My opinions about representing Clinical Psychology and the future of the British Psychological Society

I’ve probably been a member of the BPS for 20 years now, and with it the Division of Clinical Psychology and the Faculty for Children, Young People and their Families, and within that the network for Clinical Psychologists working with Looked After and Adopted Children (CPLAAC). I’ve been to the annual Faculty conference every year since I qualified, except for the one early in my maternity leave. I read some of the publications and I follow some of the social media. Over the last decade, I’ve done a long stint on the Faculty committee, and I’ve spent 5 years as chair of the CPLAAC network. I’ve responded to policy documents, represented them on committees, written papers and edited a periodical. So you’d think with all the energy and time I have put in that I am a great fan of the organisation.

Unfortunately, whilst I am hugely admiring of many of the individuals involved with the DCP and Faculty, and some of the recent Presidents of the Society, I’m pretty ambivalent about it as a whole. I think their website and social media suck. I spent ages looking at how to help them with that through the faculty, only to find out the scope for change was minimal and was within their user-unfriendly structure. Most of it was hard to navigate, and key documents were hard to find, the documents and information on the site were often out of date and much of the content was hidden behind walls for members and separated into silos by the Society structure that were impenetrable by topic. I was censored and then locked out of the BPS twitter account whilst live tweeting talks from a conference on behalf of the faculty because I quoted a speaker who was critical of the BPS’s communication with the media and public.

My experience of running clinpsy.org.uk is that we make everything accessible, searchable and google indexed (apart from the qualified peer consultation forum that is a closed group, and the archive of livechats and other member content that can only be seen when logged in). We are also able to respond to things immediately, and often talk about current affairs. So it is quite a contrast. The view of the BPS on the forum is fairly negative, despite myself and several other qualified members trying to put the advantages of having a professional body.

One theme comes up across both spaces – that lots of people like to moan, but very few are prepared to take the actions that help to change things for the better. So, when a document is put out to consultation, or members are canvassed for views by BPS Divisions or Faculties it may be that no clinical psychologists respond at all, or perhaps just one or two nominated by the committee, someone with a vested interest, or the same old voices who feel a greater sense of responsibility for the group. I’m sure the same would be true on the forum, as lots of people like to read the content, some like to ask questions but few actually write up content for the wiki, or help with the maintenance tasks like checking and updating links. However, people pay quite a lot for their BPS memberships, whilst the forum is entirely free and run by volunteers, so it is perhaps fair to have different expectations of service. The difficulty being that the BPS expect the few members who do contribute to do so for free, in their own time, over and over again. I worked out that one eighth of my working time as a self-employed person was being spent on unpaid committee and policy work, and I don’t think that this was unusual. Certainly the chairs of networks and faculties give up a large amount of their own time, and although higher up the tree some days are paid, these are not paid sufficiently to reflect the amount of time that is spent on the job.

So when the DCP sent me a link to a survey recently, I had to reflect my views and tell them that I don’t think that the BPS works for clinical psychologists in the UK, and this is predominantly because of the nature of the larger organisation.

I have witnessed time and time again that clinical psychologists, including those on faculty committees and in the DCP committees, are inhibited rather than facilitated in responding to topical issues, speaking to the media, expressing opinions or taking action by the slow, conservative and censorial wider organisation of the BPS. Even sending representatives to sit on government fora, guidance or policy making organisations involves an overly bureaucratic process of formal invitations and nominations that often means the window has closed to have our voice heard. Likewise the process for agreeing documents for publication is onerous and slow and means months of delay. The Royal Colleges and bodies for other health professions make responses to news items in a timely way, but we don’t. We are constantly told not to be political by expressing any opinion, when, as I understand them, the charity rules are not to be party political rather than not to express opinions that affect political policy at all. I would argue that our role as powerful professionals, effective clinicians, supporters for our clients and compassionate human beings requires that we are political in the wider sense, because we should be advocating for the psychological wellbeing of the population and putting the case for provision of adequate mental health services. I would consider that this includes an obligation to argue against policies that cause hardship and emotional distress, and to put forward a psychological understanding of events and individuals in the news.

