Friday, 27 June 2025

You get to choose your hard thing



Chartered Psychologist Dr Jennifer McClay with a personal and professional take on ‘emotionally-based school non-attendance’, or ‘school refusal’.

20 June 2025



My parents wanted me to be okay and to learn, so they did what they were told was right to get me into school. Things like, 'don't let her watch TV or do nice things', don't make home too comfortable', make her get up and sit in her school uniform each morning'. Typing this, I can still feel the skirt digging tight, collar scratching, cuffs scraping, shoes rubbing – locked in a school uniform cage. Terrified, because it put me one step closer to school.

I limped on only as far as my second year of high school and left with no qualifications. But I'm the first person in my family to go to university, earned my PhD at 25, and later qualified as an Educational Psychologist. I think that shows grit: 'perseverance and passion for achieving long-term goals... maintaining effort and interest over time'. As does the fight my own daughter put up to never walk through that school door again. If there's one thing that girl has in abundance, it's grit.

My mum told me recently that a turning point for her had been when she took me into school for a meeting. She said she couldn't believe the physical change in me. That I curled in like a terrified animal, and she could see the genuine and pure terror. Before that, she didn't get it. She didn't realise that I was experiencing such visceral fear.

Education professionals have moved on in how we conceptualise school refusal, redefining it as school phobia, and landing now on emotionally based school non-attendance/avoidance (EBSNA/EBSA). 'It's can't, not won't' is a phrase used to help people understand. But despite our renaming and reframing, I don't feel that day-to-day practice has moved on all that much. On the ground, parents are still often under immense pressure and intervention can remain heavily within child. When resources are tight and there are often few options or accommodations, there is still an assumption that this child should go back to school. And because of that goal, 'school refuser' can still feel closer to the reality.
The retreat from school

It's quite alien to me when people puzzle over EBSNA: as if it's incomprehensible why children might not want to go to school. With the sensory challenges, the social difficulties and anxieties, the exhaustion of managing the demands and interactions and touch, sounds, smells, talk, response, eyes on you and words coming at you not understanding what the other kids mean, why they're laughing, why the teacher seems so annoyed and everything feels wrong but you don't know why… I'm baffled by people who manage places like school with ease, even pleasure.

There's a family I know who do everything, dance, martial arts, scouts, choir, any and all social events, and somehow I only recently had the epiphany that it's because they like these things and find them enjoyable, restorative, and fun, not stressful, overstimulating, and exhausting. How different folks can be. It makes me think of Boyce's The Orchid and the Dandelion, the beautiful neurodiversity as biodiversity model, and how we're not right or wrong, normal or pathologised, just all different as carrots and apple trees.

Thanks to the internet, we're more informed these days about neurodiversity, school trauma, stress, and burnout. But many parents and professionals still report hearing the same advice as my parents did. The pressure on children and their families is enormous. And it still feels like, rather than accept there may be problems with school – the whole entity – a lot of time can be spent questioning what's wrong with the child and family. Questions of cause rarely seem to centre on school, and even if they do it's assumed without question that this child should go back.

When retreat from school is gradual, change rarely comes quickly enough to help. Or is enough. Adaptations aren't given freely. There are many high and costly hoops to jump through. Often we see a pattern where the child struggles, cracks appear, help is asked for, but the problem isn't bad enough yet, it gets worse, things may change but by then it's too late – the child is traumatised and burnt out. Or sometimes the retreat is sudden – or, more accurately, it seems so on the outside, when the mask of okay-ness suddenly crumbles.
'Touch the gate'

In her wonderful book, Your Child Is Not Broken, Heidi Mavir (founder of EOTAS Matters) describes a meeting where the teacher asks her to drive her son to school to touch the school gate, as a kind of exposure therapy. Her son suffered a fairly sudden burnout early in secondary. Heidi knows that touching the gate won't ever help because the problem is what is on the other side of it. 'I knew that,' Mavir writes, 'and I think Susi also knew that, but her painted smile and expectant look didn't give me any room to say no.'

I've been that kid. Been that parent. Had that meeting. Seen that expression. And, like Heidi, I've jumped through that hoop (or a very similar one) because if you don't it's even more your fault. And when Heidi tells her son he can trust her, he replies, 'I can't though can I Mum? When will you stop trying to trick me?'

