Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 22, 488–501 (2015) Published online 18 July 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1912

Working on the Edge: Stresses and Rewards of Work in a Front-line Mental Health Service† Gillian Elaine Bowden,1,2* Joanna Christina Elizabeth Smith,3 Pamela Anne Parker4 and Matthew James Christian Boxall1 1

Norfolk and Suffolk NHS Foundation Trust, Great Yarmouth and Waveney Locality, Great Yarmouth, Norfolk, UK University of East Anglia, Norwich, Norfolk, UK 3 Norfolk and Suffolk NHS Foundation Trust, Norfolk Central Locality, Norwich, Norfolk, UK 4 Cambridgeshire Children’s Social Care, Cambridge, Cambridgeshire, UK 2

This study sought to investigate frontline mental health professionals’ perceptions of work stress and the rewards and demands associated with their work. Locally known as ‘linkworkers’, and from a variety of professional backgrounds, these staff worked mainly in general practice settings. Individual interviews were conducted with nine linkworkers, and the interview transcripts were analysed thematically. The main themes identified were the following: demands, coping, individual resilience, ownership and creativity, boundaries, secure base and service philosophy and ethos. Themes, categories and sub categories were presented and discussed with seven of the linkworkers in two focus groups. Focus group transcripts were analysed, and additional themes of recognizing limitations, disillusionment and the dilemma of setting boundaries were identified. These themes overlapped with those previously identified but were associated with service changes over time. The themes of ownership and creativity and service philosophy and ethos are significant, not only in relation to their impact on individual linkworkers but also in terms of their relevance for establishing and maintaining morale, engagement and a reflective culture within a service. The relevance of this work to accessible and newly developing mental health services is considered. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Message: • Supporting and listening to staff and allowing time for informal contact are valued by staff and enable the provision of empathic, compassionate services. • Without space for reflection, staff groups may be vulnerable to the development and effects of unhelpful organizational defences, which reduce the effectiveness, quality and efficiency of caring services and increase perceived workplace stress. • Services which foster staff engagement, ownership and creativity and employ “bottom up” approaches to service development are valued by staff and appear to increase staff morale and capacity to cope adaptively to change. Keywords: Work Stress, Mental Health

INTRODUCTION Work, Mental Health and Well-being The relevant National Institute for Health and Clinical Excellence guidance on promoting mental wellbeing through productive and healthy work conditions states that work has an important role in promoting mental wellbeing and that

*Correspondence to: Gillian Elaine Bowden, Norfolk and Suffolk NHS Foundation Trust, Great Yarmouth and Waveney Locality, Great Yarmouth, Norfolk, UK. E-mail: [email protected] † This research article is dedicated to the late Professor Malcolm Adams who provided research supervision for this study. Without his support and guidance, this work would not have been possible.

Copyright © 2014 John Wiley & Sons, Ltd.

‘It is an important determinant of self-esteem and identity. It can provide a sense of fulfillment and opportunities for social interaction’ (NICE Public Health Guidance 22, Promoting Mental Wellbeing at Work, 2009, p. 6). There is recognition within the guidance that ‘Work can also have negative effects on mental health, particularly in the form of stress. Workrelated stress is defined as “the adverse reaction people have to excessive pressure or other types of demand placed upon them”’ (NICE Public Health Guidance 22, Promoting Mental Wellbeing at Work, 2009, p. 6 citing Health and Safety Executive, 2004) The Foresight Report on Mental Capital and Wellbeing (2008) described mental wellbeing as ‘a dynamic state, in which the individual is able to develop their potential, work

Stresses and Rewards of Work in a Front-line Mental Health Service productively and creatively, build strong and positive relationships with others and contribute to their community’ (Foresight Report, 2008, p. 10). The Foresight report describes mental capital as encompassing cognitive and emotional resources such as emotional intelligence, which determines the individual’s ability to contribute effectively and experience a high personal quality of life. Emotional intelligence is a concept described by Goleman (1998) and is concerned with social skills and resilience. It has been linked with adaptability to change, particularly in recent organizational psychology literature (e.g., Cherniss, 2001; Kahn, 2005). Government policy in relation to mental health and wellbeing at work is clearly linked to economic concerns. The total economic cost to employers in the UK of mental health difficulties at work is currently estimated to be £26 billion per annum (Sainsbury Centre for Mental Health, 2007). Evidence cited in the Black report (2008) indicates that around 40% of claims for incapacity benefits are in relation to mental health and stress at work (Shiels & Gabbay, 2006). An influential report that directed government policy and funding initiatives is often referred to as the Layard Report (2006). The London School of Economics Mental Health Policy Group produced the report, which detailed not only economic but also social and humanitarian arguments for investing in psychological therapies for people with mild to moderate mental health difficulties including anxiety and depression. The arguments and growing evidence for attention to work and mental health appear compelling, and Layard and colleagues secured the largest investment ever made in psychological therapies in the National Health Service (NHS) for the Improving Access to Psychological Therapies (IAPT) initiative. Alongside this development, and of particular relevance to this study, the Foresight report argues for individual and corporate responsibility for change in this area. It states that ‘companies have a strong incentive to adopt working practices that look after the mental health and wellbeing of their employees’ (Foresight Report, 2008, p. 34).

