Example of a time client was stuck or challenging
Could apply SD THEORY alongside
Context:
• Re-referred to service after limited progress; persistent anxiety & panic → cyclical overwhelm, avoidance, low confidence.
• Internal factors: grief, panic symptoms; External factors: fear of leaving home, engaging socially.
• Limited progress on recovery markers: leaving house, appointments, meeting new people, bereavement counselling, considering employment.
• Jonathan felt stuck; anxiety persisted despite attempts at behavioural change.
Action:
• Introduced graded exposure, but behavioural steps felt overwhelming.
• Focus shifted to:
o Emotional validation
o Processing grief & anxiety
o Building trust & relational/psychological safety
• Reflected in supervision: felt out of depth, adapted plan to readiness & nervous system state.
• Adapted interventions:
o Guided visual imagery (leaving house confidently, calm breathing, steady posture)
o Linked imagery to dog as strength/grounding metaphor
o Micro-steps (e.g., 5 steps out front door, 5 days/week)
• Relational/Attachment-based support:
o Secure base: consistent, predictable, non-judgemental presence
o Emotion regulation: validation like caregiver soothing
o Gradual exploration: supported safe small steps outside
o Internal working models: rebuild confidence, challenge avoidance/hypervigilance
Results:
• Continued engagement despite difficulty with new people.
• More open discussion of parental grief; shared memories.
• Gained insight into link between avoidance & panic.
• Small behavioural steps → increased sense of control & reduced overwhelm.
• Strengthened therapeutic alliance → safe, non-judgemental space.
• Gradual re-engagement with disrupted daily life.
Reflection:
• Change is individualised; standard recovery markers are guides, not rigid targets.
• Supervision helped process:
o My emotional responses to “stuck” client
o Revisiting formulation, considering grief & attachment, readiness for change
• Commitment to quality of care = adapting interventions to client needs
• Tailoring cognitive, behavioural & emotional approaches → compassionate, effective progress
Example of client with complex needs/got worse
Could apply SD theory alongside
Context:
• Pp on acute mental health ward; referred for emotional regulation & stabilisation to decrease risk.
• Presentation fluctuated; increased frequency/severity of dissociation & self-harm.
• Felt frustrated & incompetent as pp was not improving despite intervention.
Actions:
• Included pp in reflective thinking and collaborated on interventions.
• Supervision: Honest reflection about feeling unproductive; used guidance to reframe approach.
• Identified barriers to applying stabilisation skills; focused on:
o Bodily, thinking, and emotional awareness
o Understanding window of tolerance
o Tailoring interventions to individual needs (autism, sensory overload, rigid/concrete thinking, over-reliance on threat system)
• Built therapeutic alliance as a secure base → reliability, belief in pp’s ability to improve.
• Practiced skills together; reinforced learning with visual aids & safety plans.
• Emphasised collaboration and co-creation of support plan.
Results:
• Reframed understanding of meaningful change → not just symptom reduction, but creating safety in the therapeutic relationship.
• Pp’s competence recognised; intervention shifted to addressing barriers to applying skills.
• Improved emotional awareness, engagement, and application of stabilisation strategies.
• Sessions were collaborative and accessible to pp’s preferred learning style & communication needs.
• Staff informed about tailored approaches; safer, more effective ward support.
Reflection:
• Interventions must be individualised and accessible, matching pp’s emotional state and learning preferences.
• Understanding pp’s distress in context is key to formulation.
• Meaningful change ≠ fixing problems; requires tolerance of uncertainty and flexibility.
• Leadership and determination needed to challenge standard medicalised approaches, balancing psychological care with risk reduction.
• Collaborative, tailored approaches enhance pp engagement and skill application.
Example of working together/ ethical dilemma/knowing limits
C – Context
Assistant Psychologist on an acute adult mental health ward.
Psychiatrist wanted to discharge a long-term patient labelled as “manipulative.”
Patient had attachment vulnerabilities and autism; abrupt discharge could trigger self-harm or overwhelm.
Ethical tension: balancing patient autonomy, safety, and systemic pressures.
A – Action
Stayed responsive, not reactive; used supervision to process personal frustration.
Adopted a curious, non-confrontational approach to MDT discussions.
Shared psychologically informed formulation (attachment + autism) to explain patient behaviour.
Highlighted strengths and countered negativity bias associated with personality disorder diagnosis.
Collaboratively co-created a graded discharge plan with support structures and gradual community transition.
R – Result
Patient successfully discharged with needs met, risk mitigated.
MDT adopted psychologically informed perspective rather than solely medicalised view.
Built stronger collaborative relationships within the team.
Optional – Reflection (high-scoring addition)
Recognised how diagnostic labels and team narratives can shape decisions and bias perception.
Learned to manage personal emotional reactions via supervision.
Balanced advocacy for the patient with respect for MDT and systemic constraints.
Reinforced importance of psychologically informed MDT working, ethical reasoning, and knowing limits of influence.
A time you managed responding to distress and managing risk
Clinical example: LP
acute crisis / immediate risk / containment / knowing limits.
Context
• Conducted a triage assessment for Louise, who disclosed recent suicide attempts and had not sought medical support due to mistrust.
• She presented in high distress, tearful and overwhelmed — conceptualised as sympathetic nervous system activation (Polyvagal Theory).
• Clinical challenge: balance emotional containment with thorough risk assessment, ensuring safety and effectiveness.
Actions
Responding to distress
• Provided a safe, non-judgemental space through active listening, validation, and empathy.
• Spoke slowly, calmly, and steadily to help regulate emotional arousal and support co-regulation.
• Prioritised containment before problem-solving, “sitting in the mud” rather than immediately offering solutions.