This kind of exposure therapy can't work. As Naomi Fisher says, you can't desensitise someone's fear reaction with exposure to a stimulus that is actually terrifying. Using exposure to desensitise a kid like me to school is a bit like taking someone frightened of dogs and trying to cure it by gradual and controlled exposure to a XL bully with rabies.

And isn't that part of the issue? We agree it's emotionally based in fear, but some professionals don't see that the fear is justified? For them there is nothing to fear, whereas for some people, there is. It hurts to be there. And maybe, to quote Keiran Rose, who said about his autistic experience, 'you don't have to understand, you just have to believe me'.

Some people link Covid to an increase in EBSNA, and that may well be true. But many of us see that reason differently. It didn't damage us. During Covid we saw a better way – smaller class sizes, remote education, less mixing and moving around, more personal space. Then all that was whipped away from us.

A child who uses a wheelchair can't go up the stairs - can't, not won't. They use the lift. And if there isn't one, we put in a lift. We don't ask them to build up their arms and drag themselves up the stairs. They can't. Yet with EBSNA (and other mental health conditions), while it may be said, it doesn't feel like the 'can't' is always taken seriously. Messages can remain that these kids just need grit, resilience building, self regulation.
The context

For families, the pressure from all sides is as invisible but present as the air you breathe. Parents and children generally encounter instant demands to return and keep up expectations of attendance, keep links, keep pressure on. And when the child can't, there is such judgment of parents. 'You must be too soft, boundaries aren't clear enough, it's separation anxiety'… and this happens to parents when they're already vulnerable. As a parent, you are exhausted, you are down and doubting yourself, and you are kicked. There is a lack of choice in our education system. For families who have a child that can't attend mainstream, they are often left without choices or options.

And despite our reframing as EBSNA, analysis of the problem and suggested solutions still often remain within child. Contributing factors are analysed. Factors such as screen time, for example, are often interpreted as part of the problem, as causal – a child is staying home to spend time on screens – not considering that this may be the result of school-related trauma and a coping mechanism and means of regulation for a burnout child in crisis (see Naomi Fisher for the role of screens). Interventions can be heavily skewed to within the child – it is for the child to learn to self-regulate, build resilience, and adaptations to the environment receive less focus.

To honestly engage with families, we must address the elephant in the room – it isn't just this child who is struggling in a context that is otherwise fine, well-designed, and fit for purpose. The system is over-stretched, under-resourced, and lacking appropriate training and support from other agencies (see the EIS position statement of November 2024). But while we may at times admit it, it is not officially acknowledged. It may be said in the meeting, but it doesn't make the minute. So in practice, blame – or 'responsibility', if that is less emotionally laden – slides off the system and lands on the child and family.

It's not just the kids who can find school a hard place to be these days. I believe most of us in education now are familiar with the news that another colleague has been signed off with stress and isn't expected to return anytime soon. We all see daily news about teachers struggling in schools, their pain and frustration that there is no help to meet the needs of the children before them. The class teacher cannot do it all.

The difference in the experience of child and adult is in the power imbalance and the twisting of the right to education into an obligation to attend school. Imagine the stressed Class Teacher, Pupil Support Assistant, or Head Teacher at the GP in tears, to be met with the response, 'Well, you have to keep going, it's so important for your future, your career progression. How's it going to look if you're off with stress? Everyone else is managing, why are you any different? Think of everyone you're letting down. What if you lose your job? Think of your bills, your mortgage. If you are off, make sure you call in everyday, make sure you get back as soon as possible, don't forget we expect you back. Get up and dressed for it and try every morning. You just need grit.'

These messages are still being given to some of our vulnerable children. And their families. That needs genuine and serious reflection. How does that feel to hear? What may the ripples be from that message, and how far and how long do they travel?

What should be said instead?

'It will be okay'

'When a child is burnt out, it's alright to take a break. They need to recover.'

'Don't worry, you have options.'

'We can help you.'

Perhaps if nothing else, then at least, 'It's not your fault'.
Grit or compliance?

Angela Duckworth defined the psychological concept of grit as a combination of passion and persistence, with success not a matter of talent or innate intelligence, but of attitude, effort, enthusiasm, and consistency – 'passion and perseverance for long-term goals'. But those goals are the goals of that individual, not somebody else's. The passion they follow is their own, not their parents' passion, not their teachers' passion. Duckworth states this in her Hard Thing Rule – everyone has a hard thing they need to do, you don't get to quit in the middle, and you get to choose your hard thing.