Work Stress Models Various models of work stress and coping have been postulated. Lazarus and Folkman’s (1984) model of stress, appraisal and coping has been developed and refined in this area of application. Typical stressors and potential mediating factors have been identified by a range of commentators. Cox (1993) reviewed physical and psychological stressors and developed a hazard-based taxonomy centred on aspects of job content and job context. These ideas, alongside approaches to managing risk and including themes of support and positive relationships at work, formed the basis for subsequent Health and Safety Executive (HSE) guidance for employers on stress at work (HSE, 2001). Copyright © 2014 John Wiley & Sons, Ltd.

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A comprehensive review (Rick et al., 2002) was commissioned by the HSE to examine the scientific evidence to support the generation of the HSE’s management standards. Rick and colleagues concluded that given the importance of context, and the relative lack of evidence that currently applies across all contexts, any standards that are developed also need to encourage a bottom-up approach to understanding how stressors cause problems in each particular organization or part of an organization, and what can be carried out locally to address these issues (Rick et al., 2002). Consistent with this, other recent HSE-funded work on organizational interventions describes both process-based approaches (Cox, Randall, & Griffiths, 2002) and standards-based approaches (Briner, Amati, & Lardner, 2003) for achieving a bottom-up approach to ameliorating stressors. The key feature of both of these studies is that they emphasize the criticality of employee involvement throughout the process. A review of current theory on the associations between work features and psychosocial (ill) health concluded that despite a plethora of evidence, much of it was of poor quality and did not allow for conclusions to be drawn about which psychological features of work were most harmful to mental health (Briner, Harris, & Daniels, 2004). Briner and colleagues pointed out the limitations of traditional stress, mediating factors and coping models and reminded us that in the original version of Lazarus and Folkman’s (1984) transactional theory of stress and coping, the authors stated: Transaction implies a newly created level of abstraction in which the separate person and environment elements are joined together to form a new relational meaning. (Lazarus & Folkman, 1984, p. 294, cited in Briner et al., 2004). Briner and colleagues argue for a fundamental revision of theory with regard to work stress and coping and suggest that far more emphasis is needed upon the complex interplay between the individual and their job whereby individuals have different ways of making sense of their situation. The authors suggest that people actively craft and shape their work environment and roles. Traditional stress and coping model informed research studies cannot adequately account for the complex transactions that may apply between individuals, groups of staff and organizational cultures, and it is difficult for widely applicable specific conclusions to be drawn.

Theories About the Emotional Processes and Impact of Caring as Work Just as work can be beneficial to mental health as well as a source of difficulties (Black, 2008), caring can be a source Clin. Psychol. Psychother. 22, 488–501 (2015)

490 of satisfaction and an intense pressure (see, e.g., Kahn, 1992). Taken together, when caring is a main part of one’s work, there is a rich and complex interplay of pressures and rewards. Consistent with the general literature on work and mental health, work stress in the caring services has typically been considered in terms of stressors, mediating factors and stress outcomes (e.g., Cherniss, 1980; Hood, 1985; Carson & Kuipers, 1998; Maslach, 1982). Menzies (1959), in her influential and classic report on a study of a nursing service of a general hospital, offered some helpful and challenging insights. Menzies undertook the research in a general teaching hospital in London, using a psychoanalytic approach. Menzies described how the very nature of a nurse’s work arouses strong and mixed feelings, including pity, compassion and love; guilt and anxiety; hatred and resentment of the patient who arouses these strong feelings; and envy of the care given to the patient. Thus, by the very nature of his or her work, the nurse is at risk of being flooded by intense and unmanageable anxiety. Building upon the work of Jaques (1955) who developed the notion of social defences, Menzies described how, in order to contain and modify anxiety, various defensive techniques were adopted by the nursing service. These included avoiding extended contact between nurses and individual patients, denial of feelings and depersonalization and avoidance of decision-taking. Although these techniques may help individual nurses to carry out their tasks without becoming overwhelmed emotionally, some of them may ultimately be unhelpful and prevent the institution’s primary task, namely delivering care to patients, from being delivered efficiently. Kahn (2005) considered issues relating to stress, burnout, teams in disarray and conflicts whilst working as an action researcher in the USA. Using formulations developed from this work and quoting anonymized case studies, Kahn describes how caregivers provide ‘holding environments’ (see, e.g., Bion (1963, 1967), Kohut (1977), and Winnicott (1960) for the theoretical background for this) by three types of behaviour: containment, empathic acknowledgement and an enabling perspective. They roughly map onto the tasks of caring Kahn identified as absorption, digestion and provision. These three aspects of the relationships between care-givers and care-seekers enable care-seekers to gain relief from their presenting difficulties. All these tasks of caring create potential strain for carers. Kahn discusses the ‘strain of absorption’ and how skilled caregivers learn to develop filters or boundaries ‘permeable enough to establish a necessary relationship with distressed others, yet impermeable enough to hold onto the real distinctions between themselves and others. This allows caregivers a form of “detached concern”; they identify with those seeking their care, but not so much that they lose sight of their role’ (Kahn, 2005, p. 25). This is a difficult balancing act, and maintaining the balance is, in itself, a potential source of stress. Copyright © 2014 John Wiley & Sons, Ltd.

