The Concept of 'Psychological Safety'

5/28/2018 The Concept of 'Psychological Safety'

1/11

Page 1 of 11

The Concept of Psychological Safety: a proposal for aservice 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.


2/11

Page 2 of 11

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.


3/11

Page 3 of 11

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

notbe 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 well-

being. Seager refers to this as the professional family and

describes it as comprising the wholeteam 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.


4/11

Page 4 of 11

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 un-

containing 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.


5/11

Page 5 of 11

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 un-

valued are at greatest risk of successful suicide attempts.

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.

One man, his voice shrieking his distress, left a messageon our answerphone to say that he had tried drinkingbleach to no effect and so now he was going to eat loadsand loads of chocolate. Funny? Momentarily. Tragic canthere be any doubt?

Why he thought chocolate would kill him, none of us couldsay but when it did not, he hanged himself in a public carpark.


6/11

Page 6 of 11

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


7/11

Page 7 of 11

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. But was the DBT itself either necessary or

sufficient? 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:


8/11

Page 8 of 11

Psychological safety is about the total service ethos and

the total experience of the service user.

Psychological safety is less about containment in

buildings and institutions than containment in

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.


9/11

Page 9 of 11

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 pre-

clinical 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


10/11

Page 10 of 11

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

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

The man who committed suicide by hanging hadbeen an inpatient for some months before this,resisting all attempts to discharge him by turningdown the residential options offered. During thistime he rarely complied with treatment, preferring togo fishing during the day and returning to the wardat night.

But how do we understand treatment in thisinstance? To the ward staff it was being available to

talk, to join groups, or to engage in occupationaltherapy but to him maybe it was just the sense ofsecurity he derived from being surrounded bypeople who would respond to his emergencies andnot let him harm himself.
mailto:[email protected],ukmailto:[email protected],uk


11/11

Page 11 of 11

References

Feldman, S. (2006). What are Patients Looking for? Medscape

General Medicineonline 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. (Original

work published 1957).

Seager, M. (2006). The Concept of Psychological Safety a

psychoanalytically informed contribution towards safe, sound &

supportive mental health services. Psychoanalytic Psychotherapy

20 (4) 266-280.

Acknowledgment

With huge thanks to Martin Seager for inspiring and guiding this

paper.

The Concept of 'Psychological Safety'

Documents

Transcript of The Concept of 'Psychological Safety'