How can you find passion in something you don't want to do? Following someone else's or society's demands? This is not passion. This is not grit. This is compliance – submitting to the demands, wishes, or suggestions of others. Or it's conformity – adjusting behaviour to be more consistent with the opinions of others or the normative standards of a social group. Our education system requires compliance and conformity, not grit.

There is a wide literature on the inefficiency of and damage caused by coercion, and the importance of choice and voluntary action for positive change (e.g. Kurt Lewin's work on managing change). We know that increasing pressure creates conflict, resistance, and resentment (see Sam Harris's interview with Daniel Kahneman for an interesting discussion of this.) And we know it can reduce motivation, a key ingredient of grit. So, all other things aside, the approach many still take to EBSNA is unlikely to work as it is built around applying pressure to children and families.
Now and next

Let's take the refusal out of EBSNA and truly accept can't not won't. Instead of trying to make them go and then trying intervention after intervention aiming to help them tolerate the intolerable, we could be truly child centered – consider what this child needs first to heal, right now. Positive experiences, recovery, screen time, rest, agency, and then what next?

If we're not making changes first, if we're not putting in the lift, how can we ask the child to just try harder? With persuasion, pressures, coercion, with ear defenders, time outs, self-regulation, five-point scales, is this in their long-term best interests? What are they really, deeply learning about life and their place in it from being in school in this manner?

Covid showed us other ways, some in schools and some not. Remote education, for example, is now plentiful in the private sector, with many models from live online full days to 'pick and choose' courses. But often they aren't cheap. In Scotland, I-sgoil is a remote school offering interactive online learning (at home or as a hybrid model) for those unable to attend school.

It's not for everyone, but nothing is. And that's really the point. We need more choices within the current system, and to work towards a system that truly does value grit over compliance.

Dr Jennifer McClay (CPsychol)

Educational and Child Psychologist

Wave Psychology

SOURCE:

Wednesday, 18 June 2025

Awkwardness





See podcast:

This time on the podcast Meg-John interviewed Elsie Whittington. Elsie is a researcher at Manchester Met Uni who did her PhD on consent and studies youth sexuality.

For the podcast episode Elsie and MJ decided to focus on awkwardness because this was such a big theme in Elsie’s research that it ended up being a whole chapter of her thesis.

How is awkwardness relevant to sex and consent?

Pretty much every one of the young people who Elsie spoke to for her research said that a huge thing they feared during sex was awkwardness, and this was a major barrier to having conversations about consent, or to pausing or stopping what they were doing if it wasn’t feeling good.



The sex educators and advisors that Elsie spoke with also said that awkwardness was a big barrier to talking about sex openly in schools and youth groups – and evidence suggests that medics, therapists, and other professionsal feel similarly awkward about bringing up issues of sex and consent.
What is awkwardness?

Most of the participants in Elsie’s research said it was a sense of embarrassment or having got something wrong. They felt awkward that they might be exposed as being inept at sex in some way if they brought up consent, or talked about what they wanted, for example. They were scared of losing face and looking stupid.

Interestingly the word awkward – from the Latin – means wrong (awk) and direction (ward – like backward and forward). So it’s literally about a fear of going in the wrong direction. On the podcast we linked this to the sexual script that is taught in media, sex advice, sex ed, etc. Part of why there is awkwardness around sex is that there is a sense of the ‘right direction’ that we could (intentionally or unintentially) deviate from. Even worse, there’s often a sense that trying to do it consensually will risk us going in the wrong direction.
What do we generally do about awkwardness?

In all aspects of life we’re taught pretty thoroughly to avoid awkwardness – perhaps particularly if we’re from cultural backgrounds which have a horror of embarrassment and where saving face is important. We might struggle with restaurants or shops or other unfamiliar environments if we sense that we don’t know the script – and therefore risk being awkward.

As with so many difficult feelings our default may be to assume that the presence of awkwardness is a bad thing, and that avoiding it is a good thing, at whatever cost.
Why is this risky?

When it comes to sex – which feels like such a loaded, vulnerable situation with potential for awkwardness – people may even prefer to risk unwanted or non-consensual sex than facing an awkward pause, silence, or conversation. Awkwardness is also a reason often given for struggling to suggest contraception.