G. E. Bowden et al. Interestingly, parallels can be drawn between Kahn’s concepts and ideas within frameworks proposed in other areas of caring such as parenting. ‘The Solihull Approach’ (Douglas & Brennan, 2004) advocates the three dimensions of containment, reciprocity and behaviour management for families with infants and young children. Containment and reciprocity are seen as essentially underpinning attachment. Containment describes the process of processing anxiety and emotions so that the ability to think is restored. Reciprocity focuses attention on the attunement between the parent and child and refers to genuine listening and responding and a ‘connectedness’. Health visitors trained in and using the Solihull Approach have reported changes in practice, feeling more positive about their jobs, an impact upon referral processes and an improvement in partnership work with other professionals (Whitehead & Douglas, 2005). More recently, approaches such as Adolescent Mentalization Based Integrative Therapy (AMBIT; Bevington et al., 2013) have been developed, which advocate a mentalization-based stance to working with hard to reach young people. Mentalization has been defined as an individual’s ability to understand or reflect on the context of, or the causes of, self and others’ thoughts and feelings (Fonagy et al., 1991). The authors describe AMBIT as a framework for keeping therapeutic work on track when the experience of the work is chaotic and destabilizing. Strong emphasis is placed on the use of peer and live supervision, in the context of a ‘Team around the Worker’ approach. AMBIT approaches recognize the impact of factors such as counter transference on the workers ability to maintain a mentalizing stance and therefore advocates a teambased approach to enable workers to successfully meet the demands of their role and avoid adopting a nonmentalizing stance in relation to young people in their care. Returning to caring more generally and developing these ideas further, it is also relevant to note that the care-givers themselves are also likely to have relevant personal experiences and feelings, which may complicate the relationship with a care-seeker. Roberts (1994) has considered this in some detail. Roberts states that workers may ‘unconsciously hope to confirm that they have sufficient internal goodness to repair damage in others’ (Roberts, 1994, p. 116) so as not to experience the anxiety, guilt, grief or other emotions lodged within them from earlier experiences. Robert’s ideas are theoretical, and it is difficult to provide supportive verification from data. However, from a cognitive perspective, there is some evidence that could be seen to support this view. Bamber and Price (2006) proposed a schema focused model of occupational stress, which emphasizes ‘early maladaptive schemas (EMS)’. This model hypothesized that people with ‘EMS (unconsciously) gravitate towards occupations with similar dynamics and structures to the toxic early environments and relationships that created them’ (Bamber & McMahon, 2008, p. 96). Clin. Psychol. Psychother. 22, 488–501 (2015)

Stresses and Rewards of Work in a Front-line Mental Health Service

Burnout The term ‘burnout’ has often been used to describe responses to stress in work with people (e.g., Maslach & Pines, 1977). The concept of burnout was first expressed by Freudenberger (1974). Freudenberger’s description depicted idealistic young men and women who, initially fired with enthusiasm to meet idealistic aims, worked hard to try to achieve the impossible, reaping few rewards for their efforts and ultimately at the expense of their own health. Research applications of the term burnout have typically considered three aspects of the ‘burnout’ response to stress: (a) emotional exhaustion; (b) depersonalisation related to the work environment; and (c) a sense of diminishing personal accomplishment. In a longitudinal study, Cherniss (1980) interviewed 26 public human services professionals from four occupational groups in the USA. Each participant was interviewed at least twice and up to four times with an average of 5 months elapsing between interviews. The participants were initially newly qualified and new to their workplaces. Cherniss used thematic analysis and serial hypothesis testing (Rapaport, Gill, & Schafer, 1968) to identify patterns or themes in the interview data. As recommended by Briner et al. (2004) above, Cherniss assumed and allowed for developing patterns of transactions between people and the social systems of their work. As a result of this process, Cherniss identified ‘sources of strain’ for these new professionals including the following: (a) mistrust; (b) organizational conflict; (c) rigid role structure; (d) isolating work practices; and (e) entrenched patterns of uncommunicative social interaction that link directly to communication behaviours in the workplace. These factors led Cherniss to state that it is a ‘sense of helplessness in the face of failure that is the major contributor to burnout’ (Cherniss, 1980, p. 78). Cherniss (1995) followed up the original sample 10 years later. Cherniss was particularly interested in establishing what happens to a professional’s commitment in work and concern for service recipients over time. The interviews were analysed qualitatively using the grounded theory approach, initially developed by Glaser and Strauss (1967) and subsequently refined and elaborated by Miles and Huberman (1984). Three distinct outcomes for interviewees were identified. Some people had made radical career changes and no longer worked in human services. Others had, to some extent, recovered from burnout but ‘never completely regained the kind of idealism, caring and commitment they had when they began their careers. Once burned, they were cautious about investing too much of themselves in either their careers or their clients’ (Cherniss, 1995, p. 12). A third group, however, ‘managed to sustain -or regain- the idealism that they had as novices. They continued to work in public service, helping the needy, advocating for social change…They hadn’t just survived, they prevailed’ (Cherniss, 1995, p. 13). Copyright © 2014 John Wiley & Sons, Ltd.

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Although these insights provide useful theoretical frameworks to help us think about work stress and caring, they also confirm the great complexity of meaningful study and analysis in this area. Difficulties at work may stem from a multiplicity of causes. As a consequence, rather than look for a single theoretical framework to explain how all psychosocial features of work impact on all types of outcomes, it may be more helpful to consider the individual’s view of their situation and factors, which they find stressful and/ or rewarding as well as the characteristics of the workplace. In addition, it may be beneficial to consider the protective factors that are relevant for people and how these can be facilitated within organizational structures.