• Affirmed her strength in opening up and used her own words in documentation to accurately reflect her experience and maintain a client-centred approach.
Safety and effectiveness
• Conducted a structured but sensitive suicide risk assessment, exploring:
o Suicidal thoughts, intent, and planning
o Protective factors such as social support
o Feelings of entrapment or hopelessness
• Balanced information gathering with maintaining emotional regulation, ensuring questions did not overwhelm.
• Conceptualised risk using the Integrated Motivational-Volitional Model, considering both drivers and moderators of suicidal behaviour.
Knowing limits
• Recognised that risk level required escalation beyond my role.
• Obtained consent for referral to mental health services, safeguarding wellbeing while respecting autonomy.
• Maintained professional boundaries, recognising the importance of supervision and multidisciplinary collaboration.
Result
• Louise, initially hesitant, agreed to engage with support and continue attending sessions.
• She demonstrated increased willingness to discuss her wellbeing and took steps to accept help.
Reflection
• Distress can be held safely while also managing risk; emotional containment is essential before problem-solving.
• Learned the importance of asking the right questions to establish level of risk (not all suicidal thoughts equate to intent, and absence of intent doesn’t eliminate risk).
• Documenting in the client’s own words supports accuracy, client-centred practice, and ethical standards.
• Models like IMV help structure thinking about risk and protective factors.
• Supervision and collaboration are crucial when managing complex risk, reinforcing professional limits and safe practice.
Example of demonstrating nhs value of respect & dignity
C – Context
• Working therapeutically with MN.
• Power dynamics present at multiple levels:
o Interpersonal: History of feeling unsafe in relationships; bodily autonomy and safety concerns.
o Professional: Previous experiences of feeling directed or misunderstood by services.
o Structural: Stress and instability linked to conditional DWP support and financial insecurity.
• MN often described as “self-sabotaging,” with professionals viewing behaviour as avoidance or non-compliance.
A – Action
• Chose validation over pathologising.
o Reframed “self-sabotage” as a protective strategy developed in response to threat.
o Co-explored a shared concept of “protection mode.”
• Used Transactional Analysis collaboratively to:
o Explore power dynamics.
o Strengthen “Adult ego state” responses.
o Reduce internalised critical or shaming voices.
• Reflected rather than directed — prioritised autonomy.
• Created space for MN’s spiritual beliefs, integrating them into:
o Goal-setting
o Meaning-making
o Strength identification
• Explicitly named structural power (DWP, conditionality, bureaucracy) to validate confusion and pressure.
• Encouraged agency:
o Small behavioural goals.
o Assertive communication.
o Reconnection with passions and interests.
• Maintained clear professional boundaries (confidentiality, structure, next steps) to ensure safety.
R – Result
• MN shifted from a “freeze” state to more engaged participation.
• Increased insight into protective patterns.
• Greater sense of autonomy and self-efficacy.
• Strengthened therapeutic alliance.
• Reduced shame linked to previous service interactions.
🌿 Reflection (This Is Where You Score Highly)
• Recognised importance of assessing MN’s mental state before interventions — ensuring not to push growth when in freeze.
• Learned that respect and dignity require:
o Naming power
o Avoiding pathologising survival strategies
o Creating psychological safety before change work
• Reflected on how my own spirituality may have contributed to a non-judgmental stance — remained mindful not to impose it.
• Recognised that empowerment is relational and systemic, not just individual.
Example you have shown cultural humility?
C – Context
• Client: Ana, survivor of 10 years domestic abuse, separated in 2017.
• Experienced structural and interpersonal discrimination:
o Cultural suppression (unable to speak Chinese, practice traditions with social involved).
o Disempowered in legal and social service settings.
o Experienced bullying in prison; ongoing fear and anxiety as a foreigner.
• Power dynamics:
o Structural (court, DWP, probation, social services)
o Interpersonal (professionals perceived as dismissive or biased)
o Personal (Ana’s fear, reduced trust, and sense of vulnerability)
A – Action
• Prioritised building trust: aware that Ana had experienced systemic betrayal and often did not trust professionals. Focused on ensuring she felt heard, seen, and respected, and feel safe
• Validation over pathologising: reframed coping as survival/protection mechanisms.
• Respecting identity and values: created space for religious beliefs, integrating these into goal-setting and coping strategies. Christianity gave her strength
• Acknowledged structural and relational power: explicitly named barriers and validated feelings of discrimination, fear, and frustration.
• Reflective awareness of own privilege: recognised that my whiteness could represent part of the systemic power that had contributed to Ana’s oppression; used this awareness to avoid assumptions, centre her perspective, and approach interactions with humility.
• Encouraged agency: guided goal-setting, assertive communication, engagement with passions/interests.
• Suggested self-care strategies: gentle movement, breathing exercises, and boundary-setting to manage stress.
R – Result
• Ana began to feel heard and empowered, demonstrating increased agency (petition, goal-setting, communication with caseworker).
• Strengthened therapeutic alliance and trust in professionals- was very grateful in carrying this as piece of kindness to challenge thoughts around mistrust
• Increased insight into systemic and interpersonal power dynamics shaping her experiences.
• Positive movement toward emotional safety, self-care, and reconnecting with her cultural and spiritual identity.
Reflection
• Prioritising trust and being aware of my positionality (whiteness, professional role) was key to creating a safe, respectful space.
• Recognised need to continually check Ana’s mental state before interventions — avoid overwhelming her.
• Explicitly acknowledging systemic power helped Ana reframe experiences of discrimination and reclaim agency.
• Reinforced the importance of supporting client autonomy while navigating structural and interpersonal barriers.