Sex advice and media – including much advice around consent – is largely to blame for people preferring risky non-awkwardness to consensual awkwardness. It presents a script for sex, with everyone telepathatically knowing what to do without communication, and no awkwardness. Even consent ed often presents consent conversations as straightforward and not awkward. We need to see more realistic images and examples of people navigating awkwardness around sex and consent. It simply isn’t possible to get to that point without a lot of practise (including plenty of awkwardness).
How could we approach awkwardness differently?

We spoke about the importance of staying with feelings: learning how to be with awkwardness, recognising that it’s possible to feel and won’t destroy us. The most we can practise being okay with awkward feelings, the more we’ll be okay when those happen during sex.

Naming awkwardness can really take the sting out of it. Saying ‘oh that’s awkward’ or referencing the awkward turtle meme helps to make it a bonding, perhaps funny, moment rather than something that feels terrible.

It can be great to model the capacity to be awkward and it be okay for other people – if it’s something you can do. You can bring in cultures with friends where you see anybody feeling awkward as a great sign that a conversation would be helpful. Naming awkwardness and asking how others are doing can be helpful for social dynamics, and good practise again for when this comes up in relation to sex (whether sex itself or conversations about it).

© Meg-John Barker and Justin Hancock, 2020


SOURCE:

'We have a duty to carry out socially relevant research'


Ella Rhodes reports on the impact for British Psychological Society journals.

16 June 2025



Studies published in British Psychological Society journals are having an impact on global education, health, and pandemic preparedness policy. A recent BPS analysis of data from Altmetric, which monitors mentions of journal articles in government guidelines, white papers and other publications, found articles in our journals were cited by bodies including the World Health Organisation and the World Bank.

Three studies published in the British Journal of Educational Psychology featured in the top 10 BPS journal articles with the greatest policy impact in 2024. One of these was an open-access paper by University of Sussex researchers Dr Lewis Doyle, Dr Matthew Easterbrook, and Professor Peter Harris. They explored teachers' perceptions of an identical piece of work written by students who appeared to be from varying ethnicities and socioeconomic backgrounds.

Teachers judged lower-socioeconomic-status (SES) students' work to be of lower quality than higher SES students and rated their ability and potential as inferior. The researchers suggested these unconscious biases among teachers could be part of the reason students from lower SES backgrounds tend to perform worse at school.

Their work was cited by the European Commission's Joint Research Service in its paper on the impact of COVID-19 restrictions on learning loss and education policy in Europe. The Pandemic, Socioeconomic Disadvantage, and Learning Outcomes also drew on case studies from Germany, Italy, the Netherlands, and England to explore the learning challenges created by COVID-19, particularly for students from socioeconomically disadvantaged backgrounds.

Doyle said his and colleagues' research, including the British Journal of Educational Psychology article, sought to use social psychology to better understand and combat educational inequalities. 'As a scientific community, I think we have a duty to carry out socially relevant research that can have a positive impact on society.

'Finding that teachers may be biased in their judgements is an important discovery to share with other academics, but in terms of real-world impact, it is far more important to communicate these learnings to teachers and policymakers themselves. This article gained a large amount of media attention and enabled us to reach a broader audience than may otherwise have been possible. We have subsequently shared these findings in workshops and meetings with teachers and school leaders and hope that this will lead to impactful change.'

In 2020, the British Journal of Educational Psychology also published a study by Canisius University researchers Professor Kristin Finn, Dr Clancy Seymour, and Anna Phillips, which again explored bias among teachers. They asked middle school and high school teachers to assess a fake essay which also included a photograph of students of varying weights – they found overweight students were more likely to be given lower grades, and were assumed to have lower grades overall.

The European Parliament's Policy Department for Economic, Scientific and Quality of Life Policies included these findings in its document Current challenges and opportunities for addressing obesity. The report, produced for the parliament's Subcommittee on Public Health, explored obesity prevention and management in the EU, healthcare for people with obesity, and environments which promote health.

The Covid-19 pandemic also featured extensively in the top 10 BPS journal articles with most policy impact, including a longitudinal study in the British Journal of Educational Psychology on teachers' mental health during the first year of the pandemic. University of York researchers – Dr Lisa Kim, Dr Laura Oxley, and Professor Kathryn Asbury – looked at 24 primary and secondary school teachers' job demands and resources in April, July and November of 2020.