Change in Organizations Change is constant. Cherniss, when describing the ‘Emotionally Intelligent Workplace’ (Cherniss, 2001) commented that, when he asks employees and their bosses to identify the greatest challenges their organizations face, ‘the need (of people) to cope with massive, rapid change’ is the main challenge (Cherniss, 2001, p 5). The NHS has and is continuing to undergo massive, rapid change. One of the most significant changes is that, as described above, healthcare staff are asked to do more with the same or fewer resources. An inspirational service at the vascular surgery unit in Birmingham, led by Simon Dodds, won an award for innovation in terms of making better services for patients, which staff felt proud of and which cost less money. Dodds (2006) described this as a ‘three wins’ approach. Although describing what they did as ‘common sense’, Dodds has since reviewed literature on innovation and how change happens in large organizations and commented that the common threads of ingredients for success are the following: 1. A shared passion that constantly drives the search for a solution. 2. An insatiable curiosity and no fear of considering new ideas. 3. The collective skills and experience of a cohesive team that allow us to leap hurdles, to learn from setbacks and to deliver solutions. Dodds (2007) subsequently termed the approach his service used as ‘value stream improvement’, which has been adapted from general commercial industry to healthcare. Models from industry are now becoming influential in healthcare. However, as Dodds is aware and as his views on the common threads for successful change indicate, these processes can sound mechanical and, in human services, engagement with service users and staff is crucial. Alimo-Metcalfe et al. (2007) completed a 3-year longitudinal study of leadership dimensions, assessed by Clin. Psychol. Psychother. 22, 488–501 (2015)

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492 questionnaires, within 46 mental health teams. They found an engaging leadership style within teams increased employee motivation, job satisfaction, commitment and productivity whilst reducing job related stress.

Policy Context To return to recent government policy in relation to healthcare, aside from the recent focus on health, wellbeing and work stress, there is another strand of policy related to more accessible, front-line services which is relevant to this research. New Horizons: A Shared Vision for Mental Health (Department of Health, 2009) replaced the National Service Framework for Mental Health (Department of Health, 1999) that has driven mental health service developments for the past 10 years. New Horizons has now been superseded by the coalition government’s mental health strategy No Health without Mental Health (Department of Health, 2011). The new focus on both recent strategies is on wellbeing and preventative and early intervention for mental health difficulties. This focus places more emphasis upon accessible primary care and community services. To genuinely engage with communities whilst intervening early with large numbers of people is challenging, and mental health services have typically found this difficult to achieve.

Research Aims It was the intention of this research to co-construct findings with linkworkers, within the context of the service of which they were a part. No particular model of interaction or isolated stressors was predicted, but rather, complexities and transactional processes were expected. The research aims were broadly subdivided into the following: (i) To investigate how stress was understood amongst linkworkers. (ii) To consider which aspects of the linkworkers’ role were perceived by them to be stressful (iii) To consider which aspects of the linkworkers’ role were perceived by them to be rewarding and/or protective against the negative aspects of stress (iv) To develop an appreciation of relevant social and contextual issues. (v) To consider relevant team or organizational issues. (vi) To use these findings to inform service developments.

METHOD Information from participants in the study was gathered from two main methods: individual interviews and focus groups.

Individual Interviews Local Context The research was conducted within an NHS mental health trust, which obtained foundation trust status during the course of the research. Most of the services within the Trust were provided on a locality basis. The service within which the research was conducted spanned two localities with a population of approximately 220 000 and 32 general practice surgeries. The service was known locally as the Linkworker Service and was adapted from the Gateway worker national policy initiative (Department of Health, 2002). It was a relatively new service with a new role in mental health services, with the first staff in post in Spring 2003. They were ‘front line’ staff in that they were usually the first point of contact for people with mental health difficulties. They also worked at the interface between primary care and secondary mental health services providing mental health assessments and brief interventions for individuals and sign-posting to other services when indicated. Linkworkers also offered specialist guidance to primary care staff on how to manage mental health difficulties in primary care. They were frequently the only mental health professional in a primary care setting.

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Individual face to face interviews were undertaken with nine linkworkers who opted to participate out of the team of 10. All participants were offered a choice of interviewer from researchers involved or with an external interviewer unconnected with the service. All interviewers had a background in clinical psychology (either qualified or in training) and experience in qualitative research methodologies. Previous research on work stress and coping guided the initial structuring of open interview questions aimed at enabling the interviewee (and interviewer) to explore a range of possibilities. Question topics included: • Description of role. • Likes and dislikes in relation to work. • Perception of inevitable pressures at work and what could be changed. • Ways of coping. • Strengths and weaknesses of the service. • What would they like to change about the service. As data were collected, the questions were reflected upon within research team meetings in order to see if refinement or new areas of questioning were indicated. It was assumed that meanings would be constructed during Clin. Psychol. Psychother. 22, 488–501 (2015)

Stresses and Rewards of Work in a Front-line Mental Health Service the interview process. Particular attention was therefore paid to ‘negative cases’, where unexpected or novel views or representations were expressed. All interviews were audio recorded. The interviews were scheduled to run for up to an hour but, on one occasion, overran. As soon as possible after the interviews, the audio recordings were transcribed by the interviewer or another researcher and researcher ‘post-scripts’ were made following interviews three to nine inclusive. The main researcher and two of the other researchers analysed the transcripts.

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epistemological basis assumed that findings are created via the interaction between the participant, the data, the researcher and the evaluator. As such, the findings reported here are dependent upon the value systems of each party and the context within which they operate Main themes, categories and subcategories are presented below in Figure 1.

