Heart and Head

It is an interesting fact that most people make decisions based on their emotional “gut feeling” but then justify them logically in retrospect. So you pick a house or a car that feels right, but tell people you chose it because of the miles per gallon or the lovely neighbourhood. Maya Angelou put it rather perfectly when she said

I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.

However, if you ask me why I think BERRI can benefit a placement provider or a local authority, then my first port of call is facts and explanation, rather than finding the emotional hook that will persuade people that it feels like the right thing to do. Maybe its the scientist-practitioner thing showing through, but I feel like it is more valid or legitimate to make the case in the language of logic and facts, than to try to pull on people’s heart strings, and I am very loathe to make any claims I can’t prove with quantitative evidence.

I think that is partly because of my personal style. I have previously blogged about how I am not a typical clinical psychologist in terms of not seeing myself as primarily a therapist. I wonder whether that is because I tend to start with a more intellectual approach, and address the language of emotions less than many people in my profession. For example, I like to operationalise how I conduct assessments, or the information I like to share in consultations, so that it can be replicated more easily, and to evaluate everything I deliver to check that it is effective. It doesn’t mean I’m not mindful of feelings that arise for people I interact with, or in myself, or that I’m emotionally closed off. In fact, quite the opposite, as I quite often find myself becoming tearful when discussing the stories of the children and families that I’ve worked with (or when reading the news or discussing the current political situation, and even when watching films or reading novels for that matter). I’m likewise prone to a giggle or a belly laugh, sometimes about entirely inappropriate things. I’d say I’m pretty comfortable expressing both positive and negative feelings, and responding to those in others. But when communicating information to others, particularly in writing or as a presentation, science is my starting point.

Maybe it comes from eight years of academic study and writing before I qualified as a clinical psychologist, or maybe it is because I am used to presenting to my professional peers through journal articles and conference presentations. But ask me to explain about a topic or project and my first instinct is to tell a summary of the context and then share my methods, results and conclusions. However, I am mindful that to be an effective salesperson I need to be able to pick out the message that will be emotionally resonant with the listener to focus on, and to capture hearts as well as heads.

To that end, I’ve been working on how we communicate the impact of BERRI on individual children, as well as its benefits for organisations and commissioners. To do this we have started to capture some stories from cases where BERRI has made a difference, and then to anonymise these enough to present them in the materials that I present at conferences and on social media. I had always thought that the lovely animation that Midlands Psychology commissioned to show how they had changed the autism service was a brilliant example of this. I felt like they managed to tell the important elements of their story in an engaging way, and that this couldn’t help but make people see the improvements they had achieved. We didn’t have their budget, but I wanted to capture something similar in our case study animations.

Luckily for me, I had recently reconnected with an old school friend, Joe Jones, who is brilliant at this kind of thing. His “explanimations” for the renewable energy sector had been great at simplifying complex ideas, and he knew all about my business, as he had been helping us to look at our comms. We talked about what I wanted from an animation, the tone we wanted to convey, and the stories that we could tell about different case examples. Joe showed me how The Girl Effect had been able to capture an emotionally compelling story in very simple graphics, where the character created represented every girl, because she was effectively anonymous and culture free.

The result is a short animation that I think captures what we are trying to achieve with BERRI. Obviously, there is more information that will set the simple story into context, which I can tell people in the rest of my presentation, or as they enquire. But as a hook that helps people to see the impact it can make, I think he has done a great job.

BERRI Case Study – Daniel from Joe Jones, Archipelago.co.uk on Vimeo.

What do you think? Does it explain what we are offering? Does it appeal to both heart and head?

Can you make things better for children and young people in Care whilst saving money?

That seems to be the critical question in an age in which there is no money in the budget to try anything innovative just because it will create improvement. To be able to try anything new that involves spending any money we have to evidence that double win of also saving costs. A few years ago when I was in the NHS, I found that really frustrating – I had so many ideas about how we could do things better by creating new services or better collaborations with other agencies, or reaching out to do the proactive and preventative work that would save money down the line, but it was almost impossible to get them off the ground because the budgets were so tight. Since then I’ve tried various things to unlock the spend-to-save deadlock, but it was only once we started looking at the economic impacts of some projects using BERRI that we had clear evidence that we could save money whilst making services better, and on a fairly substantial scale. Our pilot in Bracknell Forest saved £474,000 in the first 12 months whilst making services better and improving the outcomes for the young people involved. And that was just a small scale pilot within a single local authority.

After so many years of being told that improving outcomes whilst saving costs would be impossible it sounds unlikely, but it is true. We made life better for the children involved – in some cases in ways that entirely changed the trajectory of their lives – whilst reducing costs for the local authority. The savings generated would be enough to fund services to address the mental health needs of all Looked After Children whilst still lowering the overall cost of Care. I’m not prone to hype, but that feels pretty extraordinary! Importantly we did it whilst also making life easier for the carers, professionals and placement providers involved. So it is no great surprise that we are now working with many Local Authorities to scope out and deliver wider scale projects.

So, what are we doing that is different? And where do the savings come from? Using BERRI we are identifying psychological needs effectively, and then addressing them early. For some young people that leads to significant change in their behaviour, risks or mental health, that then opens the door to different placement options, and for a small proportion of children the placement costs are substantially reduced. I’m not talking about forcing children in residential care to move to foster placements for financial reasons. I’m talking about better identifying the types of placements and services that young people need. For some, that will mean that they get to access residential care without having to break down a long series of foster placements to do so. For others it will mean that they get access to much increased mental health input, or specialist services. For many it will mean helping their carers to better understand their needs so they can make minor adjustments to the day to day care. But for some children it can open (or reopen) the doors to a family placement.

It may also have an impact on their longer-term trajectory, as it is well known that addressing mental health needs in childhood is easier and more cost effective than trying to address the difficulties they go on to develop in adulthood if these needs are not addressed. Using the BERRI helps carers to see behind the presenting behaviours and to recognise emotional, relational or attachment needs, or feel empowered to support these more empathically. Importantly, it can evidence the impact of the great work that many carers and organisations are doing already to support children by showing the changes they are making over time. It can help to set goals to work on, and to monitor what is and isn’t working effectively to create positive change. BERRI also helps to pick up learning difficulties, neurodevelopmental difficulties and disorders, so that children can then be more thoroughly assessed and care and education can be pitched appropriately.