They found that teachers' mental health and wellbeing, particularly among primary school leaders, generally declined across that period. The uncertainty in their roles, workloads, negative perceptions of their profession, concern for the wellbeing of others, health struggles and having multiple roles had a particularly negative impact on teachers' mental health and wellbeing, while having social support, autonomy at work and coping strategies impacted positively on them.

A 2024 report commissioned by the European Agency for Safety and Health at Work cited these findings. This report looked at artificial intelligence in education and advocated for a teacher-centred perspective in discussions about the use of digital technology in education.

Several pandemic-related papers published in the British Journal of Health Psychology were also included in the top 10. One of these was a study by Frederik Jørgensen, Dr Alexander Bor and Professor Michael Bang Petersen, which explored the protective behaviours people had taken during the COVID-19 pandemic, and attitudes towards the pandemic and society more broadly.

This research, published in 2021, included surveys of more than 26,500 people living in Denmark, France, Germany, Hungary, Italy, Sweden, the UK, and the USA. The findings showed that one of the major reasons people followed protective advice was a feeling of self-efficacy, and the impact of fear on those behaviours was small among those who felt higher self-efficacy. The authors suggested governments could foster compliance without resorting to heightening feelings of fear among the public.

This study was cited in a paper on incorporating trust into planning for future health crises, including pandemics, in the Bulletin of the World Health Organisation by Thomas Bollyky from the US Council for Foreign Relations and Michael Bang Petersen. In that paper, they proposed that policies should ensure the trust which already existed in communities should be sustained during health crises, in part by using honest and transparent communication, and that strategies should be introduced which promote cooperation in communities where trust in government is low.

Another top 10 study in the British Journal of Health Psychology looked at people's intentions to take the COVID-19 vaccine in the face of information about its efficacy. Professor Colin Davis (University of Bristol), Matt Golding, the founder and creative director of Rubber Republic, and Professor Ryan McKay (Royal Holloway, University of London), asked more than 480 people in four different conditions about their intentions to take the Covid-19 vaccine.

Giving people information on the safety and efficacy of the COVID-19 vaccine increased their intentions to have the vaccine. The researchers also found a stronger increase in Covid vaccine intentions in a condition where participants were shown safety and efficacy information about the Covid vaccine alongside information that the flu vaccine's efficacy was much lower than the Covid vaccine.

The World Bank cited this research in its policy research working paper Behaviorally Informed Messages Increase COVID-19 Vaccination Intentions: Insights from a Global Meta-Analysis. This paper analysed 28 online experiments, which involved more than 120,000 people, and found behaviourally-informed messages significantly increased vaccination intentions among unvaccinated people.

Chair of the BPS Research Board, Dr Richard Stephens, told us: 'It's no secret amongst the community of psychology researchers that the evidence-base can be so impactful. We understand how to design and run robust studies that provide meaningful insights into psychological processes that affect people's decisions and, consequently, their lives. But it's so wonderful to see my peers (and forebears) spreading influence, worldwide.'

SOURCE:

Όταν νιώθουμε τύψεις επειδή φωνάξαμε στο παιδί- Η απάντηση του παιδοψυχολόγου







O σύμβουλος γονέων και παιδοψυχολόγος Ιωάννης Γλωσσόπουλος μιλάει για ένα θέμα που έχει απασχολήσει όλους τους γονείς. Για τις τύψεις που βάζουμε όταν φωνάζουμε στα παιδιά, όταν συνειδητοποιούμε ότι δεν ξέρουμε πώς να θέσουμε όρια, όταν νιώθουμε κακοί γονείς, όταν είμαστε απλά εξαντλημένοι.

Οι συμβουλές του είναι πολύτιμες και κυρίως πολύ καθησυχαστικές για τους γονείς που προσπουθούν καθημερινά να γίνουν η καλύτερη εκδοχή του εαυτού τους:


Φωνάζεις στο παιδί σου και μετά νιώθεις χάλια.
Δεν θες να το πληγώνεις.
Δεν θες να είσαι "αυτός” ο γονιός.
Αυτός που είπε ότι δεν θα γίνει ποτέ.
Κι όμως… εκεί βρίσκεσαι.
Με φωνές που δεν σε εκπροσωπούν και τύψεις που σε βαραίνουν.
Δεν είσαι κακός γονιός.
Είσαι κουρασμένος.
Εξαντλημένος.
Και πολλές φορές, χωρίς σωστά "εργαλεία."




