In Meet the Researcher, a series of interviews about inspirational academic research at St George’s, University of London, our people explain their work and its impact on society.

AngelaSweeney

Dr Angela Sweeney is a NIHR postdoctoral research fellow in the Population Health Research Institute. She is interested in the links between trauma and mental health and how the mental health system can retraumatise survivors. She is a passionate advocate for the introduction of trauma-informed mental health services in the UK.

Can you tell us what you are working on at present?

I'm working on my Fellowship which is examining assessment processes for talking therapies and how to improve them. I'm looking at people's experiences of assessments, what the literature says, including through a systematic review; and have just finished a qualitative study looking at our participants' experiences of them. I'm now at the stage of drawing all this together to generate guidelines for how to conduct safe, positive assessments. It's a five year project, due to finish at the end of this year.

What talking therapies are you looking at?

It includes any therapy that is delivered through talk – including CBT, counselling, trauma-specific therapy and IAPT. For the qualitative component we've conducted a dyadic study: usually people would interview some service users and some assessors and then analyse the data separately, but we've interviewed service users and assessors who participated in the same assessments in separate interviews and then looked at the data together. We hoped that conducting the qualitative study in this way would enable us to gain a unique understanding of what it is like for two linked people to go through the experience.

Why did you decide to research this area?

Experiential evidence from survivors suggests that talking therapy assessments can be problematic, but until now this hasn't been subject to much research scrutiny. The majority of people using these sorts of services will have experienced significant trauma of some kind, which informs how they will engage with the services. But the assessment processes often haven't been designed with that in mind. The purpose of the assessment from a service perspective is to assess eligibility and manage demand. This can mean that people involved have to make difficult choices around, for example, how much to reveal of themselves to secure help, or how much to hold back to protect themselves. These assessments are crucial in people getting the help they need.

What have you found so far?

For service users, it's been clear that people are often quite desperate at this stage. Merely getting to this point has often meant being moved from one service to another with a lot of stress or disappointment along the way. The assessment itself then carries the emotional weight of this journey. This one-hour meeting is therefore invested with hope that they might get what they desperately need, but also fear that they will be rejected. The result is either hope; or what feels like the end of the journey.

Assessors, meanwhile, often struggle to balance the procedural demands of the service – assessing eligibility and so on – with the human needs of the person before them. There's an inevitable distance between the parties initially and the most successful encounters were where the assessors helped to close that distance. The assessors' expertise, empathy and compassion were all really important in whether that distance was closed and whether the encounter was successful, in terms of it being positive for both parties.

What else did you find?

The system is clearly under huge pressure and that is having an effect on people. Often services can't see the volume of people wanting to access them. That makes it harder for people to get an assessment, and if they do, strict criteria make it more likely they will be rejected.

The working environment for these assessments, especially in the NHS, is often in completely unacceptable conditions – water running down the wall, for example, or in buildings that would be deemed unfit for habitation by councils. What does that signify to people about how valued they are? People in the service often have experienced significant trauma in life - in childhood for example – and have a fear of authority – so if you think you have to convince the person that you should be seen in this service but it's stacked against you, you will lose hope.

What else are you working on?

I'm a co-investigator on the ‘Violence, Abuse and Mental Health; Opportunities for Change' which was launched last year by UK Research and Innovation. It's one of eight new mental health networks that aim to bring researchers, charities and other organizations together to address important areas of society. I'm working with Professor Louise Howard and Dr Sian Oram from King's College London and others from a wide range of disciplines and backgrounds. Since women are more likely to have suffered the most severe domestic violence and abuse, and it's now largely accepted that that causes mental health issues, what do we do about this? It's early days but it's an exciting project. I'm also about to start work on a new grant investigating iatrogenic harm in mental health social care with survivor research colleagues which I'm also really excited about.

How did you end up getting into this work?

I'm a trauma survivor myself and I've witnessed the harm that is inflicted, often unintentionally, on trauma survivors in multiple ways. The reason I get so excited about trauma-informed approaches is that it is a constructive and positive way of shifting to a better way of doing things, that isn't about criticising or blaming but more about trying to bring everyone along together in a compassionate way. That's why I got into it. There's a lot of anger about the way trauma survivors are treated within the mental health system.

What do you mean by trauma?

Trauma includes sexual abuse, domestic violence, and betrayal traumas, in childhood and adulthood. It might also include severe bullying, experiences of racism, and so on.

Your work must take you into uncomfortable territory?

Yes – particularly when you come up against harm done to the most vulnerable such as children. At times it does become quite overwhelming. But this is one of the reasons that as a society we find it hard to face up to the scale of abuse - because it is individually overwhelming.

If you could change one thing about society and the way it operates what would it be?

It would be for society to accept the level of violence and abuse that is perpetrated against predominantly women and children. The sheer horror of these experiences, and our limited ability to comprehend what humans are capable of, prevents us from accepting the scale of abuse. That not only silences victims, it means that women and children continue to suffer. Acceptance is the essential first step to us taking the level of action that is needed.