We are also learning from our increasing data set what scores are typical in different settings, how individual children compare to the general population, and which variables are important in preventing negative outcomes in adulthood.

I sometimes use the metaphor of the cervical cancer screening programme. At a cost of around £500 per woman each 3-5 years, the screening programme prevents 2000 deaths per year. About 5% of women screened have abnormal cells, and 1-2% have the type of changes that are treated to reduce risk. As a result women who are screened are 70% less likely to get cervical cancer, which has an enormous human cost, but also costs £30,000+ to treat. Screening has saved the NHS £40 million. Most importantly it has led to the discovery that the human papillomavirus is significant in the development of cervical cancer. This has led to preventative treatment programmes with 10 million girls in the UK receiving the HPV vaccination. This has reduced the rates of cervical cancer (with 71% less women having pre-cancerous cervical disease), as well as preventing genital warts (by 91% in immunised age groups). It also has the potential to reduce other forms of cancer, as HPV is responsible for 63% of penile, 91% of anal, and 72% of oropharyngeal cancers, with this and the importance of herd immunity leading to the decision to immunise boys as well as girls in many countries.

I would argue that the case for psychological screening, particularly in population groups that have experience trauma, abuse or neglect, is even stronger. More than half of children in Care have a diagnosable mental health condition, and half of the remainder have significant mental health need that doesn’t reach diagnostic thresholds or doesn’t fit into a diagnostic category. They also go on to higher risks of a range of negative outcomes than the general population, including having a higher risk of heart disease, cancer, strokes, fractures and numerous other health conditions, as well as more than fifty times higher risk of homeless, addiction, imprisonment, requiring inpatient mental health care, or having their own children removed into Care. Like cancer, these have an enormous human cost on the individual and their network, and they also have a huge financial cost for the public purse (some estimates suggest £2-3 million per young person leaving Care, when including lower contributions to tax, increased benefits and the cost of services). If we can understand and address the issues that lead some young people down these more negative paths, and address those needs as early as possible in their lives, hopefully we can increase the proportion of young people who survive difficult early lives and go on to healthy happy adult lives.

If you want to learn more about BERRI and the impact it can have on your services feel free to get in touch. Or you can come and learn more about the pilot in Bracknell Forest and the larger scale projects we have started to expand on it, as I am presenting at the NCCTC next month with Matt Utley from the West London Alliance.

How not to apply for a job in psychology

I’ve been shortlisting for a new post today, as we’ve already received 43 applications for the advert I put up yesterday morning*. For a profession in which there is a narrative that prestigious Assistant Psychologist posts are almost impossible to get, the quality of applications is surprisingly poor. I don’t mean that the applicants themselves are surprisingly poor, as they seem to generally be alright, but the way they have applied for the post is, for far too large a proportion of those applying, pretty disappointing. It isn’t going to affect the outcome of the process, as there are some really good applications so we won’t have any trouble finding enough to interview, but there are far too many people who rule themselves out of the running unnecessarily. Many of these applicants might be quite good, but their applications fall far short of my shortlisting criteria for really obvious and easily avoidable reasons. That means that for people who do follow a few simple tricks** you greatly increase your chance of successful applications – not just in my post, but in any application within the field of psychology, and probably most of the advice will generalise to other job applications too.

Before you think that I’m a control freak with unreasonable expectations of applicants, please remember that the context is that 70+ candidates will apply for my vacancy before I close it, and NHS posts will typically attract 100-200 applicants within a short period of time, leading some to close in just a few hours. The balance of supply and demand here means that it’s a shortlister’s marketplace, and only the best applications from the best applicants will lead to an interview. That means that qualified CPs selecting for AP posts have to set high standards to let them narrow down the number of applicants quickly to a manageable amount that they can then shortlist in more detail. And having spoken to many other people who have been responsible for shortlisting similar posts and seen the posts on the thread on this topic on the clinpsy forum, my expectations and frustration with candidates who fail to do the simplest things to present their application properly are echoed by many of my peers.

Whilst these posts are particularly competitive and the application process has some sector-specific features, like the nature of GBC, and the relative values given to particular kinds of experience, what I am talking about are basic job seeking skills that should be taught by every career service or recruitment website. Not only that, but if you do a search on clinpsy you will see that the expectations held by people shortlisting for AP posts are clear, and there is a lot of advice available on this topic in the public domain. We are not expecting people to crack some secret code or have access to hidden insider information: Most of the things that would make the difference are things that require common sense and a bit of effort. My main grumble is as simple as people not reading the instructions on how to apply that are given in the job advert and firing off applications that aren’t specific to the post or don’t contain the required information, or that are really badly presented.

When it comes to my current post I’m not even asking anything too onerous. I haven’t set a task or asked anything unusual. I just want candidates to send a short CV and a covering letter saying how you fit the requirements of the post, with details of two referees. Surely that’s the minimum expectation when applying for a job, and pretty parallel to the NHSjobs expectation of giving education and employment history and then writing the supporting information and references? Yet a significant proportion have submitted applications with no covering letters, no references, or no information about why they want the job or are suited to it. To me that’s like going fishing but not taking a rod or a net.

In terms of essential criteria I’ve asked for a degree conferring GBC at 2:1 or better (or a degree level qualification in statistics or research), along with a driving license (or a transport plan for candidates with a disability to be able to complete the job). Yet many applicants have told me they will complete their undergraduate degree this summer, or don’t have a driving license. There are international applicants who haven’t shown me they can lawfully live and work in the UK. There are then applicants who haven’t given me information I need in order to see they meet my essential requirements. Perhaps they qualified abroad or with joint honours and they haven’t told me that they have GBC. Several haven’t given me a degree grade. Others might tell me that they had a particular job, but not give the hours or the dates so I can’t see how much experience they gained.

The process has really taught me how NOT to apply for a job in psychology, and I thought that might be expertise worth sharing. If you follow the advice I’ve numbered below, you too can be confident that you will maximise your chance to not secure a post!