Γιατί τα όρια δεν μπαίνουν μόνο στο παιδί.
Μπαίνουν πρώτα σε σένα.


Στο πότε λες "ναι" ενώ μέσα σου είναι "όχι".
Στο πότε κρατάς, κρατάς, κρατάς... και μετά ξεσπάς.
Στο πότε δεν φεύγεις για να μην κλάψει και τελικά φωνάζεις για να σταματήσει.
Όριο είναι να πεις "τώρα δεν μπορώ άλλο", πριν φτάσεις στο δεν αναγνωρίζω τον εαυτό μου.
Όριο είναι να πεις "χρειάζομαι βοήθεια" και να την αναζητήσεις.
Όριο είναι να πεις στο παιδί "σ' αγαπώ, αλλά αυτό δεν γίνεται".

Μπορείς να γίνεις ο γονιός που θέλεις.
Όχι όταν δεν φωνάζεις ποτέ.

Αλλά όταν κάθε μέρα κάνεις λίγο χώρο για σένα και λίγο χώρο για εκείνο!


ΠΗΓΗ:

Friday, 13 June 2025

Making time for humanity in mental health care



Manuela Maletta, Mental Health Practitioner, looks to bridge some gaps.

15 May 2025


'Lara' was referred to me by her GP. She had struggled with mixed anxiety and depressive disorder for years and had gone through several antidepressants – each discontinued either due to intolerable side effects or a brief period of effectiveness. She had also completed two courses of Cognitive Behavioural Therapy with limited benefit. Her GP felt they had exhausted all alternatives available in primary care – therapy, medication – and believed Lara's case was not severe enough to meet the criteria for secondary care intervention, usually reserved for people who score high in risk assessments, or who present with eating or personality disorders and subsequently experience complex mental health issues.

This is a situation I see increasingly often in the course of my work as a Mental Health Practitioner. In my early years as a behavioural therapist working with neurodiverse clients, with a complementary career in the performing arts, I became quite sensitised to the matters of narratives, time, and dissonances. It is through this lens that I now observe people with complex and longstanding mental health difficulties, caught between the limitations of primary care and the thresholds of specialist services. People who don't quite 'fit' the system.
Lara

The NHS Long Term Plan (2019) called for the creation of integrated models of care, aiming to promote collaboration within Primary Care Networks (PCNs) and Community Mental Health Services. These models were designed to help people like Lara (all names here have been changed) – people whose needs fall in the gap between IAPT (Improving Access to Psychological Therapies) and secondary care. According to the King's Fund, between 2010/11 and 2014/15, referrals from primary care to community mental health teams in England increased by 19 per cent. During a similar time frame – from 2005 to 2015 – the British Medical Association reported that prescriptions for antidepressants doubled. This signals a system under pressure, where medication often becomes the default response to complex emotional distress.

In a 2018 survey by Mind, involving 1,000 GPs, around 40 per cent of respondents estimated that mental health was a significant component of their daily appointments. This aligns with what many practitioners experience: mental health now represents a substantial part of the GP caseload, and yet primary care is not always equipped with the time, training, or pathways to support these patients fully.

Long waiting times and stretched resources create bottlenecks. GPs are left managing patients with increasingly complex needs, often without access to timely support or clear clinical pathways. This results in fragmented care, where mental and physical health are rarely addressed in a coordinated way. Barriers to integration include logistical challenges, funding limitations, and the absence of shared systems or protocols. The result? Patients feel unsupported, GPs feel overwhelmed, and practitioners are left to try and bridge the gap, often without formal authority or structure to do so.

This is where the integration of Mental Health Practitioners (MHPs) into primary care comes into focus – not just as a theoretical improvement but as an urgent, practical solution. A shift towards compassionate, timely, and holistic care. Lara came to me with a deep sense of hopelessness and the belief that every option had already been tried and failed. She felt like a lost cause. But I believe mental health professionals are, at their core, creatures of hope (just like philosophers are 'functionaries of mankind'!).