Individual Interviews Demands

Focus Groups It was intended that this research would be collaborative within our service and would form part of a reflective process. For this reason, two focus groups were arranged to provide an opportunity for the members of the Linkworker Service to discuss their experience of the research and other team or organizational issues which may be relevant. Both focus groups were facilitated by the two trainee clinical psychologists, and themes from the individual interviews were presented. The group was scheduled to run for up to 90 min. The discussions were audio recorded and transcribed. The focus groups also gave an opportunity for the researchers to check with participants the validity of the meanings and understandings that were being constructed. In addition, it contributed to ‘triangulation’ of method. Triangulation within this context refers to the process of investigating a phenomenon using a range of methods or perspectives in order to enhance the comprehensiveness and trustworthiness of the findings. The data from individual interviews and focus groups were analysed using methods derived from grounded theory. The information was categorized and organized into higher level categories, potential linkages between categories were made explicit and comparisons were made to explore complexities. In this way, emergent theory was grounded in the data obtained. Reflexivity was emphasized throughout the research process to enhance rigour. Reflexivity is an attitude of attending systematically to the context of knowledge construction, especially to the effect of the researcher(s), at every step of the research process. Reflective information was gathered in the form of initial assumptions, reflexive journals, ‘post scripts’ and research team communication.

FINDINGS It is impossible to do justice to the complexity and richness of the information gathered from the interviews and focus groups. However, we have endeavoured to summarize the categories and sub-categories of information that we consider have particular salience or significance. Our Copyright © 2014 John Wiley & Sons, Ltd.

Demands were sub-grouped into those which had more general service relevance and those which were felt to have a more individual impact. Many comments coded in categories assigned to individual demands concerned the pressure experienced when a service user was in crisis, and it was difficult to gain access to other services or when there was no other service. The linkworker was confronted with the emotional pain of another individual, which they felt unable to ameliorate whilst feeling a sense of responsibility to do something to help. An example of service demands is captured by the following quote: Doing this job we saw the referral rate obviously rise very very quickly and we thought ok maybe these were a group of people who, had unmet needs because the service hasn’t been there and we thought it would peak and then drop off a bit, but it didn’t it was just a plateau, and its plateaued for 3 years now, since I’ve been in post and trying to manage more and more referrals come in. Individual demands were typified by statements such as There is no space during the day you know, I mean I think there was a day a few weeks ago and somebody who I had seen previously, a family member, had made contact expressing concerns and we managed to kind of keep things safe for overnight but I knew in anticipation the following day that that I was likely to get another phone call so I had 7 people booked in for assessments that day and then the crisis came in too. Comments were made with regard to responsibility and the pressure of feeling solely responsible for the provision of care to individuals: I think that’s hard, sometimes you think oh god have I made the right decision, particularly sometimes when you’re positive risk taking when you’re thinking gosh if this goes horribly wrong then it’s on my shoulders.

Coping Various coping strategies were referred to by all the linkworkers interviewed. They included maintaining a Clin. Psychol. Psychother. 22, 488–501 (2015)

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Figure 1.

Themes, categories and subcategories of factors relevant to work stress and coping for linkworkers

work-life balance, taking time out, offloading to colleagues, using humour and applying mental health strategies to themselves, including problem solving and cognitive strategies such as reframing. The following quote was coded as an example of coping in relation to offloading with colleagues in the team. I’m allowed to actually meet up on a Monday and go [offloading gesture] with all my colleagues and have a moan and then a laugh. It sort of sets you up for the week really, yeah that’s a real strength of the team I think which is probably one of the things that will be eroded gradually which is what I dread. Copyright © 2014 John Wiley & Sons, Ltd.

Individual Resilience The theme of individual resilience incorporated comments related to categories defined as autonomy, feeling valued, learning from it, responsibility, personal and professional development, beliefs about stress and making a difference. Comments could imply resilience, the importance of it or the lack of it. Again it’s a developmental thing isn’t it. Knowing, ok, that’s started again, you know you need to stop, you need to look after yourself and be kind to yourself.

Ownership and Creativity This theme captured pride about what has been accomplished both individually and as part of a team and was Clin. Psychol. Psychother. 22, 488–501 (2015)

Stresses and Rewards of Work in a Front-line Mental Health Service strongly linked to staff belief in the service model and the role they played in shaping service delivery. Maybe I was very fortunate about coming in at the beginning but on a personal level there’s some ownership as well, there’s some ownership of the service we’re very proud of it, we’ve worked very hard, amazingly hard and we’ve worked within our team, whatever we’ve achieved we’ve achieved within our team. Contrastingly, there were some comments which suggested concerns over changes and how interviewees might have little control or influence over these. I guess coping first of all is also about making sure that the team are actually managing because there have been some incredibly difficult times with huge uncertainty and that like goes down to the future of the actual service itself and you know to split us into too small a team (…) so I guess I can cope better if I feel the team are managing.

Boundaries The theme of boundaries was particularly significant to stress and coping for linkworkers and could be viewed at different levels and in different ways. Comments coded relevant to crossing boundaries were in relation to how the service provided by linkworkers could cross agencies. It had links to access, creativity and initiative, and autonomy. The benefit of the job is that I’m now in the surgery and I can now provide some of that information to some of those people. For me that’s like wow that’s fantastic (…) some of the work GPs will come up with, “have you got any ideas about?” rather than actually refer people so for me the strength of the service is actually being visible, being there and the people who actually do the job are there able to give people quick access to, maybe sometimes quite basic information that they didn’t know exists. On occasions I guess sort of there are days whereby you feel a little bit blitzed because again, I guess, being the lone practitioner, and being in a GP surgery you are very accessible. People know where you are and they will find you, which is very good but it can also work the other way (…) and of course you have to try to balance all that out. Creating limits to manage high demand was captured by the theme ‘boundaries to make it manageable’ and exemplified by the following quote. You regulate yourself and I say sometimes I’m not answering the phone, I’ll take a message (…) I just need some time and you can’t really control if five people want to speak to you. Copyright © 2014 John Wiley & Sons, Ltd.