So my first set of tips on how not to apply for a job are:

  1. Apply for jobs where you don’t meet the essential criteria
  2. Do not read the instructions on how to apply
  3. Do not write a covering letter (or supporting information section) at all
  4. Do not specify your degree grade
  5. Do not mention if you have GBC, even if you have an atypical qualification
  6. Apply from abroad but don’t worry to mention that you have the right to live and work in the UK
  7. Don’t tell me whether posts were full time or part time or the dates when you worked there

The next issue is that many (and in fact probably most) applications don’t tell me why you want this particular job, or how you meet our person specification. They fire off information that tells about their experiences and skills, but does nothing to show how they meet our shortlisting criteria, which are spelled out in the person specification. Few have told me why they want this job in particular as opposed to any job with an AP title or a CP supervisor. Some tell me about their aspirations to gain a training place and/or to have a career in clinical psychology, but (whilst I am aware that the post is a good developmental opportunity and I’m happy to support the successful candidate to develop) I’m not recruiting someone to help them achieve their aspirations. I’m recruiting to get a job done within my team, and their aspirations don’t tell me why they will be better at that job than the other 30+ people who have similar aspirations.

A significant proportion of applications consist of just a CV, perhaps with a very brief generic covering note. Many look like a mass mailing that the candidate sends out to every job listing that contains particular keywords. The result is that they feel like someone reading me a script to try and sell me double glazing or PPI claims without knowing anything about me – they have invested minimum effort but hope that if they apply to enough posts one might bite. In fact, many applications feel like they’ve taken less time to send out than they would take for me to read, and the impression given to the short-lister is that the person doesn’t care about the post at all.

Maybe it’s something about the internet age that people expect to be able to apply for a post with just a couple of clicks, like putting an item on an online store into their basket and then clicking to check out. If you had to invest the effort in phoning up for an application form and then filling it in by hand, as you did when I applied for my AP post in 1995, it might seem more obvious that you needed to make that effort count. But even then not every candidate would explain why they wanted the post. However the internet age also makes it easier to cut and paste the right chunks of information or to edit existing text. So it also makes it easier to tailor an application to a specific post.

So my next set of tips on how not to apply for a post are:

  1. Don’t read the job advert – the job title, pay and location are all the information you need
  2. Fire off a generic CV with no information about why you want the post or how your skills are suited to it (for bonus marks express interest in a different client group or service)
  3. Don’t even worry to read the person specification, that’s not important
  4. Don’t tailor your application to the job, just send the same application out to every post, regardless of the context or population.

The other big advantage is that the internet lets you check spelling and even grammar, so you really don’t need to submit applications that are peppered with typos and spelling mistakes. If you are dyslexic, get someone else to check it before submitting. If you feel too much time pressure to delay individual applications for proofreading then prepare the content you will need to configure most applications in advance so you can get someone to proofread your main blocks of text in advance. Word processing software also lets you count the number of characters, words and pages before you paste content in to your application, so you can easily follow any specified requirements. Which is why it is so puzzling to get six page CVs when I set a limit of two.

There are then other issues with how people present their applications. I get that pasting a CV into a recruitment site can mess with the formating, but you can normally use a preview feature to get the chance to see how it will appear to a recruiter, so it is worth checking. Simplify layouts and fonts and remove massive gaps that appear so that the CV looks neat and tidy. Keep it as short as possible. If I can write my CV on two pages, having worked in psychology for 24 years, managed teams in the NHS and now running my own business, I’m pretty sure that you don’t need six pages by the age of 23. And I’m sorry to break it to you, but I don’t care what your responsibilities were when you worked in that shop, or pub, or holiday resort in the summer before your degree. If you really want to mention it, I’m fairly sure one line would cover it. Otherwise it looks like you can’t prioritise – which is off-putting because being able to pick out the most salient information is an essential skill when deciding what information needs to go into a report.

So my next set of tips on how not to apply for a post are:

  1. Make lots of typos, and ensure to include as many spelling mistakes, punctuation errors and examples of poor grammar as possible (for bonus points, you could spell the name of the organisation or short-lister wrong, or try some text-style abbreviations)
  2. Lay your CV or application out so it is as unintelligible as possible, and definitely don’t check how it will appear in the application system
  3. Don’t worry about any requirements with regard to length, more is always better
  4. Put in lots of information about irrelevant experiences, such as work in retail and hospitality

I hope this blog doesn’t seem like I’m putting people who are just starting out in their psychology career down, or criticising those who have applied in a hurry for fear of the post closing before they have time to submit anything at all. My goal is entirely more positive – to share how simple it can be to make that impossible aspiration of gaining interviews for AP posts come true. There are certain really simple behavioural changes that can remarkably increase your odds of success.

So what can I do to improve my chances of gaining an interview?

First, apply to non-NHS job vacancies. It takes a little more effort to find them, and the quality can be more variable. However, they are a great foot in the door, and much easier to secure than their NHS equivalents as they tend to have lower numbers of applicants and to stay open a bit longer. If an NHS AP post means you have a 1 in 50 chance of an interview, a post outside the NHS might increase your odds to 1 in 15 for a fairly popular post, or even 1 in 3 if the post is only advertised on a company’s website and social media and not on a major recruitment platform. Yup, that one simple trick** can increase your chances by a factor of five!

Second, follow the instructions. Read the advert carefully and do what they tell you to do. If they ask for a two page CV make sure that you send one the right length. A 600 word essay? Well worth the effort, as sending it will double your chance of success compared to applying to a post without this requirement, as fewer other applicants will make the effort, whilst sending an application without it is posting your application straight into the no pile.

Third, tailor every application to show how you meet the person specification for that particular job, and to show you understand and are enthused about what the job will involve. Ideally you need to respond to every point of the person spec in a way that is clear and obvious to the shortlister, and probably in a similar order to that used in the specification. If they want a 2:1 or higher that confers GBC then you need to give your degree grade and specify it confers GBC, rather than assuming that the shortlister will know or be willing to check on Google whether this is the case. If you are applying from abroad or have international qualifications then it is worth stating whether you have the right to live and work in the UK, and explaining the scoring system and/or the UK equivalent of your degree grade.

Fourth, pick your battles. It is better to write fewer applications but to give each one more time so that it is of really good quality and tailored to the particular job than it is to send out hundreds of generic applications. Choose posts that you are enthusiastic about rather than applying to every AP post you see. Think about whether the location can work for you and whether you have relevant experience and/or transferable skills to bring. Make sure every application is up to the highest standards, even if this means they will sometimes close before you submit them***. In such a competitive field it is probably only worth applying for posts where you meet all the essential criteria.

