Dr Edith Steffen

It’s Wednesday morning, and traffic is crazy as usual. Will I make it on time? I am racing down the leafy A roads in this somewhat secluded part of the county, leading to the beautiful old hospital site which houses the local in-patient ward, our community mental health service and also boasts a number of boarded-up, decaying buildings, waiting to be turned into upmarket apartments for commuter belt executives. I have no time this morning to get nostalgic about the loss of this site. I foolishly scheduled supervision with our Assistant Psychologist for 8.30am, when I should know better that this is difficult for me to make. However, today is one of the lucky days when I rush up the steps to the entrance just on time, calling a quick ‘Morning’ to the first few members of staff trickling in. No time to stop for a chat – got to quickly get to my desk, grab my supervision folder and rush to meet our Assistant Psychologist.

I enjoy our supervision sessions. We’ve now had these sessions about once a week for a year and know each other quite well. We have a bit of a chat about the morning traffic and then settle down to set the agenda. We talk about the clients she is currently seeing, for example she is working with someone who is afraid of using the bus, and she reports back on the graded exposure work she is doing with the client. We note that it’s going really well. I praise her for having been very sensitive to the client’s anxieties while maintaining a stance of confidence in the work and staying focused. The next client presents more problems. The client is missing sessions and it is not clear how engaged he is. When he does come, there seem to be tensions. I encourage her to explore her feelings towards the client and I use self-disclosure to normalize her experience. We think together about what her countertransference may indicate and how this could inform the work. These are the times when I feel very much in touch with my identity as a counselling psychologist. We give space to what is going on in the relationship with this client. Some new insights emerge as we reflect together. We finish supervision with thoughts about her current workload. Our annual audit is coming up, and I check that she has enough space in her diary to work on it.

We go next door to the meeting room as it is time for the monthly business meeting. The atmosphere in the team is relaxed and friendly. The different professional sections give feedback on news and developments: nurses, social workers, OTs, psychiatrists and psychologists. We go through some statistics with regard to referrals and discharges. There are also some comparison tables with other services in terms of achieving targets, which we look at in a half-disgruntled, half-resigned way. At the end of the meeting there is some time for planning our ‘away day’, which lifts the general mood again.

Straight after the meeting, I am seeing my first client for today, a young man I am currently assessing for EMDR. It is our second assessment session, and we complete a timeline of his trauma history. The abuse he experienced as a child is horrendous, and as he talks about it, I feel like crying myself, but at the same time I experience a strong wish to protect and contain him. My observing self notes the tightrope walk of listening/exploring and containing, but also that we are developing a good working relationship in which I can check in with the client at each stage about proceeding.

Following this session, I have a half-hour slot before the next session. This is the moment I can have a coffee, check my emails, write notes, talk to colleagues and prepare for the next session. There is never enough time to squeeze everything in – writing notes is usually the job that gets postponed. A care coordinator pops in to talk about one of her clients, wondering if psychological therapy would help this person. I make space for a brief consultation. As I listen to the details of the case, I fleetingly remember how I used to want to do therapy with everybody and could rarely see a reason for excluding anyone. Through experience I have developed more discernment, and in this case my sense is that the client, who has experienced a great deal of upheaval in their circumstances, could perhaps do with more help at the moment with their living situation before engaging in therapy. However, their particular crisis situation has possibly had an impact on the care coordinator, who may have got caught up in the client’s anxiety. I validate the feelings and share them, and we think together about what might be the next steps for this client. My sense is that the care coordinator also feels emotionally supported by having been listened to.

Midday. The next session is a joint assessment session with our trainee. The client experiences distressing voices, has a background of neglect in childhood and experienced drug-induced psychosis as a teenager. He recently attended an Understanding Distressing Experiences group and now feels ready to take things further with one-to-one work. I leave a large part of the assessment to the trainee, as she needs to get more experience with assessments but make notes for us to share afterwards, including which books and papers she might want to draw on for her formulation.

Following this session I have a lunch break scheduled. This usually means I have a soup or a sandwich at my desk while I reply to emails, write notes and book new appointments. I share an office with a senior clinical psychologist with whom I get on really well. We talk about the waiting list and who will next have a free slot. Clients tend to be referred to psychology by their care coordinators and psychiatrists. We ask them to discuss the referrals with us first and then ask the client to complete a two-page form so we get a sense of what this is about for them and how engaged they might be. We read a couple of such forms, getting a picture of the clients’ presentations and talk about whether they could be seen by a trainee or assistant, as they both have spaces for new clients.

The phone rings, and I receive a call from Children’s Services. I had to report child abuse to them earlier in the week, as a client told me that she had been witnessing child abuse in her family. I always feel a bit anxious when I have to deal with other authorities, but I also know that I am doing the right thing, and I am glad that services are responsive to the alert. I pop next door to let our manager know they are on the case. We talk briefly about another client, who has been calling him to complain about various things. Although the complaining is sometimes part of this client’s coping mechanisms, we still need to take them seriously and respond accordingly. I observe to myself that I can draw on the pluralistic repertoire of counselling psychology here. There is not just one truth: the client has a complaint that can be taken at face value and responded to in a person-centred way but that doesn’t preclude that we can also think about it psychodynamically and possibly explore further in our sessions what motivates the complaining (if the client is ready for this) or behaviourally (if working in a third-wave CBT way) to understand the function of the complaining for the client.

I then need to rush to my next session at 2pm. This is with my individual DBT client, whom I have been seeing for well over six months now. I feel pleased to see that she has not self-harmed this week. I reinforce her and we move down the ‘target hierarchy’ to work on other issues, in this case binge-eating. Together we work out what triggered her recent binge and what function it had for her, in this case self-soothing. We then think of other ways for her to self-soothe, and we jointly agree for her to try out at least two of these strategies as homework.

After the session, I meet with psychology colleagues to prepare the next ACT group session on Friday. We decide who will be doing what and who will buy raisins (as we will be doing the Raisin Exercise for mindfulness). I look forward to Friday, as I have been working towards running an ACT group here for at least two years, and it has finally become a reality. It’s an exhilarating group, and the group members have commented how different it is to other things they have done in the past.

It is 3.30pm. I am seeing my last client for the day, a woman who feels stuck. She does not know whether she wants to ‘get better’ or not. We explore the ambivalence as we have done before without much of a change. She talks about her resistance to therapy. I wonder why she keeps coming, but I don’t ask her, as I get caught up in the stuckness and feel paralysed. I make a mental note that I need to take this to my own supervision.

At 4.30pm I have finished with my client work but not written any notes. This is, unfortunately, typical. I still need to get a couple of letters written before 5pm and get on with these. Then I start writing notes. I don’t really mind staying late, as I can write much better at this time of day and am more efficient without the other distractions. At 6pm I have finished and I look at the list of reports I need to write, and my heart sinks. I decide that I will write reports another day. I pack up, lock up the notes and note that all in all, I feel quite happy. I look fondly at my desk and the books and files around, and I think of how many years of studying and training it took to get into this incredibly privileged position, doing such an immensely challenging, meaningful and rewarding job. Despite the challenges presented by the clients we see and the restricted service environment we are in and the need for us all to do better, I feel it has been a worthwhile journey.