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Secure Base The theme of secure base covered a range of factors related to linkworkers reporting that they had a safe base or team, which supported them to do their job or, alternatively, feeling isolated or that their security was under threat. I really feel so valued and I feel that sort of nurtured feeling that you get when you feel that people actually understand and listen and I often feel that the job that I do outside is reflected by what I feel when I get supervision, that sort of supervision and that attentiveness that people give me that I can then give to other people, for me that 110% yeah, [I] don’t recommend that anyone do this job without supervision it’s so valuable (…).

Service Philosophy and Ethos Service philosophy and ethos was considered at various levels. There was a general tendency for linkworkers to report positive views in relation to their own team and service but less positively in relation to the broader (i.e., Trust) service. The consistency or inconsistency of service priorities with individual linkworkers own beliefs about mental health was also often referred to. It fits very much with the philosophy and the way we practice. Is recognising that you can’t isolate out aspects of a person, you know physical health, mental health, spiritual well-being, that you know, you look at that person as a whole. I mean because if somebody sees a psychiatrist and the first time they will take a mental health history, there will be a mental state examination and but it seems to be primarily focused on reducing the symptoms yes whereas I think where I see my job is primarily looking at the whole person and in trying to enable them to function better.

Focus Groups The focus groups occurred several months after the individual interviews, and some major service changes had occurred in the intervening period. Additional clinical work had to be carried out from existing resources, meaning more work for fewer staff whilst additional administrative tasks had also been introduced. Unsurprisingly, the focus groups were characterized by anger and many more comments indicative of demands exceeding resources. The linkworkers communicated that things had changed since the individual interviews, and there was now less time preserved for the more protective elements of their job. Most of the comments could be coded within our pre-existing coding structure. However, we felt Clin. Psychol. Psychother. 22, 488–501 (2015)

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496 that three other categories of comments were being articulated. We termed these recognizing limitations, the dilemma of setting boundaries and disillusionment. Recognizing limitations and the dilemma of setting boundaries could be seen as further sub-categories of the boundaries theme, and disillusionment seemed to be a category within the individual resilience theme. The relationship of these new categories to the previously identified themes is illustrated in Figure 2.

usually seen as an individual responsibility although there were some references to suggestions that the service create boundaries such as referral criteria. Within the focus groups, there was an apparent resignation to the fact that there were limits to what the service could provide and that sometimes linkworkers had to say ‘no’. I think recognizing your limitations is one because that’s quite difficult you know it’s really quite hard to say to someone there’s absolutely nothing I can offer you.

Recognizing Limitations

Dilemma of Setting Boundaries

In individual interviews, recognizing limitations was coded as ‘boundaries to make it manageable’. This was

References to this were made during the individual interviews too but were often quickly followed with comments

Figure 2. Themes, categories and subcategories of factors relevant to work stress and coping for linkworkers with additional categories from focus groups data

Copyright © 2014 John Wiley & Sons, Ltd.

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Stresses and Rewards of Work in a Front-line Mental Health Service about other services becoming more available and the advantages of having a flexible role. In the focus groups, there seemed to be an increasing acknowledgement that boundary setting was necessary for the Linkworker Service itself, but there was also a real difficulty in accepting this and letting go of a notion that the service could be available to everyone who might need it. Whether it’s a case of being a bit stricter with our boundaries. Which I think we are going to have to, I mean I think the boundaries to make it manageable is going to have to happen but that’s a shame because then I think that’s going to lose the ethos of what we do which is to see, I see it as seeing anyone with distress.

Disillusionment Disillusionment seemed an extremely important aspect of what was being communicated in the focus groups. On coding it, we were reminded of what is often termed ‘burnout’ (Freudenberger, 1974) or even learned helplessness (Seligman, 1975), which in a caring professional context has been termed ‘professional depression’ (Oswin, 1978). I was thinking back to when I was a student a student nurse and I would observe kind of experienced members of staff and that some were kind of great but others were incredibly apathetic and just didn’t seem to really give a shit about anything and thinking at that time, I’m never going to be like that (…) I can see now how that happens, I could see now how you could be like that because you just think ‘what’s the bloody point, nothing I do or say makes a difference’.

DISCUSSION The main findings relate to how ‘stress’ was understood by linkworkers and which job factors linkworkers found rewarding or supportive and those they found stressful. We shall consider how these findings relate to relevant theoretical models. Additional and unexpected findings which relate to how the service developed over time will also be summarized and considered.

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interviewed. These included feelings related to control and responsibility for care, demands and managing boundaries and ownership and creativity in relation to a developing service. Linkworkers were in the front line for demand for mental health services and were confronted daily with potentially infinite demand and finite resources. Linkworkers utilized a range of ways of coping. These were identified within the theme of ‘coping’ and were subdivided into individual and team strategies, although there was frequently overlap. Interestingly, there were also comments linked to service gaps and unmet need, which were sometimes made noticeably in relation to demands but at other times were expressed in terms of frustrations with other services and ‘negotiating’. Ownership of the development of their role, considered within the theme of ‘ownership and creativity’, was particularly relevant for linkworkers who were involved in developing a new service with a ‘shared vision’. These themes are captured in Dodds’s (2006) ‘three wins’ approach to organizational success including a shared passion, considering new ideas and a cohesive team to deliver solutions to problems. This bottom-up approach to service development is an example of staff engagement, which Alimo-Metcalfe et al. (2007) found increased employee motivation, job satisfaction, commitment and productivity whilst reducing job related stress. Over time, this changed, and additional administrative tasks were imposed into the linkworker role, which weakened the shared vision and feelings of co-production and ownership and for some led to ‘disillusionment’. Following the theoretical framework used to inform this research, it is interesting to speculate how much of the processes were about promoting safe and effective practice and how much were about avoiding emotional contact and consequent anxiety, a social defence initially identified by Menzies Lyth (1959, 1988) and more recently applied to 21st century organizations and practices by Krantz (2010), Hoggett (2010) and with regard to the IAPT initiative, Rizq (2011). Although some defences are protective and necessary, rigid social defences actually inhibit task accomplishment. This can lead to disillusionment inhibiting carer’s ability to carry out their primary task of delivering care leading to dissatisfaction and potentially increased turnover (Krantz, 2010).