Finally, check your working. Make sure you have spelt names and organisations correctly, and not made any silly typos or cutting and pasting errors. If you can, get someone else to read your text so you can get feedback on how to improve it. Even if that isn’t in time for the application you wrote it for, it will mean you don’t make the same mistakes next time. Preview the application to check the formatting if this is possible.

Then fire it off and cross your fingers!

 

*I’ll be reading more over the coming days too as we normally keep the advert open for a week or 75 applications, whichever comes first. Edited to add: We closed after 5 days and received a total of 86 applications. We invited five people to interview.

**cliche internet phrase

***In this circumstance it is worth sending an email to the appointing officer or point of contact given in the advert explaining what happened and attaching your application. They may consider it anyway, and even if they don’t you risk little by trying.

The misrepresentation of evidence

About a week ago I was involved in a heated twitter debate about this blog post. I felt, as I said on twitter and in my extensive comments about the blog, that it entirely misrepresented the evidence about Adverse Childhood Experiences by implying that because of risk multipliers within particular population groups, certain negative outcomes were almost inevitable for people with multiple ACEs. The author repeatedly asks rhetorical questions like “If 1 in 5 British adults said they were abused in childhood in the last CSEW (2017), why hasn’t our population literally collapsed under the weight of suicides, chronic illness, criminality and serious mental health issues?” Likewise, she asks how anyone can be successful after childhood abuse if the ACEs research is correct. I replied to explain that this simply isn’t what the data tells us or what risk multipliers mean, so the exceptions are expected rather than proof the finding is incorrect. For example the claim that a 1222% increase in the risk of suicide amongst people with 4 or more ACEs meant these people were doomed, in reality means that the odds increase from 1 in 10,000 to 1 in 92, meaning that 91 of every 92 people with 4+ ACEs do not die by suicide.

ACEs are a very useful population screening tool, and have provided incontrovertible evidence of the links between traumatic experiences in childhood and numerous social, psychological and medical outcomes that has been highly informative for those of us designing and delivering services. To me it seems like an example of how a simple piece of research can have a massive impact in the world that benefits hundreds of thousands of people. Yet that blog repeatedly implies ACEs are a harmful methodology that “targets” individuals and to is used to “pathologise and label children, arguing that those kids with the high ACE scores are destined for doom, drugs, prison, illness and early death”. It has been my experience that ACEs are used not to pathologise individuals, but to to highlight increased vulnerability, and to identify where there might be additional need for support. For example, I have used this data to argue for better mental health services for Looked After Children.

I felt that the repeated misrepresentation of the maths involved in interpreting risk multipliers undermined the entire message of the blog, to which I was otherwise sympathetic. (For the record, it is entirely appropriate to highlight bad practice in which it seems certain professionals are applying ACE scores to individuals inappropriately, and making people feel that their life chances are restricted or their parenting under scrutiny because of their childhood experiences of trauma). But unfortunately the author took my polite, professional rebuttal of elements of her blog as a personal attack on her – to the extent that she misgendered and blocked me on twitter, and refused to publish my response to her comments about my reply to her on the blog. That’s a shame, as the whole scientific method rests on us publishing our findings and observations, and then learning from the respectful challenge of our ideas by others with knowledge of the topic. But I guess we are all prone to defending opinions that fit with our personal experience, even if they don’t fit with the evidence.

Thinking about how uncomfortable it felt to see someone I considered to be a peer whose expertise I respected misrepresenting the evidence and being unwilling to correct their misconceptions when challenged, but instead trying to discredit or silence those making the challenge, it struck me that this was an example that highlighted a wider issue in the state of the world at the moment. Evidence is being constantly misrepresented all around us. Whether it is the President of the USA saying there is a migrant crisis to justify a wall (or any of the 7644 other false or misleading statements he has made in office) or the claims on the infamous big red bus that Brexit would give the NHS £350 million per week, or Yakult telling us their yoghurt drink is full of “science (not magic)” now that they can’t pretend live cultures are good for digestive health. There are false claims everywhere.

I stumbled into another example just before I started writing this blog, as I (foolishly) booked accommodation again through booking.com, despite the horrible experience I had last time I tried to use them (which remains unresolved despite the assurances from senior managers that they would reimburse all of my costs). I booked a room in a property in London which they have euphemistically called “Chancery Hub Rooms” to stay over whilst I delivered some training in Holburn. It wasn’t a hostel or a hotel, but just a small terraced house. This time it had keypad entry to the property and to the individual room, which is a system that I have used successfully several times in Cambridge. Unfortunately it didn’t work so well in London, as they changed the codes twice without informing me. Once this resulted in locking me out of the room on the night of my arrival (and meaning that the beeping on the door as I tried the various codes they sent me woke the lady in the neighbouring room, due to the total lack of sound insulation in the property) and then by locking me out of the property the following evening, when all my stuff was locked inside. It also had glass inserts above the room doors that meant your room lit up like Times Square when anyone turned the landing light on. I then discovered that the building (which I already recognised to be small, overcrowded and not complying with fire regulations) had walls like cardboard, when the couple in the next room had noisy sex, followed by noisy conversation and then a full blown argument that lasted from 3am to 4am – despite me eventually in desperation asking them quite loudly whether they could possibly save it for a time that wasn’t keeping everyone else in the building awake. Of course Booking.com didn’t see it as their problem, and the property management company just blamed the other guests for being inconsiderate.

So I felt like I should be able to reflect my negative experience in my review. But oh no, Booking.com don’t let you do that. You see, despite seeing that properties appear to have scores out of ten on every page when booking, you can’t score the property out of ten. What you can do is to determine whether you give a smiley that ranges from unhappy to happy for each of their five ratings (which don’t, of course, include quality of sleep or feeling safe). So if you think the location was convenient, the property gets a score above five out of ten, no matter what other qualities mean you would never wish to sleep there again. But worse than that, the Booking.com website forces reviewers to give a minimum length of both positive and negative comments, but only displays the positive comments to potential bookers. So my “It was in a quiet, convenient location” gets shown to clients, but you have to work out how to hover in the section that brings up the review score, then click the score to bring up the averages, then click again to access the full reviews, and then shift them from being ranked by “recommended” to showing them in date order to actually get an objective picture. Then you suddenly see that at least half the guests had terrible experiences there. However, there is no regulator to cover brokers, and fire regulations and legal protections haven’t caught up with private residences being divided up and let out as pseudo-hotel rooms.

