Olivia Birch, Sahfa Shafaqat, Lucy Tolley

Black Country Healthcare NHS Foundation Trust, Older Adult Community Mental Health

 This blog shares reflections from three Mental Health and Wellbeing Practitioners (MHWPs) working in Older Adult Services within the Black Country. Through their stories, they explore the realities of stepping into a new role, working with complex needs, and adapting their practice to support older adults in the community. Together, their reflections highlight common challenges, the importance of MDT working, and ideas for how the MHWP could continue to grow and adapt to Older Adult Services.

Introduction

Mental Health and Wellbeing Practitioners (MHWPs) hold a vital role within community mental health services, especially when supporting older adults who often face unique psychological challenges shaped by age-related factors such as physical health deterioration, social isolation, bereavement, and life transitions including retirement. In community settings, MHWPs provide accessible, tailored mental health care, helping older adults maintain independence and wellbeing outside of institutional settings.

In community mental health, MHWPs have a role that goes beyond diagnosis to include thorough, person-centred therapies aiming to improve their mental health and ability to function. They provide evidence-based interventions, many of which are based on cognitive-behavioural therapy (CBT) and tailored to the unique requirements of older adults. Behavioural activation and graded exposure are important therapies that are frequently administered through organised programs like the GOALS program. These programs seek to decrease anxiety by progressively facing fearful circumstances and promote participation in meaningful activities MHWPs also provide problem-solving training to enable people to better cope with everyday obstacles and enhance coping strategies

Promoting good sleep hygiene, which can be challenging in later life and has a major impact on mental health, is another important area of intervention. In order to reduce suffering and improve interpersonal relationships, MHWPs also support older adults in identifying and controlling their emotions. Guided self-help programs tailored for the older adult population have demonstrated encouraging results in lowering symptoms of eating disorders such as binge eating disorder and bulimia nervosa. Increasing motivation and social engagement, which are protective factors against anxiety and depression, is another crucial aspect of the MHWP's job, as is fostering self-efficacy and confidence.

Anxiety, depression, cognitive impairments including dementia, and adjustment difficulties are common mental health conditions among older people. Sensitive and adaptable interventions are required because these illnesses frequently present with complex symptoms and co-morbidities. In order to lessen the strain on secondary mental health services and enhance the quality of life for older persons, MHWPs provide these interventions in community settings, promoting early identification and management.

This blog explores how Mental Health and Wellbeing Practitioners (MHWPs) can effectively support older adults in community settings. Through three personal reflections structured using the Gibbs Reflective Cycle (Gibbs, 1988), it highlights the importance of adapting the role to meet older adults’ needs, using supervision to manage emotional demands, and navigating the unique challenges of community-based work.

Challenges in the community

by Sahfa Shafaqat

Description

As a Mental Health and Wellbeing Practitioner working within a community service for older adults, I faced several obstacles that impacted both my professional growth and the quality of care I provided. The service focuses on supporting older adults who are experiencing common mental health difficulties like anxiety and depression. These conditions can be exacerbated by physical health issues and social isolation. The community setting requires flexible and person-centred interventions, often delivered in patients’ homes or local clinics, which introduces practical and emotional challenges.

Feelings

Initially, I was both nervous and enthusiastic about working with this patient group. Whilst I acknowledged the value of this work I was worried about how stigma and generational beliefs may impact engagement in older adults. Systemic challenges including limited resources, time restraints, and the complicated nature of multiple health conditions in this population occasionally made me feel frustrated. However, I also felt a strong sense of purpose and motivation to help improve the wellbeing of these individuals.

Evaluation

One significant challenge was managing the balance between providing timely, effective interventions and working within limited appointment times and resource constraints. With high caseloads, it was challenging to maintain the frequent visits and more flexible approach that many older adults required. Additionally, other factors such as cognitive impairment and resistance to mental health can limit the effectiveness of several interventions, due to reduced engagement.

On the positive side, working in a community setting allowed me to see clients in their own environments. This provides valuable insights into their social support networks and daily routines. This is often central to the successful implementation of CBT-based interventions as it requires changes to everyday life behaviours. Furthermore, building trust over time often led to breakthroughs in engagement and progress.

Analysis

These challenges show how difficult it can be to provide community-based mental health services to older adults. Engagement with, and the effectiveness of interventions are impacted by factors such co-occurring physical health disorders, sensory impairments, and the stigma associated with mental illness. In community mental health services, demand frequently exceeds capacity, time and resource constraints are evidence of larger systemic problems (Department of Health & Social Care, 2018). Furthermore, it takes both ideas and specific training to modify traditional methods to account for cognitive or sensory difficulties.

Conclusion

I've learned from this experience how crucial patience, adaptability, and commitment are when working with older adults in community settings. Despite systemic constraints, engagement and outcomes can be improved by developing therapeutic relationships and personalising interventions to meet the needs of each individual. To address the complex relationships between physical and mental health difficulties, I also came to appreciate the importance of multidisciplinary collaboration. Promoting more funding and training to better assist those in this group will be beneficial for future work.