Whilst there are great people involved in the committees and a lot of good will and energy, the BPS itself makes contributors impotent. It inhibits rather than amplifies the messages we should be sending outwards and it fails also to represent us as a professional group. It is not effective at representing our interests in government policy, national or regional workforce issues, professional negotiations, disputes about funding or other professional matters.

The structure of the BPS also drowns out the fact that the majority of practitioner members are clinical psychologists by giving equal weight to tiny factions and much too much weight to academics and students – the focus on the latter two groups means that the BPS failed to address issues of regulation properly and has left us with a legacy of problems with the remit and standards of the HCPC (including who is included and excluded in the scope of regulation and the criteria for equivalence of international psychologists, which I will no doubt blog about another time). In these areas it has not only failed to promote the profession, but also to protect the public.

Unlike other professional bodies, the BPS does not offer much by way of professional advice and representation for its members (eg about workforce and pay issues, disputes with employers). It doesn’t act like a union to defend individual members or the interests of the profession, or provide us with insurance or collective bargaining. It doesn’t show our value to the public or those in power through media statements, responses to news and current events and policies, representation on government and policy bodies. It is ineffective in building the status and public awareness of the profession. I believe our professional body should constantly articulate the need for proper mental health services and highlight the useful role the profession can play in meeting those needs. Likewise it should constantly express opinions about government policy and other issues that may be harmful to the psychological health of the population, and highlight what we think would help and the role we as a profession can play in systemic changes and in planning strategies at the population level that prevent or reduce distress.

So I think radical change is needed. If that isn’t possible as a program of reform from within, and Jamie Hacker Hughes’ Presidency suggests it wasn’t, then we need to split the DCP away from the BPS and/or build something new that is fit for purpose.

If you also have an opinion about the BPS and/or DCP, whether or not you are a member, please answer their survey here. Feel free to cut and paste any part of this blog into your response if you wish to do so. Likewise feel free to share a link to this page, and if you are an aspiring or practising clinical psychologist you are welcome to join in the discussion about the BPS on the clinpsy forum.

A promise to my daughters

As well as being on the progressive left politically, I’ve increasingly identified as an active feminist over the last decade. I’m sure that this has been apparent from my blog, which has at times posted about this topic explicitly. So this has been a depressing few months for me. After the inauguration of a racist, misogynist sex pest as the POTUS, and in the context of the thoroughly depressing situation in the UK with the toxic politics of austerity and Brexit, I have been thinking about the kind of world I want for my daughters. I have also been thinking about what I can do to to instil in them the values that I think are important and will help them have the kind of future I would want for them.

The massive turnout across the USA and around the world for the Women’s March has been a heartening message in a hard time. It is empowering to think that women all around the world and for several generations, as well as their allies, are working towards the same goals of equality and to further progressive causes (such as caring for the environment, LGBTQ and BME rights, and the value of science/evidence over propaganda and opinion). That sense of community and caring for each other and the future is also a refreshing change from all the aggressive posturing, selfishness and commercialism that seem to saturate the narrative at the moment.

The placards and quotes from the Women’s March have been particularly inspiring. I particularly like those shown on the MightyGirl blog. They illustrate how women all over the world are bringing up the next generation of girls to approach the world on their own terms and have whatever aspirations they want, without the boundaries of sexism and prejudice holding them back. There is one placard that says “I am only 4 years old, but I know everyone is equal” and that is the simple truth – until children are skewed by the prejudices they see around them, they understand the fundamental truth that whatever differences there are between people in how they look or how they live their lives, we are all equal in importance and all deserve to be treated with kindness and respect.

My children have often surprised me with their insight into international conflicts and world events. I remember driving them home from the supermarket when they were four years old, and them asking why the rich people of the world couldn’t give jobs to all poor people so that they could afford the things they need like food, clothes and places to live. I couldn’t really answer that, because I don’t think there is any justification for levels of inequality that mean that the richest eight men in the world have more money than the poorest half of the world population. Yet we have stopped seeing how odd and obscene that is, because we are implicitly given the message that we live in a meritocracy, and wealth is earned through hard work (when the reality is that many people inherit wealth, and few would argue that even the self-made plutocrats work harder than anyone else in the wealth spectrum). A year later, after explaining why poppy badges were being sold I remember having a conversation about whether there were still wars in the world. I said that there were, and most of them were to do with people having different religions. We talked about how wars don’t only affect soldiers, and how a recent bombing campaign had destroyed schools and hospitals. My daughters suggested that “we need to send people in that country postcards to remind them that schools are really important”, as “that is where children will learn that people are equal even if they are different, and you need to be kind to everyone”. I’ve never felt prouder.