But just as Boris has faced no consequences for his bus claims (even though he stretched them further still after the ONS said he had misrepresented the truth), and Trump no consequences for his lies, and the consultants selling contracts worth hundreds of thousands of pounds of public funds to children’s social care departments proudly told me they just wanted to get on with the doing without that slow process of validation, so the world carries on with little more than a tut of disapproval towards people and businesses who intentionally mislead others. Maybe I’m in the minority to even care. But I do care. I feel like it is the responsibility of intelligent people and critical thinkers, people in positions of power, in the professions and particularly in the sciences, to ensure that we are genuinely led by the evidence, even if that makes the picture more complicated, or doesn’t confirm our pre-existing beliefs. To counteract this age of misinformation, we all need to be willing to play our part. That is why I have always placed such a focus on evaluations and research, and have developed my screening tools so slowly and thoroughly, despite the fact that potential customers probably don’t see this as necessary. I believe that as much as possible, we should be promoting the value of evidence, educating the public (including children) to be able to think critically and evaluate the evidence for claims, and stepping up to challenge misleading claims when we see them.

 

The elephant in the room: Mental health and children’s social care services

I heard a few months ago that the Housing, Communities and Local Government Select Committee were undertaking an inquiry to look at the funding of local authorities’ children’s services, and thought that sounded like an interesting topic that might relate to my areas of interest. I therefore met with a local MP about the topic, contributed to the BPS response to the inquiry, and (on the request of the committee) submitted my own response in relation to my innovative work with BERRI. I have subsequently been called to give evidence in person to the enquiry in a few weeks time.

Given I’ve been so immersed in this issue it seemed a good topic for a blog. I’m going to start with the evidence that this sector is in crisis, before thinking more about what a clinical psychologist like myself can contribute to addressing elements of this need. Hopefully I can then write another blog in a few weeks time to talk about my experience of giving evidence, and report back about whether the politicians grasp the issues and appear motivated to do something about it.

It didn’t surprise me that this was an issue that the government wished to give more scrutiny, given the steep increase in need in this area over the last decade, whilst funding for local authorities has been substantially reduced by the government’s austerity agenda. Human distress and unmet need rarely seems to gain political attention unless it is in such a crisis that the public are aware of the issues, or it has financial implications for the public purse, and children’s social care has suddenly hit both of those thresholds in the last year or so. 

A number of factors have combined to increase need in children’s services. This includes growing awareness of child abuse and its impact (particularly emotional abuse which has long lagged behind the more tangible forms of abuse), along with reduced stigma in disclosing having been abused (due, for example, to the publicity surrounding the Jimmy Saville scandal, the various institutional abuse enquiries, and the #metoo movement) and a reduced tolerance for forms of abuse that had been normalised or ignored in the past (due to cases like Baby P and the Rotherham child sexual exploitation trials, and subsequent prosecutions in many other areas). A lot of teenagers who had been allowed to remain in unsuitable living circumstances because of the belief that they would “vote with their feet” if removed are now appropriately protected and brought into Care, perhaps because of some precedent setting cases in which people have taken successful legal action against local authorities and have been compensated for failures to protect them in childhood. This includes an enormous legal settlement for two Care leavers from Jersey, who have received tens of millions of pounds compensation.

Children in Care are also entitled to stay in their foster placements up to the age of 21 where they want to and it would be beneficial for them, and to have support after leaving Care from a personal advisor until the age of 25. Another pressure is the reduced use of secure units on welfare grounds, and a reduced willingness to incarcerate children in institutions for recurrent minor offending. The increased stress, shame and social hardship of benefit changes and increases to cost of living has led to move children growing up in poverty, and more families developing the risk factors that can cause harm to children, such as drug or alcohol use, mental health problems, domestic violence and family breakdown. This has had a particularly negative impact in families in lower socioeconomic groups.

It is therefore unsurprising that over the same period of time the demands for social care services have risen steeply. Over the last decade there has been a 9% increase in referrals to social care and numbers of children considered in need, but there has been a 84% rise in child protection cases, and 26% more children are in Care. This creates a lot of additional workload for children’s services, with a 122% increase in demand for section 47 enquiries, and a 125% increase in Care Proceedings (as less children are now informally Accommodated with parental consent). Yet the budgets have shrunk, so there is no resource available to meet this need.

The financial picture is genuinely shocking, and yet it has hardly made the news (perhaps because looking at the numbers is considered too technical or boring for the lay public, and the political and news agenda has been hijacked by the continuing debacle of Brexit). But reviewing the figures makes sobering reading. The cuts to local authorities since 2010 are unprecedented. The National Audit Office highlighted the extent of the shortfall in their report on the financial sustainability of local authorities published last year. They point out that central government spending on social care has halved. This has been masked by changes in how funding is delivered, and some additional funds from council tax being made available to spend locally, but the cuts are still enormous and amount to a real terms reduction of nearly one third of the entire budget for local authorities, but the burden is again being disproportionately felt in more deprived areas.

Such cuts are unrealistic and unsustainable, as they make the total budget too small to cover anything other than statutory services, which are legally protected. This means that councils have no means to make ends meet without dipping into their savings. The report shows that two thirds of local authorities had drawn from their reserves by 2016-17, so there is an ever decreasing amount left in the pot for contingencies, and the audit office predicted that 11% of authorities will empty that pot by the end of this financial year. Councils are having to sell off properties and come up with increasingly radical plans to try to fulfil their minimum duties. Recently Northamptonshire County Council had to declare themselves bankrupt as they had no means to cover statutory services from the available budget.

This mismatch between demand and resourcing has led to enormous cuts to non-statutory services, with two thirds of the spend on preventative and community children’s services disappearing. This means that, as with mental health, there is a minimal set of brief services delivered for milder or less entrenched difficulties, but that there is then an abyss in which no services are available until they reach the threshold for the crisis-focused specialist services – which are expensive and time-consuming to deliver and can’t keep up with demand. The focus has moved from collaborative work to assessments and interventions that are perceived as the end of the line, despite the absence of the precursor interventions that might have enabled change.

