunteering. Some placements also offer a contribution towards expenses or a stipend, which volunteer roles generally do not. 

3. Consider the ‘Increasing Access to Psychological Therapies’ (IAPT) initiative for an alternative career as a psychological therapist. IAPT was launched in 2007 to provide greater access to psychological interventions for people with mild-to-moderate anxiety and depression. It is now planned to expand in order to provide therapies to 1.5million adults per year by 2020/2021. There are two main types of psychological therapists working in IAPT: Psychological Wellbeing Practitioners (PWPs) and High-Intensity CBT Therapists (HITs). PWPs are recruited into training positions with IAPT services on an NHS band 4; once they are qualified, they are paid at band 5 and can progress to band 6 (for information on NHS pay bands, see here). Similarly, HITs apply to train with specific NHS services. They train on band 6 and are paid on band 7 once qualified. Sign up to NHS jobs for alerts about these roles. A follow-up of HITs suggested that 79% stay in IAPT services after qualifying, 61% become CBT supervisors and 23% progress to more senior roles. It also possible to self-fund training to qualify as a CBT therapist, by undertaking a postgraduate course accredited as Level-2 by the British Association for Behavioural and Cognitive Psychotherapies (BABCP). 

4. “Remember at the end of the day, it’s just a job”. This was the best advice I was given before I attended my interviews for the Clinical Psychology Doctorate. A qualified Clinical Psychologist called me to give me some advice, and these words helped remind me that I wasn’t auditioning for the X-Factor: at absolute best, I would become a qualified psychological therapist. Imminent fame, stardom and riches were not around the corner. Being a Clinical Psychologist in the NHS is a wonderful job, but it is not without stress and strain, like any other healthcare related job. So, relax: it’s just a job.

5. Vary your experiences. Working as a research assistant or assistant psychologist will give you great experience for the Clinical Psychology doctorate, but more than a year in any one post will have diminishing returns. While you will always need to balance the opportunity to gain varied experience with the need to pay your rent and bills, it’s worth remembering that having a broad skillset will give you the strongest CV and application.

6. Treat applications like assignments and interviews like exams. You cannot assume that the knowledge and experience you have will naturally shine through: work hard to sell yourself. Consider carefully the range of experiences you have had. For example, what is the range of client groups you have worked with? What experiences have you gathered? Think carefully about the knowledge you have in relation to engaging different client groups, conducting assessments, collecting and storing sensitive data, managing risk, and applying psychological theory to individuals, for example by contributing to formulations or interventions. Also consider carefully the job which you are applying or interviewing for: who is interviewing you, and what is their area of interest? Which client group will you be working with, and what things might you need to be conscious of? Which therapeutic modalities might you be using, such as CBT or psychodynamic approaches? One way to impress your interviewers is to appear prepared for the opportunity they are offering.

7. Consider alternative psychology disciplines. If you have a BPS-accredited undergraduate degree, Clinical Psychology is not your only option for working therapeutically. For example, many posts which are open to Clinical Psychologists are also open to Counselling Psychologists. To train as a Counselling Psychologist, you can either do a self-funded doctorate degree or the BPS qualification in counselling psychology; this involves three years of supervised practice. More information is available here. Alternatively, for psychologists interested in working with forensic populations, Forensic Psychology may offer a fulfilling alternative career to Clinical Psychology. In some secure hospitals, much of the work of Forensic Psychologists involves delivering psychological therapy. To train as a Forensic Psychologist you can either complete a Doctorate in Forensic Psychology or a Masters in Forensic Psychology followed by two years of BPS training and supervised practice. More information on becoming a Forensic Psychologist is available here. It is also worth noting that the University of Birmingham now runs a four-year doctorate which offers candidates a dual qualification in both Forensic and Clinical Psychology (see here). 

8. Look for research opportunities. As an undergraduate I undertook some voluntary work as a research assistant with a professor and lecturer in my department. It was one of the best decisions I made: it paved the way to my Medical Research Council-funded PhD in Resilience to Suicidality and kick-started my love of improvement in healthcare. It also helped me to gather a range of experiences in working with clinical populations, as my PhD involved undertaking psychological assessments with people with psychosis and testing a novel mood-boosting intervention in this group. I would highly recommend seeking research opportunities to aspiring Clinical Psychologists. If you are currently a psychology undergraduate, seek opportunities with clinically-oriented researchers in your department. If you are a psychology graduate, sign up for job alerts at jobs.ac.uk and look for opportunities which would allow you to gain experience working with clinical psychologists and/or researching with clinical populations.

9. Keep your eye on the proposed role for ‘Clinical Associate Psychologists’. This is anticipated to take the form of an apprenticeship which will last 18 months and produce psychology professionals who undertake psychological assessment and formulation, and who deliver psychological interventions. At the moment, it is suggested that each Clinical Associate Psychologist will train on a Band 5 salary and be paid at Band 6 once qualified. The plans are currently in development, but should be in place in the coming year. 

10. Take heart: the need for psychologists is not diminishing. While the sense of competition may feel overwhelming, the demand for psychological therapies is increasing, which is reflected in the introduction of the IAPT initiative and the new role of the Clinical Associate Psychologist. While getting a place on the Clinical Psychology Doctorate may be challenging, if you have a passion for psychological work, the future is bright!

Finally, I want to note that while the cap on funded places for the Clinical Psychology doctorate produces a low success rate at the point of enrolment, I believe it also offers significant benefits. First, the competition that the cap creates means that aspiring Clinical Psychologists need to seek additional experience and training after their undergraduate degrees to strengthen their applications. This experience ensures that all doctoral trainees know the discipline they are working in and can feel confident in their career choice before they sign-up to the three-year course. This is reflected in the high retention rates of courses (99.4%): students rarely fail to complete their doctorate, once they’re on it. Second, it means that once qualified, Clinical Psychologists have good job prospects: 95% are employed in a clinical psychology job within 12 months of graduating. Deregulating the number of doctorate training places could shift this balance, creating the possibility that qualified Clinical Psychologists could become unable to find employment. By ensuring that applicants are experienced and committed, I believe that continuing to fund all forms of postgraduate psychological training offers the best outcome for applicants, healthcare providers and clients.