'Psychology in the UK is way behind the States'

Expert's Corner with Dr Louis Monaco, Clinical and Forensic Practitioner Psychologist.

Dr Louis Monaco

Dr. Louis Monaco is a Clinical and Forensic Practitioner Psychologist, and a Chartered Clinical Psychologist of the British Psychological Society. He runs a private practice in London and Paris and carries out expert witness work. 

Having originally trained as an accountant at Hofstra University in New York in 1985, Dr Louis Monaco’s current role is miles away from his days immersed in figures and balancing books. Today, he runs his own private psychology practice in London and Paris with extensive experience in clinical work in forensic/correctional settings and providing individual and group psychotherapy. He specialises in long-term individual psychotherapy, marital/relationship psychotherapy and psychological assessments and evaluations.

“I trained to be an accountant, I did it for four years and I hated it,” says Dr Monaco. “One day I was at work typing numbers into a machine and I had this realisation that it was meaningless and I couldn’t do this work for the rest of my life.”

“I wanted to make a contribution, to help people. I had a fascination with the criminal mind and had aspirations to be a profiler thanks to the TV series ‘The Profiler’, (which was compelling, particularly to an accountant). I was just fascinated by how the mind works and then how that relates to families and couples,” he adds.

The prison went into lockdown on September 11

In September 1994, Dr Monaco studied a Master of Science at San Francisco State University, specialising in Marriage and Family Therapy. Having “not been tortured enough”, Dr Monaco then studied for a PhD in psychology at the California School of Professional Psychology.

While studying for his doctorate, he worked as a Psychiatric Counsellor/Mental Health Manager for the Jail Psychiatric Services at the County Jail in San Francisco. He undertook emergency mental status evaluations, involuntary hospitalisations, crisis assessment and treatment and carried out long- and short-term individual and group therapy with inmates in the County Jail system.

“There was a lot of psychodiagnostic testing and therapy with people who hadn’t been sentenced,” said Dr Monaco. “It was hard work, people were trying to kill themselves, the prison would go into lockdown, in fact I was there on September 11 and there was a lockdown.”

He admits that it was somewhat intimidating when he first started working there “as you walk in and the door slams behind you, you are locked in there, the guards are there”.

Ironically, it was a dream to live in the EU

One of his first roles on graduating was clinical supervisor at Riker's Island Prison Health Services in New York where he provided psychological services to patients within the jail facilities who exhibited difficult or complex problems requiring a higher level of professional intervention.

Dr Monaco explains that it was very run down and there were no windows. It could also be an intimidating environment. “I witnessed violence but I did not experience it directly. Generally in prison, inmates are amenable to the mental health staff because they know we are there to help and they are not usually violent to mental health staff unless they are psychotic. However, I have seen violence towards the guards and other patients.”

Typically, the offenders would be people with psychosis, personality disorder or drug abuse disorders. Many had come to the attention of mental health services for the first time in jail. They may have been involved in a violent offence in the community and been placed in prison and only then would they receive mental health care. Often when offenders had become mentally ill having taken too many drugs, they often improved once the drugs were removed.

Another of his first roles in psychology in the States was at Saint Peter's University Hospital Child Protection Centre in New Jersey where he was a Psychologist/Post-Doctoral Intern where he carried out extensive psychological evaluations on Family Services referred individuals and families and adult, adolescent, and child perpetrators and/or victims of alleged abuse.

Psychology in the UK is way behind the States

Dr Monaco worked in the States for four to five years, largely within correctional services working with people with mental health problems who had broken the law. However, in 2009 he followed his dream to move across the pond to the UK as “ironically, I had always wanted to live within the EU”. He took a role as consultant psychologist at Cygnet Hospital in Stevenage, Hertfordshire where he headed up the Department of Psychology and provided individual and group psychotherapy to adults hospitalised under the Mental Health Act 1983 which he carried out until 2011.

While Dr Monaco is pleased he made the move, he has witnessed a huge disparity between the States and the UK. “The practice of psychology in the UK is really behind the States and other EU countries in terms of training and status – way behind.”

“Here it would have been impossible to retrain, I would have had to have gone back to my under-graduate course and start over,” said Dr Monaco. “It’s not just the States where things are improved, other EU countries like Italy have great training.”

In the States, whether you are a clinical, forensic or counselling psychologist, you study for five years, for a doctorate and then specialise. In the UK you study for a three-year psychology degree. But because Dr Monaco didn’t have the under-graduate degree, the British Psychological Society initially refused him entry. It took a number of arguments where he stressed he had a Masters’ degree and Doctorate that he was finally allowed to join.

“When I came here I thought I was going to go out of my mind, I worked at the hospital and OTs were seen as ‘above’ psychologists. In status and scope of practice, I had much more liberty in the US,” he adds.

Dr Monaco currently runs his own independent practice and takes on expert work, including assessments for WillisPalmer. Psychology, for him having studied in the States, is a mix of being a scientist and practitioner, learning all the latest up-to-date research and applying it in a professional setting with children, families, individuals or couples.

Parents are hostile, but it is not aimed at me

For WillisPalmer, Dr Monaco undertakes psychological assessments of parents in court proceedings. This involves clinical interviews and psychological testing, putting the results of these through ‘formulation’ and coming up with a theory about the level of functioning in the parents. These parents will have come to the attention of the local authority either for the first time or through ongoing issues relating to substance abuse, mental health, domestic violence or other issues affecting parenting. “Generally I will be assessing if they have the capacity cognitively or personality to provide adequate care for children, either with support and if so what support, or without it.”

“It tends to be a specific assessment and then the local authority may have certain questions or areas they want looking at. You always have to be flexible. If they have questions about cognitive functioning then I would do an IQ test, if the authority had questions about parenting then I would use a parenting assessment or personality test,” explains Dr Monaco.

It can, however, be difficult to engage with some parents who while they are not hostile towards Dr Monaco per se, are cautious about the local authority and see his involvement as an extension of that. “It’s not aimed at me personally. Having worked in prisons, it’s not difficult to deal with and I explain that it is an opportunity for them to put their side of the story across.”

Prison work is very time consuming

Dr Monaco also carries out expert work with children either relating to care proceedings or problematic behaviour or risk assessments for the local authority to assess whether a child may pose a danger to other children, potentially with violent or sexual behaviour. While Dr Monaco has worked with children as young as six who have been victims of abuse and where he would use play as part of the assessment and other age-appropriate techniques, he prefers to work with adolescents.

Another string to his bow for the expert work he conducts is his forensic work where, for example, someone may have committed a crime in the community and a solicitor has requested an assessment to see whether the person is presenting a mental health disorder and if so, what level of risk is there for that person to remain in the community and what intervention might help. He may also need to ascertain whether there is substance abuse and whether that is contributing to the criminal behaviour. Dr Monaco would produce a report which would go to the courts and it is this type of work he has done a lot of in the past.

“It is very time consuming, especially if you are working around correctional services and their timescales as you may get to meet an offender for an hour and interview them, then they may have to go for a meal and so you have to wait an hour for them to return,” he adds.

Dr Monaco’s array of skills are testament to his journey since leaving accountancy, and more recently the States, and for him it has definitely been a good move. “I love the UK, I love what I do and I work with a great network of colleagues here in the UK,” he concludes.

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