And so, we began. Not with a new medication or a fresh referral, but with presence – with time. We were standing in front of a puzzle with scattered pieces and had been told perhaps they were the wrong ones. But no, Lara – these were your pieces. Our work was to look at them from the right angle.

This is the gift that working in primary care integration can offer: the gift of time. The time that GPs and many other professionals simply don't have. Unlike the strict 10-15 minute appointment slots common in general practice, MHPs are typically able to offer 30 or even 60 minute sessions. This extended time allows for deeper exploration – not just of symptoms, but of the stories, patterns, and social contexts behind them. We are positioned at the intersection of medicine, psychology, and community support, and often act as bridges across systems. In doing so, we have the potential to bring a uniquely integrative and human approach to care, one that values presence as much as intervention. And sometimes, this approach is what changes everything.
Joseph

Joseph had always found it hard to talk about his feelings. Stigma – especially around masculinity and mental health – was deeply embedded in his narrative. At one point, he had briefly mentioned his emotional struggles to his GP and had been given the link to self-refer to IAPT. But he never did. He felt like 'jumping in the dark'.

Joseph didn't know what to do with a self-referral link. He needed a person – someone to walk alongside him as he took the first steps. From our early sessions, it became clear he wasn't looking for therapy in the conventional sense. He needed human connection and validation. He needed someone who could listen without judgement and offer some structure and support for the isolation that was weighing on him.

As we explored his story, it also became clear that much of his discomfort stemmed not from generalised anxiety but from the internalised stigma of growing up as a gay man in an environment where this was not safe or accepted. This wasn't just about mental health – it was about identity, shame, and isolation.

We investigated LGBTQ+ community groups, connected him with our social prescriber, and explored opportunities for volunteering, so that Joseph could try to take a step outside of himself. These small but significant interventions helped Joseph begin to reconnect with others, and consequently with himself. His mental health improved not through clinical intervention alone, but through validation, connection, and a sense of belonging.
Craig

Craig was a young offender from an ethnic minority background. Recently released from prison, he had been issued several fit notes excusing him from probation appointments, though these were inconsistently granted by different clinicians, with varying descriptions of his symptoms. It raised an important question: what exactly was he being excused from?

When Craig came to see me, his presentation revealed layers of trauma that had never been named or supported. He described severe anxiety dating back to early childhood, significant behavioural issues at school that had led to exclusion, and clear symptoms of PTSD following his incarceration.

He hadn't shared any of this with his probation officer. He didn't know how to. He said he found it difficult to leave the house at all. The only reason he had made it to the appointment was because 'the GP practice is local, and the doctors are there to help'.

His PCL-5 scores indicated severe PTSD. He was supported to share these findings with probation, and adjustments were made to ease his attendance. We also referred him for trauma therapy while continuing to meet regularly while on the waiting list to maintain engagement.

Despite a history of reoffending, Craig became determined to break the cycle. He developed a new vision for his future.

What made this possible? A safe space, presence, and time.
Integration in practice

Integrated models of care have demonstrated improved outcomes for individuals with mental health conditions or long-term physical illnesses. Research shows that collaborative approaches within the NHS can reduce hospital admissions, increase patient satisfaction, and improve cost-effectiveness.

In my day-to-day work, integration means everything from supporting people on the SMI register to engage with annual health checks, to providing brief interventions such as grounding techniques and motivational interviewing. I refer patients to other services and advocate for patients with rejected referrals, attend MDTs and interface meetings, liaise with consultant psychiatrists and clinical psychologists, and work across both the GP practice and the Trust.

This dual-anchored role has its complexities. In the beginning, there was little clarity. I essentially have two managers, two sets of supervision, and often two conflicting sets of expectations. It took a few joint meetings and some honest conversations to clarify my remit and strike the right balance.

I now feel fortunate to work for an excellent trust and an equally nurturing and collaborative GP practice. Both are aligned with my values – patient-centred care, empathy, and teamwork. I've been granted a clear remit, along with the flexibility to adapt it to the needs of the people I support.

One of the most valuable aspects of this role is being able to choose the length of a session, whether 30 minutes or a full hour. While I technically offer a maximum of 4-5 sessions, I continue to see patients for longer when needed, if the intervention remains beneficial or if periodic welfare checks are part of the plan.