How Stress was Understood

Discussion of Results in Relation to Theoretical Models of Stress and Coping

Earlier research (e.g., Kinman & Jones, 2005; Briner et al., 2004) indicated that representations of occupational stress are multi-faceted and linked to a diverse range of personal, environmental and societal factors. Findings from analyses of transcripts of interviews with the linkworkers in this research were consistent with this view. However, there were clearly stress related factors specific to the caring role, which had particular salience for the linkworkers

In general, the results from this research were consistent with models of work stress and coping that suggest a complex interplay between individuals and their work (e.g., Briner et al., 2004) whereby linkworkers actively craft their roles, finding many aspects positive, whilst in excess, they could become sources of stress. It is possible to map many of the themes arising from the coding of the interviews on to the notions of containment,

Copyright © 2014 John Wiley & Sons, Ltd.

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498 empathy and enabling developed by Kahn (2001, 2005) during his studies of caregiving organizations. The theme of ‘demands’ identified in the transcripts illustrates the strain that the linkworkers feel in relation to being aware of and receptive to hearing about another’s distress together with the responsibility of trying to help alleviate suffering. The overarching theme of ‘secure base’ can be seen as a precursor enabling containment, which is considered important in both Kahn’s model and the Solihull approach (Douglas & Brennan, 2004). Containment would also be consistent with maintaining a mentalizing reflective stance as described in AMBIT models of practice. In all three perspectives, caregivers are viewed to contain careseekers by making themselves accessible, actively listening and receiving their experiences with compassion. This was evidently considered important by the Linkworkers interviewed as was the provision of supervision and a reflective space where they also felt heard and valued. This is relevant for clinical practice in light of the Francis report (2013) that considered care failings at Mid Staffordshire NHS Foundation Trust, where lack of support for staff and disengagement were identified as key problems in the delivery of inadequate care. Conversely, ‘dedication, compassion and effective teamwork contribute to the welfare of patients and should be valued. Pride in achievement needs to be fostered’ (Francis, 2013). Undoubtedly, the role of an organization entrusted with providing care should be, in part, about enabling carers to feel supported and empowered in this role so that they can cope with demand and tolerate a level of empathy. This is consistent with the Health and Safety Executive stress management standards for mitigating work stress (HSE, 2001). The themes of ‘individual resilience’ and ‘boundaries’ identified in this research can be linked to empathy, reciprocity or ‘connectedness’, which also feature in Kahn’s model with comparable concepts in the Solihull approach and mentalization in the AMBIT model. Empathy requires the capacity to explore and tolerate the emotional pain of another. In order to sustain this, it is necessary for the caregiver to reflect on what is happening and make sense of it. Within the interview transcripts, there were numerous references to individual and organizational boundaries and sometimes with explicit references to the requirement for ‘boundaries to make it manageable’. Another issue related to boundaries was in relation to the number of people presenting to the service. An important part of the service ‘ethos’, as it was described, was that it aimed to help people in emotional distress rather than using traditional ‘secondary care’ methods of treating people with psychiatric diagnoses who were eligible to receive services. Diagnostic systems in psychiatry have always been criticized for their poor reliability, validity, utility, epistemology and humanity (see, e.g., Boyle (1999), Bentall (2004)) and the British Psychological Copyright © 2014 John Wiley & Sons, Ltd.

G. E. Bowden et al. Society Division of Clinical Psychology’s statement on diagnosis (BPS, 2013), which calls for a paradigm shift in relation to our understanding of mental health issues. One of the issues encountered by the Linkworker Service was the lack of explicit and traditional boundaries for access developed for their new way of working and the linkworkers’ concern that they and their service would be overwhelmed. Nevertheless, there was an apparent pride in their alternative service vision and a belief that the service ethos was consistent with their personal values.

Development of Service and Stress Over Time Additional findings which were not predicted and did not form part of the original research questions were related to how the service developed and changed over a period. New categories emerged from the focus groups, which we termed ‘recognizing limitations’, ‘disillusionment’ and ‘dilemma of setting boundaries’. These comments were reminiscent of ‘professional depression’ (Oswin, 1978), the emotional exhaustion and lack of personal accomplishment aspects of burnout (Maslach, 1982) and also of the follow up work of Cherniss (1995). The similarity with Cherniss’ work appeared to be about the loss of idealism and different strategies for coping with this. The data coded within ‘ownership and creativity’ suggested personal investment in the service vision and philosophy. If, as suggested above, there are powerful unconscious motivations for carers related to their own wishes to provide ‘ideal’ care, disillusionment could be profoundly depressing. A possible limitation of this study is that, alongside rapid change within the NHS, the social defences constructed within organizations (Jaques, 1955) also change rapidly so that, even if reflection upon some of these defences were possible, other changes are imposed, which can replace their effect. It is therefore very difficult to develop a helpful understanding of which institutional defences may be contributing to stress and reducing the effectiveness and efficiency of caring services at any given time. It is interesting to speculate about which individual and social processes may contribute to this way of working that has the impact of defensive distancing and could have the same effect as the ‘depersonalisation’ component of burnout (Maslach & Jackson, 1981). Southall (2009) suggested that the clinical/managerial split in NHS services contributes to high levels of stress amongst clinicians but cognitive dissonance fosters maladaptive coping strategies (such as working harder). In turn, this makes shared ownership of problems and constructive dialogues less likely, threatening the ownership and creativity of the team. Clin. Psychol. Psychother. 22, 488–501 (2015)

