Sub-theme 2.2: Collaboration (MDT/joint working)

Collaboration was another major theme that emerged from the process of applying IPA to the data collected. Three out of the five triads emphasised the importance of using a shared, MDT approach. Working jointly with client-therapist-support worker was frequently

expressed as important in creating positive changes and also frequently mentioned and appreciated by the clients with learning disabilities. Collaboration and liaison with other MDT colleagues was also often considered very helpful in the process, enabling success from psychological therapy.

Experiencing a collaborative approach was important for clients, in order to make therapeutic progress. Several participants with learning disabilities mentioned that they had experienced a helpful, collaborative kind of approach, from which therapeutic progress had been

possible. Jacky referred to the importance of being able to work with therapist 2 Nichole about her problems: “You see I know other people can listen to me, but I can say a lot to Nichole, and she’s got a lot of stuff out of me now, if you know what I mean…” (Jacky - PWLD -Triad 2 - 4.86). She was not always able to specify exactly what it was that she liked or had helped, but it was clear she found talking and the relationship she had built up with Nichole was important for them both, allowing change to occur: “with talking to her, I just shot up!” (7.184).

Edward also spoke about the benefits of being able to work alongside and talk to his therapist Tim and his other support networks, which he had not been able to do in the past prior to his referral: “If I’m in a mood over something, I kind of tell people… they hammer me, to say what’s wrong.. with me… and as soon as I’ve said what’s wrong with me, it’s all

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alright… it’s no bother…” (Edward – PWLD - Triad 3 - 3.62). Edward added details about some of the specific activities he had worked on with Tim, “I came up with a chart...it’s like a face… and you can either put a smiley, or an upside-down face to say how I’m feeling… So as soon as they come through the door they see, Edward’s upset and … they know what’s happening, staff would know… And if it’s happy and joyful, then I’m in a good mood” (6.162).

This chart was a collaborative, joint initiative, with Tim having used and adapted or simplified charts with his clients previously. Here he involved Edward in this process, using a client-led approach: asking about suitable, meaningful symbols (which Edward later mentioned in his interview) that he would like to include in his chart and would be likely to respond well to when used with Tim and his support workers, as a result of the reciprocal roles in the therapy and taking part-ownership of the process (Reciprocal Roles and collaboration in therapy has been widely found to be important for therapeutic success when working with PWLD – Psaila & Crowley, 2006). Abbey also spoke enthusiastically about the collaborative work she had been involved in with Penny during and in between her sessions: “she did ask me to keep a diary, at first I did… for my sleeping habits … to keep myself calm so I don’t kick out at Kevin in my sleep. I tried out all different techniques before I went to bed” (Abbey – PWLD - Triad 4 - 5.125).

A collaborative approach was also important for therapists in their work with PWLD.

Collaborating with clients involved a shared, communicative approach towards the therapy, frequent questions, checks and mutual agreement about the methods and ways of working, as reported here by therapist 1 Eve: “it was a case of checking with him you know, ‘would it be helpful to talk a little bit more about that?’” (Eve – T - Triad 1 - 2.42). She elaborated upon her approach which centred on placing Sid at the core of the therapy sessions and utilising a Compassion Focussed Approach, to ensure she was on the right track, “I was trying to walk next to him… Not pushing him too far or lagging behind – making sure I was really there with him in the sessions” (9.282). Similarly, Janice mentioned the importance of sensitivity to Neil’s needs and not imposing upon him, “he said he didn’t feel I imposed anything on him, I

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just made suggestions that I thought might be useful” (Janice – T -Triad 5 - 10.264). She

“gradually eased in topics that were difficult for him, such as his self-harm, his behaviour toward his mum, his family and his strategies and things like that” (5.117). Nichole added to this theme of collaboration, tailoring every step to the issues and scenarios Jacky presented in her sessions: “it was following her timeline, it depended on what we came up with,

depended on what particular approach we might use for that particular scenario” (Nichole –T - Triad 2 - 3.97).