To me, the elephant in the room when it comes to children’s social care is mental health need. I don’t just mean the clean single-condition, diagnosable treatable mental health need that gets through the doors to CAMHS. That’s the need up on the sterile concrete plains of mental health research that Prof Miranda Wolpert describes so well. I mean the real messy need down in what Miranda calls the swampy lowlands where real complex people live in varied circumstances, where numerous issues intersect to create barriers in their lives that are not straightforward to address, and do not fall into the simple diagnosis to treatment pathway that currently gets through the doors to CAMHS. That’s the need that determines the outcomes for these children, and the pathway on which they leave Care and try to negotiate adulthood. It is that need which determines whether they can go on to happiness, employment and family life or whether they become one of the Care leavers who end up facing prison, homelessness, mental health problems, addiction, conflict and/or their own children going into Care.

So what are these broader mental health needs? In my experience, a complex and interwoven picture of trauma, adversity, behaviour problems, attachment difficulties, developmental disorders or delay and mental health needs is typical of children in Care or receiving social care services. As well as the traditional “mental health” needs of anxiety and depression I see a much broader picture that is expressed in a variety of ways. Some children act out with their behaviour, others withdraw and show signs of emotional difficulties (including low mood, poor self-esteem, and a lack of positive identity or perception of belonging). They often struggle to form healthy relationships/attachments to others, and can present a risk to themselves and others. They have an increased prevalence of conditions like Learning Disability, Autism, ADHD, or psychosis that add an additional layer of challenge in standard services effectively meeting their needs. That is why my BERRI assessment system attempts to cover all of these areas.

Seen as a group, children who are Looked After have high levels of mental health difficulties (45% have a diagnosable condition, and over two thirds have significant mental health need), so it would be easy to blame the Care system. However, this extraordinary level of need is predominantly caused prior to them coming into Care. It is well established that Adverse Childhood Experiences lead to multiple layers of vulnerability, and these are very prevalent for Looked After Children (my own research suggests an average of 4 historic ACEs per child, along with 2 current vulnerability factors at the point they come into care, such as involvement in gangs, sexual exploitation, school exclusion or the criminal justice system). Looked After Children are in the vast majority traumatised children, who have experienced abuse and/or neglect. But these problems don’t occur in isolation. They are contextually embedded. Children in Care come disproportionately from families that experience the adversities of poverty, crime, family breakdown, and poor housing. They are more likely to be born to parents who have lower education, higher risks of unemployment, and a higher incidence of mental health problems, substance misuse, domestic violence and a history of abuse or neglect in their own childhoods. As a result, their parents are less able to provide safe and stable care. Patterns of difficulty often carry through many generations of the family, and the problems they face are a symptom of our increasing social inequality. 

However, CAMHS are not really set up to meet these complex and interwoven needs, and cut off at 18 years of age, whilst children can stay in care until they are 21 and receive leaving care services until the age of 25. They also have ongoing needs that will need to be revisited over time as they develop or different themes emerge as they enter different life stages or face different challenges. It might be that a dental care model, in which there is long-term oversight but with responsive services as and when they emerge works better than the time-limited episodic care that is currently on offer. Likewise services need to be embedded so that they collaborate with placements and other support services, rather than stand in isolation.

The wider context of the underlying contextual and vulnerability factors mean that treating symptoms or even specific conditions might be an ineffective model of intervention. We need to think back to Maslow’s hierarchy. These children first and foremost need their basic needs met, and to have reliable food, shelter and warmth. They need safety and security, medical care and an environment that doesn’t contain ongoing risks. They need opportunities for identity and belonging, such as education, employment, hobbies, peer relationships, and family. They need intimacy and trust in their friendships, sexual/romantic relationships and relationships with carers. When that is reliably in place they need opportunities for achievement and being valued, so that they can gain self-esteem, confidence, status, responsibility and individuality. The icing on the cake is then self-actualisation, the chance to explore creativity, set goals, reflect on morals and values, and feel purpose and fulfilment. Mental health needs only fit in mid-way up that pyramid. We cannot expect a child to have a positive outlook and good coping strategies and social skills if they are not in a safe environment, don’t have their basic needs met, or cannot trust those around them. To see the point of going along to a therapist takes enough self-esteem to believe you deserve to feel happier, and you then need the organisation and social skills to get there, and the trust to confide your story, or a carer who will advocate for you and help you to achieve these steps. There are many building blocks that need to be put in place by the caregiver and environment before therapeutic interventions are possible, and it may be that when we get these other elements right, the child is able to recover using their own resources and that of their caregivers, without ever seeing a therapist.

My perspective is that if we can help to identify needs of children as early as possible and skill up the caregivers and the systems around the child, we can make the most impact. That is why I have increasingly moved from working with individual children to working with their caregivers and the systems that surround them, and have developed the BERRI system to identify needs and help carers understand them, as well as developing and delivering training to help carers and professionals understand the needs of the children and young people better. It doesn’t have the depth of working psychologically with a single individual, but it has the scope to make impact on a much wider scale, and it fits better with my personal strengths and interests. As I’ve said before, I’m not the most patient therapist to walk a long journey of recovery or personal development with a client, but I do have strengths with assessment and evidence-based practice.

My aims have always been to address human needs. I believe that Clinical Psychology in its simplest form is an attempt to make people happier and more able to lead fulfilling lives, and that is what drew me to this profession. And within that broader mission, my focus is to work with the most vulnerable members of society at the earliest possible point in the lifecycle, which has brought me to working with Looked After Children and the broader population of children and families receiving (or in need of) social care services. Recognising the mismatch between the level of need and the resources available to meet that need has increasingly led me to focus on systemic and population level interventions. Rather than drowning in the burnout that comes with trying to solve an overwhelming problem, I’ve tried to find a niche where my skills can make an impact. Having looked at this population group from multiple perspectives, and tested out projects in various settings, I have become increasingly persuaded that there is scope to make positive changes through the use of better systems to identify need, and increased clinical governance over the choice of placements and interventions. 

I have tried to develop practical, cost-effective ways to make a difference, and to gather evidence of their efficacy. I have then tried to share my findings, and what is already known from research, with the widest and most influential possible audience. That is why I have given so much of my time over to writing best practice papers and contributing to policy. Through these experiences I have gradually learnt to shape the messages I share to make them relevant and understandable to various audiences. After all, whilst most of psychology seems common sense to those of us working in the profession, once you have learnt about the main findings and the methodologies for gathering knowledge, to lay people (and professionals, commissioners and politicians) it might seem very complex and unfamiliar. Over time I have learnt that being able to articulate the financial benefits of improving people’s lives helps to get decision makers on board. So my goal in responding to the enquiry was to explain both the human and financial case for greater psychological input for children receiving social care services. I don’t know how well I have achieved that, but I’d be interested in your thoughts and feedback.