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IMPLICATIONS Front-line, Accessible Services Recent national policy (e.g., Department of Health, 2009) emphasizes early intervention, health promotion and the need for services to become more primary care focused and accessible. The IAPT initiative is an example of this important shift in emphasis. There is a dilemma for staff in that some of the systems required to evidence improved access appear to mitigate against ownership, creativity and responsive contact with service users. The danger with this situation is that new services are given unachievable aims and staff and service users end up feeling disappointed and demoralized when they fail. Genuine access is about the capacity of workers to be empathic and compassionate within services that enable and support this.

A Service ‘On the Edge’ Working in a new service area, without established systems and processes was challenging in many ways. It also promoted learning. Kagan (2007), in relation to community collaboration, has argued that ‘working on the edge’ in this way broadens perspectives and generates new and richer solutions. We consider that, although this service initiative still had a long way to go in terms of harnessing the potential of many community resources, this was the principle intention. Stokols (2006) refers to ‘transdisciplinary working’, which describes practitioners working together to develop a shared conceptual framework. The implication of this is that if we want services to develop new practices rather than simply adhering to old ways of working, then we need to allow time for communication and reflection so we can establish which changes are adaptive and which might be defensive distancing practices.

Service Changes Over Time Initial interviews with the linkworkers were relatively early on in the development of the service. This new development allowed opportunities for creativity and innovation, and many comments indicated that this was experienced positively by linkworkers and allowed a sense of ownership and consistency with their own beliefs. The later focus groups indicated disillusionment. Whatever the causes, in all services, change is constant and one of the characteristics of healthy ‘emotionally intelligent’ organizations is the capacity to cope with change (Goleman, 1998). However, in order to facilitate this, certain processes are required. How organizational change is managed and communicated is an important factor in tackling work-related stress (Health and Safety Executive, Copyright © 2014 John Wiley & Sons, Ltd.

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2001). If staff are not included in service changes, we run the risk of them disengaging from the process of change.

Morale, Quality and Productivity The importance of staff ownership, creativity, consistency with own beliefs, personal pride in the service and feelings of making a difference were evidenced from this research. Consistent with recommendations from the Francis Report (2013), we consider that these qualities contribute to the welfare of people who use services and should be valued. This may well have relevance to those promoting or implementing the social enterprise agenda (Cabinet Office, 2010) whereby public sector organizations are being encouraged to divest services to staff mutuals. However, feelings of ownership of service values and direction appear to be influenced most by interpersonal processes and communications, which are a feature of all organizations. The critical issue seems to be about genuinely sharing power in organizational change processes and co-creating services with all stake-holders (including staff and service users). Pride in the service, ownership and opportunities for creativity are also likely to be linked to productivity. Alimo-Metcalfe et al. (2007) have linked staff engagement with productivity. In fact, data collected separately from this research indicated that this Linkworker Service was integral to positive health care outcomes in terms of significant reductions in referrals of people to secondary services and inpatient admissions (DH, 2006). It appears that Dodds’s (2007) approach, which fosters a shared passion, innovation and a cohesive team may be key ingredients for success. An engaging leadership style as described by Alimo-Metcalfe et al. promotes these qualities.

Maintaining Protective Factors The linkworkers’ prophesies of the erosion of protective factors turned out to be accurate. Informal team contact, which promoted good working relationships and enabled ideas and solutions to be shared reduced over time as work pressures increased. It is doubtful that losing this team time increased efficiency or effectiveness. The containment and opportunities for reflection provided by supervision also seemed less evident. A positive culture of mutual respect and shared vision takes time to develop and can be all too easily lost in responding to changes without time to reflect on their impact. In this research, one of the effects of this loss seemed to be disillusionment.

Suggestions for Further Research As Kahn (2005), Goleman (1998) and other recent organizational psychology literature indicates, resilient Clin. Psychol. Psychother. 22, 488–501 (2015)

500 organizations adapt to change and changing circumstances. Temporary expressions of dissatisfaction and descriptions of stress amongst staff are not necessarily indicative of fundamental problems and may be part of a healthy process of adaptation and important communications about what needs addressing to inform change and preserve staff morale. The design of this study does not allow confident, in depth statements to be made about the complex interaction between personal and organizational factors relevant in adaptation to organizational change. Further research on the process of organizational change and communication could help illuminate which aspects facilitate healthy adaptation within teams and services. In order to generate genuinely new ways of working, we consider that it is most helpful to privilege the views and experiences of staff most involved in delivering the services studied. Enabling the expression of divergent perspectives and paying particular attention to the views of people working ‘on the edge’ of established systems could broaden our understanding and extend our sources of solutions to problems. Valuing these accounts may foster reflective and containing practices, which enable more people to tolerate the difficult and rewarding task of providing compassionate care for others in distress.

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