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Holding Risk on the Brink of System Collapse

How can we continue to hold risk when so many clients are in crisis, and when under-resourced support and emergency services appear on the brink of collapse? Jude Boyles, manager of a Refugee Council therapy service, shares the mounting – and perhaps familiar – pressures being experienced by her team, and explores what we can do to contain clients and colleagues in a world where ambulances may never arrive.


As therapists, there will be occasions when we have to report an adult or child safeguarding concern or arrange an immediate mental health assessment for a client who has become unwell. It can be a complex process to manage and often leaves clients feeling angry and betrayed, even if they have consented to information being shared. Of course, for some it can be helpful and/or a relief. 

When working with refugees, informing others of such concerns has been a difficult process, as clients have often been frightened and intimidated by my decision to involve the state in their family. I have done my best at these times to provide a comprehensive description of the role of social services and/or statutory mental health services. But it isn’t always easy for clients to understand a process so culturally unfamiliar, especially if they are newly arrived and in the midst of a crisis. I can also not predict how professionals will respond, and whether a qualified interpreter will be booked for these crucial meetings. 

Over the past 20 years of working with refugees, when I have informed others of my concerns, however difficult it has been, I have at least been reassured that I have acted to ensure the safety of a child or vulnerable adult. Sometimes the therapeutic relationship has been damaged, but sometimes it has been deepened. At such times, I know that a necessary process has begun. On the occasions when I have had to ring an ambulance, I have waited for a short time with a client in the clinical room or on the phone knowing that emergency services will attend very soon. 

However, in the last year, I have begun to realise that emergency services are no longer able to respond quickly and indeed, may not respond at all. On one occasion I rang an ambulance, and it took approximately eight hours for them to attend, with me having re-rung them a number of times. On another occasion, they did not attend at all. I tried to reassure family members that an ambulance was on the way, but it turned out to be a false reassurance. I then had to develop a safety plan that acknowledged that emergency services might not be able to attend quickly if rung by a concerned member of the family. 

It is hard to find the words to describe how I felt when I explained to a young family member that they should ring an ambulance if their father’s mental health worsened, while discussing the narrow range of options available to them if emergency services did not come. 

These crises are happening more in my service for many different reasons. One is the fragility and under-resourcing of mental health services, another the lack of timely, flexible and culturally accessible responses to mental health distress. Either waiting lists for psychological therapy for trauma are closed or clients can wait for up to 18 months. 

In both of the above examples where I rang an ambulance, I had previously telephoned and written to clients’ GPs a number of times about my concerns. At the point when the client was now in crisis, their committed but weary responses were both collegial and sad as we explored the least harmful way of getting help for the client. 

I will never not act to protect, and sometimes sustained pressure can lead to a helpful and collaborative response from agencies that is both reassuring and hopeful. At other times, a skilled and thoughtful practitioner is immediately responsive and works alongside my team to keep someone safe, asking for our advice if they are new to the refugee context and involving the client in all dialogues and next steps. 

Sadly, the latter happens less frequently these days. More often than not, non-English speaking clients are just given a crisis team number that they are very unlikely to ring. 

Containing my team during these crises is a priority for me, and ensuring we give ourselves the space to be outraged when our sustained attempts have not led to the intervention we think is needed. In the absence of an external structure to support us to contain some of the risk we are managing, I need to work harder to support my team, so therapists don’t feel alone when a client has become desperate or unwell. 

I have to ensure that we still always act, even if we may have to battle to get the skilled emergency response needed.


Jude Boyles

Jude is the Manager of a therapy service for the Refugee Council, working with Syrian refugees resettled via the Vulnerable Person’s Resettlement Programme (VPRS). Jude edited Psychological Therapies for Survivors of Torture for PCCS Books and published Working with Interpreters in Psychological Therapy with Routledge. She specialises in working with refugee survivors of torture/war and human rights abuses, including gender-based abuse.

In 2003, Jude established the first Freedom from Torture (FFT) rehabilitation centre outside of FFT’s headquarters in London, and managed the service for 14 years. As part of this role, she provided clinical and management supervision to therapists and managers working in the refugee field in the region and carried a caseload of torture survivors. Jude has worked as a national trainer in the field of therapy with refugee survivors of torture for 18 years but has also trained extensively in the field of domestic violence and child sexual abuse for 23 years.

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