There have been times when admin has felt overwhelming, especially during referral surges, but honest communication led to increased protected time for documentation and referrals. Boundaries were also clarified around medication – I'm not trained to manage pharmacological care, and in such cases, I refer patients back to the GP.
Revisiting Lara

Returning to Lara, one of the key themes in our early sessions was the word 'overwhelm'. She often described feeling 'incapable of coping like other people'. Over time, I've come to recognise this word – overwhelm – as a flag. It's worth exploring deeply.

I began to ask about sensory sensitivities and social interactions. Lara gradually identified patterns that hinted at neurodiversity. We completed the AQ-10 screening tool for Autism and the ASRS for ADHD. Her scores were high enough, and with the Right to Choose, she accessed the appropriate diagnostic assessments relatively soon, which confirmed both ASC and ADHD.

This opened a new narrative for Lara – one that finally made sense. We discussed how unrecognised neurodivergence may have shaped her experiences of anxiety and low mood for years. We developed a sensory care plan, particularly around transitions and holidays, to prevent future overwhelm. She joined a support group and began reading about neurodivergence in girls. She later started supporting her younger brother through his own diagnostic journey.

Her life improved. Not overnight – but with time, patience, and validation.
Reflections on practical implementation

To strengthen this model, several practical elements need to be prioritised. First, co-location is vital. Physically embedding Mental Health Practitioners within GP practices enhances both access and visibility. When patients see that mental health care is a routine part of their local surgery, stigma is reduced and engagement increases.

Equally important would be ensuring that MHPs are included in the multidisciplinary discussions within both GP practices and Primary Care Networks. Being part of these integrated meetings not only improves continuity of care but would also allow for more nuanced and timely support across services.

Shared care pathways should also be clearly established. Patients, clinicians, and support staff need to understand when it's most appropriate to involve a Mental Health Practitioner, when a GP should take the lead, and when an urgent referral to secondary or specialist services is necessary. Without these guidelines, care can become inconsistent or delayed.

Finally, the principle of 'no wrong door' should underpin the entire system. No one should be turned away simply because they don't fit neatly into an existing category or meet arbitrary thresholds. If someone finds the courage to reach out – regardless of the severity or complexity of their presentation – they deserve to be heard, held, and supported.

The stories of Lara, Joseph, and Craig reflect the core truth of integrated care: healing happens when people feel seen, heard, and held, especially in systems where they've long been overlooked.

Integration is not just a buzzword. It is a necessary transformation. It calls for investment – not just in resources, but in relationships. In time. In presence. In human connection.

We must continue to build models that are flexible, collaborative, and above all, person-centred. The policy frameworks are there – the NHS Long Term Plan, the Community Mental Health Framework – but real integration happens in conversations. In listening. In adapting. In showing up.
Are we really making a difference?

Yes. When we're given the space and trust to do so, we make all the difference.

For Lara.
For Joseph.
For Craig.
And for everyone still waiting to be heard.
References

British Medical Association. (2024). "It's broken": Doctors' experiences on the frontline of a failing mental healthcare system. BMA. Retrieved from https://www.bma.org.uk

Department of Health and Social Care. (2019). The NHS Long Term Plan. NHS England. Retrieved from https://www.longtermplan.nhs.uk

King's Fund. (2017). Understanding NHS financial pressures: How are they affecting patient care? Retrieved from https://www.kingsfund.org.uk/publications/understanding-nhs-financial-pressures

Mind. (2018). GP mental health training survey summary. Retrieved from gp-mh-2018-survey-summary.pdf

NHS England. (2021). The Community Mental Health Framework for Adults and Older Adults. Retrieved from The Community Mental Health Framework for Adults and Older Adults | Royal College of Psychiatrists

NHS England. (2023). What are integrated care systems? Retrieved from NHS England » What are integrated care systems?

Royal College of Psychiatrists. (2021). Long Term Plan for the NHS in England. Retrieved from Long Term Plan for the NHS in England| Royal College of Psychiatrists

Thornicroft, G., Mehta, N., Clement, S., Evans-Lacko, S., Doherty, M., Rose, D., ... & Henderson, C. (2016). Evidence for effective interventions to reduce mental-health-related stigma and discrimination. The Lancet, 387(10023), 1123–1132. https://doi.org/10.1016/S0140-6736(15)00298-6


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