Holding the buck: Some thoughts about accountability in the modern marketplace

A couple of weeks ago, I gave a talk to the Institute for Recovery from Childhood Trauma at the House of Lords. I decided it would be too stressful to travel down that morning, so about three weeks in advance I booked an apartment through booking.com. I’ve stayed in apartments and rooms through online sites quite a few times before without incident. Normally they send a code for the door by text or email, or instructions to open a key safe. However, this booking was confirmed with instructions to collect the key from a nearby address by 9pm (I was told if I arrived later there would be a £20 late collection fee). So I caught an earlier train and got a taxi to the pick-up address, which transpired to be an office building, locked up for the night. The security guard on site who came out to see why I was loitering had never heard of this being a collection point for apartment keys. So I spent 45 minutes waiting at the pick-up address and checking the apartment address just down the road, with no ability to check my email or find the phone number of the owner due to the o2 outage. I then found a restaurant which let me use its wifi to contact the apartment owner. He answers the phone as Booking.com and says the pickup address sent to me by email was never given (despite me having it in writing on my screen as I spoke to him) and that I had not confirmed the time. He says he will send a man to meet me with a key. But he isn’t willing to send the man to the restaurant in which I am sitting, I have to go wait across the road outside Patisserie Valerie (which is also closed) for a man in a red jacket.

In about 15 minutes that man arrives. He greets me by name, but does not offer me any apologies or identification. I can’t tell if he is the man I spoke to on the phone or not. He does not provide a key to the apartment, but tells me to follow him and walks off in the opposite direction to the apartment. I ask him where we are going, he says “to the apartment”. I say that it isn’t the right way, and I don’t feel comfortable following a strange man to an unknown address. He is short with me and tells me that he is taking me to an alternative apartment, because a cleaner snapped the key in the apartment door 20 minutes previously. I find this suspicious as a) I’ve been waiting at the apartment and just up the road for 90 minutes and nobody has come or gone from it in this time, and b) why would a cleaner be in an apartment at 10pm that is supposed to have check-in from 3pm to 9pm, and c) why did the man on the phone not notify me of a change of address or email me with a change of booking through the site on which I had booked?

He leads me down less busy streets and alleys across Soho. I start to get anxious that I’m in a part of London that is unfamiliar to me, and have no idea where I am going. I will not be at the address I have booked and nobody will know where I am, its past 11pm and dark, and I’m being led by a total stranger who has shown me no ID. So I call my husband, explain the situation and start reading out street names so he knows where I am. He says that I sound nervous, and that if my gut doesn’t feel like this is safe I should trust it and go somewhere that does.

My mind goes into overdrive. I start worrying I’m being taken to an unknown address, where I might be robbed or attacked or anything. I’m thinking perhaps they gave the fake address as a means to be harder to trace, or perhaps they use the photos of one apartment in a good location to put people in cheaper accommodation in less favourable locations. Perhaps he is nothing to do with Booking.com and is just a confidence trickster. Did he definitely use my name? Was he the man on the phone? I have no way of knowing. I can’t just follow a stranger to an unknown address in the middle of the night with no explanation. I find an open wine bar to run into and hide.

Suddenly, all those feelings are right at the surface and I’m sobbing with fear and hiding behind the counter of the wine bar until the man has gone. Then the man who claims to be from Booking.com (I still can’t tell if he is also the man in the red jacket, or someone different) calls me and asks where I am, and I say “I don’t feel safe dealing with you and being taken to an unknown address, I’m going to find somewhere that feels safe to sleep”. It seems like something I should be able to take for granted, that now seems out of reach.

The staff at the bar are super-nice and patch me up, give me some water and use of their wifi. They offer me wine and fancy olives. I take the latter (and they are the best olives ever, as well as thoroughly nice people, so do check out Antidote if you are ever in Soho). When I calm down a bit, I start searching all the usual websites to find a hotel room. I then find out there is nowhere else to stay. And I mean that literally. Even when I increase my parameters to travel up to an hour from my location, nothing is coming up on any hotel booking site that isn’t fully booked. So I’m sat there in a random wine bar in Soho, 200 miles from home, and there are no longer trains to get back there even if I didn’t have to be in London by 9am the next morning to speak at the House of Lords.

At nearly 11pm I find one, very expensive, hotel with a single room available through LastMinute.com. I book it, pay and then pay £20 to get a taxi there only to find it is overbooked and they’ve already turned away 4 other customers. It is a converted Georgian townhouse with a small number of rooms, so I’m sat in the only chair in a tiny lobby. I’m repeatedly calling LastMinute, and it has gone past midnight so there is no longer even a means to find another hotel (as you can’t search for availability for the previous night), and they tell me they don’t have a room. It takes me four calls and 47 minutes on the line to speak to Last Minute’s customer services, who conclude they can’t find an alternative room for me, and don’t see that as their responsibility. At 1.25am they suggest a room is available at the Taj St James Court hotel and they have reserved it for me. I call them, they have no rooms and have never heard of me. It is now 1.30am, and I am making plans to sleep in the bucket chair I am sitting in, in the hotel lobby, as I have nowhere else to go* and it is raining heavily. Eventually at 2am the hotel say that one guest has not checked in yet, and agree to take the gamble and let me use the room. I get less than four hours sleep for twice-the-price-I’d-normally-set-as-my-upper-limit-for-a-room, before having to head out to speak at the House of Lords.

Having given the talk** I decided to complain to both Booking.com and LastMinute.com. The response from the former was “You got a refund for the apartment, so it’s all settled” and the latter offered “€20 as a goodwill gesture due to the 2 hour delay checking in”. No recognition of the fact the experience was traumatic, wasted 5 hours of my evening, cost me 3 extra taxis, and left me 200 miles from home without somewhere safe to sleep. I am faced with the realisation that trauma is subjective, and to many men hearing the tale I might have taken fright for no reason and brought the events that followed upon myself. I am forced to say “imagine if your Mum were in this situation” when explaining it to try to trigger sympathy. But nobody really cares. The apartment owner feels he has done his bit by refunding (and the website has conveniently blocked me from leaving a review). The men in the call centres were in another country, abstracted away from the problem. The customer service teams are seeing the facts in retrospect, not the feelings the experience generated, and are motivated to protect their brand rather than genuinely caring about me as a customer. The night manager of the hotel cared, because he met me in person, and saw I was upset. As a result he tried his best, but he wasn’t in a position that could resolve the problem.