Action Plan

To address these challenges, I plan to seek further training to better adapt psychological interventions for patients with cognitive impairments and other barriers. I will prioritise building strong therapeutic alliances early on to enhance engagement and develop more effective time management strategies to balance caseload demands while maintaining quality care. I also plan to encourage cooperation with other health and social care professionals and push for more resources within my team. I will also research how technology and community resources might be used to support in-person therapies where appropriate.

Adapting the role of MHWP

to an older adult cohort

by Lucy Tolley

Description

The MHWP postgraduate course focused on developing assessment, care-planning, and intervention knowledge and skills, to support individuals with severe and enduring mental health difficulties. Adapting this role to the older adult service, I became aware of several considerations that were necessary to support this age group. Such considerations included physical health problems, cognitive impairment, cohort beliefs, and age-related biases. Developing an understanding and awareness of these considerations is crucial to adapting the interventions and therefore meeting patient’s individual needs.

Feelings

From previous experience working in mental health, I felt confident in assessing patients and delivering sessions. When I started working within the older adult service, I initially felt inadequate in my role, I reflected that I had limited understanding of the complexities within this cohort. I felt worried that not only did I have to learn the new interventions I would be delivering but also begin to understand the age group I was going to be working with. Admittedly I felt a little overwhelmed with the amount of new information I had to comprehend and apply to practice. Though as I continued learning and adapting, I began to see this more as an opportunity to develop professionally, and I was motivated and driven to enhance my understanding.

Evaluation

One consideration within the older adult service is the presence of physical health problems. Although they can be present at any age, the existence of physical health problems, can increase with age. This may impact engagement in sessions, ability to attend sessions, and discussions on physical health may also lead to therapeutic drift. To address this, sessions may be delivered in a home setting as opposed to a local clinic, communication may be adapted, and agenda setting can be important to regain session focus when drift occurs.

Through understanding the patient and these considerations, interventions can be more tailored to the individual. This supports the development of a therapeutic relationship and may therefore improve patient engagement.

Analysis

Physical health problems can have a limiting function that reduces ability to engage in CBT interventions (Evans, 2007). It is important to consider patient’s recall, understanding, ability to apply sessions, additional to the setting where sessions are delivered. The delivery of CBT for older adults in their homes has been found to be effective (Stanley, Beck, Novy, Averill, Swann et al., 2003). Therefore, addressing this barrier by adopting a flexible approach may allow more older adults to engage in therapeutic work.

It is important to remain attentive to physical health problems and have awareness of the negative appraisal's patients may hold about those problems (Evans, 2007). However, discussions around physical health can lead to therapeutic drift during sessions, occurring when therapists engage in behaviours that stray from session aims (Roscoe, 2020). Agenda setting is important to address drift, contributing to productivity and flow of sessions (Zeiss and Steffan, 1996).

Understanding and meeting patient needs can help build the therapeutic relationship. When a strong therapeutic relationship is developed, interventions are delivered competently, and there is adherence to evidence base, CBT can be more effective (Waller, 2009).

Conclusion

From this experience I have learnt to be both flexible and adaptable to meet the needs of the cohort I am working with. My practice has improved as I now have a better understanding and awareness of working with older adults, and I feel more confident in addressing those considerations identified. I feel I am now more able to adopt a person-centred approach, which has allowed me to grow professionally and therefore have a positive impact on patients by tailoring care to their needs. I continue to learn and further my understanding by engaging in research, as well as using supervision and reflective practice to reflect on experiences.

Action plan

I plan to continue engaging in training and research to learn and develop, enabling me to further improve my practice. I believe it is important for MHWPs starting in their role as trainees to take time to understand the service they are working in and the cohort they are working with. Using supervision and reflective practice, I feel, is essential for trainees to share those challenges and experiences and begin to think about ways to overcome. This will enable you to feel more confident in adapting the role and minimise challenges in future practice.

Managing role stressors using

supervision and reflective

practice

by Olivia Birch

Description

Management of wellbeing and use of supervision is essential to understand the role, and have an effective, positive experience of training. Trainee psychological practitioner’s stress has been found to be related to the perceived responsibility of the role, managing the unknown and questioning their competency (Owen, Cross, Mergia, and Fisher, (2022).

One barrier in addressing these stressors is that as a newly developed role, new MHWP trainees may rarely enter a service that is prepared or knowledgeable about where the role best fits. This leads to 2 key difficulties; one, that trainees are often left managing the unknown with limited guidance, and two, that the responsibility then falls to the trainee MHWP to provide explanations to colleagues for a role they are just learning themselves. This is where supervision becomes essential in navigating these stressors.

Feelings

Understanding the MHWP role in a service that has felt unsettled by the introduction of this new role, often left me feeling uncertain. I felt unconfident in navigating the remit of the role. This allowed me to relate to many of the patients I have worked with. Many of whom have experienced being forced to revisit their values and find a new sense of purpose following the loss of role commonly experienced during retirement. Exploring these feelings in supervision and reflective practice was essential to manage safe practice and monitor for transference and counter transference.