Joint/MDT working and sharing information was helpful & important for facilitators. Joint and MDT working was agreed as helpful by both therapists and support workers, in terms of a) encouraging and sharing effective, consistent ways of working which would benefit the PWLD as well as their carers and wider support networks, although b) there may be times that MDT working is not the preferred approach and consideration of confidentiality, privacy and therapeutic boundaries may override some instances of sharing information and c) making use of multi-disciplinary teams and referrals can provide additional, client-focused services and specialist support, beneficial to the service-users and others involved.

Joint working was generally agreed as important, as therapist 5 Janice explained: “it’s trying to get everybody on board, trying to work with everybody in a similar way” (Janice – T -Triad 5 - 19.537). Janice found sharing information helpful and commented, “it’s worked extremely well – by including everybody, in what we’re doing” (17.467). She spoke about the

importance of educating and talking with carers, parents and others involved in the care and support of PWLD, because: “But once carers and parents get it, the difference it makes is huge.” (19.530). Support worker 5 Paul commented that the work wasn’t always easy, but discussions with other colleagues could be invaluable, in helping create lasting changes - “it took a lot of hard work… and a lot of … teamwork, to get Neil how he is” (Paul – SW - Triad 5 - 9.303). He also spoke about everyone learning from each other: “we can always learn from each other... I think I learn a lot from the professionals I work with…” (17.559).

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Support worker 2 Malcolm also mentioned that checking with the client and obtaining their consent to share information could result in more productive sessions working jointly with the therapist: “with a joint session… I could have, with Jacky’s consent, to bring anything up that she might have forgot – to tell Nichole, and I’ll just prompt and then Jacky’ll just come out with it.” (Malcolm – SW - Triad 2 - 4.103). Support worker 3 Ray also agreed that joint discussions could be helpful and facilitate further post-therapy explorations and

conversations: “we’ve discussed them quite a bit [therapy sessions] And afterwards we’ll say – when everyone’s gone – we’ll say “it went alright didn’t’ it?’ and have another discussion ourselves about how it was, so that’s good, and it keeps us all in the know” (Ray – SW - Triad 3 - 6.153).

Although the majority of therapists and support workers agreed about the importance and usefulness of sharing information and working collaboratively in an MDT/team, Eve spoke about there being times when this may not be appropriate: “In learning disability services there tend to be quite a large number of multi-disciplinary teams – so I felt like, I was working very much just with him, so there wasn’t really any need to share, or to talk to carers… which suited the way we were working together…” (Eve – T -Triad 1 - 13.417). Eve’s adherence to confidential, ethically-bound agreements and ways of working seemed to have been

reassuring for Sid: “it made him feel like there was you know, that true sense of confidentiality, there wasn’t any need to share anything…” (13.430). Robert had also referred to not wishing to “delve” into Sid’s private therapy sessions, indicating a shared understanding and respect for confidentiality, in their triad.

A significant benefit of working within an NHS service is having access to a range of health, adult care and other professionals, who can be contacted, and additional referrals made for PWLD, where such needs have been identified by members of the PCT. For example, therapist 2 Nichole referred to how “the whole team are involved with her – ‘cos she’s had a lot of health issues as well” (1.22) – by which she meant the health team of the CLDT

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involved. Nichole also explained that due to some of the financial concerns raised in her work with Jacky, Adult Care services and other support workers were contacted: “it resulted in actually working with her support workers – how can we help her manage her finances better, or how could they?” (5.149).

Therapist 3 Tim spoke about engaging with other health professionals which he and his client Edward also found useful: “’I’ve engaged with Speech and Language… with Occupational Therapy and with Community Nursing… which has all been beneficial – all beneficial to my client, you know – and I sort of initiate that by always arranging the first sessions where the people who are familiar with Edward can be there – so it’s not new” (Tim - T– Triad 3 - 11.509). Referrals to wider agencies and services were also found to be useful, such as the Vulnerable Person’s Unit within the police, as described here by Tim:

“I’ve also referred him to the vulnerable person unit… section of the police… and we have the police do the weekly checks, call and see Edward, have a drink of tea with him… and things like that – it’s been really useful” (11.513).

4.1.2.3 Sub-theme 2.3: The therapeutic relationship was more important than