And that’s where I finally reach the point. In a system where you book with a middleman who doesn’t actually provide the product you are paying for, nobody really feels accountable for the service you receive. And, to bring this round to being relevant to a wider point for health and social care, this model is being increasingly replicated in public services, where the NHS or local authority commission the service from another provider, who is assumed to be responsible. That split between online broker and real life provider, or the public sector split between purchaser and provider seems like a good model for each of those parties, as the purchaser delegates responsibility whilst fulfilling their obligations (or making a profit, in the case of online brokerage sites) with much reduced staffing and without having to invest in any tangible assets. The provider gains access to a wider market, rather than becoming obsolete. But somehow inevitably, as in my experience, the recipient of the service misses out in the middle, and finds out there is minimal quality control and an absence of clear lines of accountability when things go wrong or aren’t delivered as planned.

For example, there is a level of risk aversion that has made local authorities anxious about providing residential care placements, because of the prevalence of historic institutional abuse and the increasing awareness of child sexual exploitation and involvement in county lines (and the accompanying risk of compensation lawsuits). The result is a marketplace where private providers (many of them owned by international venture capital groups who pay minimal UK taxes) use unqualified, low-paid staff to care for some of the most complex and vulnerable young people in the UK, and it is hard for recipients or commissioners to distinguish them from provision that has different financial or delivery models. Likewise in health (and public transport) private providers cherry pick off the profitable services, whilst the public purse is left holding the can when they don’t deliver. There is a move to entrench this even further with the push towards Integrated Care Providers, where private organisations can manage the entire health and social care services for a particular region of the UK, in a way that is potentially unaccountable for its decisions and not subject to the rules for public sector organisations (like Freedom of Information requests, public consultation, or being subject to Judicial Enquiries if things go wrong, or even their statutory obligations). I think that might be a recipe for disaster, but then, I’m not a fan of corporations and the super-rich profiting from the suffering of the rest of us.

Update: Booking.com have agreed to reimburse my costs in relation to the apartment (but have not yet done so), whilst LastMinute.com have not yet replied, telling me they take 28 working days to respond to customer complaints that don’t accept the initial boilerplate response. I suspect that just like in health and social care, the (explicit or implicit) policy is to respond to those who kick up a fuss and have the potential to create negative publicity if things are not resolved, meaning that those who are devalued most by society have the least redress when things go wrong.

*call me a wuss, but I declined the option of having one bed in a bunk room in a hostel shared with 8-12 strangers
** which I will give again and video as soon as I shake the cold that’s currently making me croak

Reaching the summit?

For a long time, I’ve had a metaphor in my mind about how it feels to run a small business aiming to change children’s social care. The image is of me rolling a massive boulder up a hill. Progress is slow, it is hard work and I often find it tiring. Even when I rest I have to do so holding the rock in place. At times I feel like I might be reaching the summit, only to see that there is another climb ahead. I sometimes wonder why I’ve taken on this mammoth task, or whether my goals are even possible, but I am stubbornly determined that now I’m so far up the hill I don’t want to give it up. Maybe that is about sunk cost. But I’ve chipped off the worst of the bumps from the rock and got my rolling technique worked out, so I keep telling myself that if anyone can get this thing to the top of the hill, I can. Over the years of my journey I’ve tried to encourage other people to help me to push, so I am not bearing all the weight, but whilst I’ve had good company at times and plenty of encouragement, it has always seemed like the task is mine alone. That has been reinforced by numerous people telling me how I’m uniquely skilled at rock-rolling, even though I know that I was no better than many other people at the start of my journey. In fact I’m pretty sure anyone with some pretty basic skills who rolled a rock for this long could be standing in my shoes.

Of course, that bypasses the fact that I had to be willing to spend a lot of time on this, be resilient in the face of obstacles, and give up other easier opportunities to stick with it. And the fact I had the intellectual, social and personal characteristics to work out how to do this, choose a viable route and make improvements along the way. And it also omits to mention that had I known the real scope of the task would take me over a decade I might not have taken it on at the beginning. On the other hand, perhaps the fact it was difficult enough for nobody else to take on was why I did it. I think those who know me might point out it isn’t the first time I’ve jumped in at the deep end, and that I don’t do things in half measures. I don’t like taking the easy route in life, and if I set myself a challenge I like doing the task properly. I’ve always thought about what I can do to make the most impact, rather than to have the easiest life or earn the most money. I prefer to cut my own path, than to take one that is already well-trodden, and to find a way to enjoy the challenges of the journey.

So here I am, pushing my boulder and feeling like I’ve come quite a long way over the years. I might be deluding myself, but the gradient appears less steep these days. In fact, it feels tantalisingly close to reaching level ground, and I am starting to imagine what it might be like to roll my boulder down the other side of the hill. I’m trying not to be complacent that I’ve reached a point at which the boulder is stable enough not to roll back the way we came up, but people are starting to talk about how this boulder is not just on the level, but given one more push might gain enough momentum to create a landslide that will divert the river to irrigate the lands the local population need to farm. That would be beyond my wildest dreams. I mean, the motivation behind all this is to improve the lives of people who are having a tough time, but to think that it could have impact on the scale some people are now anticipating is mind-blowing. That would mean my big gamble of investing so much time and effort into this project could pay off in terms of impact. In a way that’s the great thing about indirect interventions – that they can make change that ripples out on a much bigger scale. In my boulder metaphor I’m trying to make change not by trying to teach them new farming skills one by one, but by trying to address some of the systemic barriers that impair their life chances, so that they have the opportunity to find their own ways to thrive.

So this blog is a marker of me standing at what I hope might be the top of the hill, and crossing my fingers the gaining momentum part happens. The mixture of hope and uncertainty is stressful to balance. When it’s a bit more concrete I’ll write a bit more, and hopefully I’ll not need a metaphor to couch my cautious optimism in, and can tell you about the actual project and the steps I’ve taken to progress it.