Evaluation

One challenge was managing the instability of the role. As a new role we were frequently uprooted to find where we may best fit within the existing service. This included a significant shift in changing management over to an alternative service that offered group interventions. This resulted in us MHWP’s relearning what was expected of us within our new service, as well as re-teaching and remarketing ourselves to our colleagues. This highlighted the essential role of management and supervision in providing support and taking on some of the pressure. This support unfortunately came with limitations. As much of the role involved being flexible and finding what fits through experience, often questions and concerns brought to supervision could not have clear cut answers. The flexibility required in older adult care, at times felt cognitively dissonant to the heavily structured approach taught in the university training.

A strength of working in a role with a high need for support and supervision, has been developing strong reflective skills and building therapeutic relationships with patients, through the shared understanding that change can take time. An additional strength in when developing the supervisory support has been exploring the feelings created from that cognitive dissonance. Successful and frequent supervision allows the trainee to feel safe to explore the impact that personal responses to intense patient affect can have in building a strong therapeutic relationship and appropriate boundaries in practice style (Bridges, 1999). Overall, I feel this has encouraged my growth as a practitioner.

Analysis

I feel that these challenges are a result of the NHS’s adjustment to planned community transformation. The MHWP role at its heart was created with the new system in mind, and so much of the instability and resistance we have found in service in response to the role has been reflective of colleague’s anxieties about a changing system and defending boundaries of role confusion.

Conclusion

I’ve learned the value of group reflective practice and community from this experience. Much of the difficulties noted can be soothed through building relationships with colleagues and sharing experiences. This can come from having a positive workplace culture that allows individuals to be honest and open when there are difficulties. Externally to service I have felt the value of having safe spaces to connect with other MHWPs over the shared experience.

Additionally, I have learnt to better manage uncertainty and to sit with the feeling of not knowing. Whilst the support of supervisors is invaluable, independent learning is a constant and dynamic process throughout all stages of practitioner careers. Building strength in finding my own conclusions has been a useful lesson.

Action plan

Moving forward, I intend to continue to encourage shared reflection among my colleagues to support the ideal of collaboration and interconnected working. This involves normalising the anxiety that change can bring and exploring the creative and successful ways that roles can support each other to promote effective patient care. Additionally, I will continue to use supervision to manage the boundary between flexibility and therapeutic drift on a case-by-case basis, to support client individuality.

Final Reflections

To summarise the main challenges discussed in the above reflections, we understand that older adults are a complex patient group, and practitioners in this division often face a unique set of challenges requiring adaptability to appropriately meet patient needs.

The above reflections identify systemic issues including resource, capacity, and time limitations alongside complications to practice such as physical, sensory or cognitive impairment. Additionally, beliefs and biases about approaching therapeutic intervention were discussed in relation to barriers to engagement and therapeutic drift. This requires a balance of firm expectation and agenda setting, and flexibility in tailoring care to the patient. Finally, challenges in relation to wider understanding of the role in services were discussed. In regard to the stressors of role instability and questioning practitioner competency, the approaches to supervision and practitioner wellbeing were explored.  These challenges contribute to the complexity of adapting care to this cohort. 

In reflecting on our experiences as MHWPs within older adult community settings, we identified several key strengths. These include being able to build trusting therapeutic relationships, personalise interventions to each patient, and show flexibility when dealing with systemic constraints, cognitive impairments, and physical health problems. To manage the emotional and professional demands of this changing role, the reflective process made clear the importance of peer support, reflective practice, and supervision. The lessons we learned from each other's experiences highlighted the importance of patience, adaptability, and a person-centred approach in providing successful care in this setting.

Moving forward, steps must be taken to improve older adults' access to mental health care (Miller and Cameron, 2024). To fully prepare practitioners for the specific requirements of this community, such as managing cognitive decline, understanding generational stigma, and adapting evidence-based interventions, the MHWP course could be more adapting to the complexities of this age group. Second, to address the issues of large caseloads, limited resources, and time constraints that limit therapeutic improvement, more funding must be allocated to community programs. Finally, confusion about roles could be addressed by promoting further multidisciplinary collaboration and insights into new roles.

To meet the growing mental health demands of older adults, we must encourage systemic change while continuing to reflect, adapt, and develop as practitioners. Through ongoing learning and structural improvements, MHWPs can make a significant, lasting impact on the wellbeing of older people in our communities.

For future trainees, it is important to take time to understand the service you are working in and the age group you are working with. It will be helpful to build good working relationships across the multidisciplinary team, to learn from those around you and to support with understanding. Furthermore, make good use of group reflective practice and supervision. Engaging in reflective practice will allow you to share and make sense of your experiences and challenges, some that may have also been experienced by other trainees or assistant psychologists. Supervision will be important to formulate those experiences or challenges, informing possible solutions and allowing you space to reflect on what you may do differently in future practice.

Above all, try to remember this is an opportunity to learn and develop. Our experiences, positive or negative, allow us to grow as professionals even on the days when progress feels invisible.

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