I’d like to think I’m good role model of a woman facing the world on my own terms, setting up my own business and being “the boss” at work, as my kids see it, and being an equal partner in my relationship, which does not conform to traditional gender roles. We’ve worked hard to expose our daughters to a range of interests, and given them a variety of experiences. I’d hope that they can make choices about what they enjoy or how they want to present themselves unencumbered by narrow gender expectations or unhealthy/unrealistic body norms. Our bedtime stories have characters of both genders who solve their own problems, rather than princesses passively waiting to be rescued by a prince to live happily ever after. I’d like to think we’ve also modelled the way that we interact with each other, and with a wide variety of people with respect. We have taught them to appreciate diversity and to admire those who defy convention or achieve something despite adversity.

But I’m not sure I’ve done enough to show that we can take action to address issues we see happening in the world around us. I should have taken them to the march on the weekend. I think it would have been a great experience for them, but frustratingly I’m still too unwell to travel. So I need to think of other ways to involve them in activism. And I need to do more myself than donate to charities, sign petitions and write messages on the internet. At a time in which the news is dominated by a super-callous-fragile-racist-sexist-nazi-potus I want my daughters to know that I’ve done everything I can to give them the maximum range of choices for their future lives, and the best chance of being judged by their actions rather than their appearance. So I will finish with the words from a placard that resonated with me: I am no longer accepting the things I cannot change, I am changing the things I cannot accept.

Sherlock jumped the shark

Warning: Contains plot spoilers for series 3 (and for August Rush)

I think Benedict Cumberbatch and Matin Freeman are great actors, and the BBC have made a very stylish production of Sherlock with complex and nuanced characters. Both Sherlock’s use of drugs and the relationship between the two men has been portrayed in an interesting and convincing way. I particularly enjoyed the hint of Asperger’s in the way that Sherlock can use his visual observation skills and visual memory to reason in a way that seems almost impossible to a layperson, whilst struggling with interpersonal relationships. So it was with high expectations that I watched the latest set of episodes, and found them sorely disappointing.

I should say that it isn’t the first time I’ve built up my expectations of a film or show only for the reality to not live up to them. I have long identified a pattern I call “the Total Recall effect” whereby films seem to vary in their quality according to my expectations. The first time I watched Total Recall (the 1990 original, starring Arnold Schwarzenegger) I thought it sounded like a weak premise with a wooden actor, but was pleasantly surprised. The second time I watched it, some years later, I remembered it as a good film and was sorely disappointed. The third time I watched it, after several more years,  I nearly turned it off, remembering it to be dire. However, it wasn’t that bad and I enjoyed it enough to stick with it until the end. I learnt that my expectations influenced my subjective experience; hence naming the Total Recall effect.

I also hate films that mix realism with implausibility. I’m fine with suspending belief entirely for a fantastical tale, or for enjoying the interplay of characters in a different time or place (eg I love Firefly’s futuristic western set in space) but I hate it when stories that are designed to seem within a stretch of reality suddenly take a leap into the impossible. In the film August Rush, for example, I had that experience of a semi-plausible plot jumping the shark. It was a stretch I could just about tolerate for the boy to reject family placements and stay in the care system in the hope of finding his real parents, and to then run away in search of them (despite the fact he’d have been adopted as an infant, would never have known anything but the love and belonging of his adoptive family, and wouldn’t have felt quite the same yearning). His relationship with music was beautifully captured and was the highlight of the film. But the grand finale where everything fell into place, and his parents were both seeking him and each other, and were present in the right place at the right time to hear the concert and recognised it calling to them, then recognised each other and him, made it all fall apart.

That accounts for some aspects of my disappointment with Sherlock but not all. To be honest, whilst I applaud the idea of also including female characters and narrative as a general aspiration for all media, I wasn’t a fan of Watson’s wife being an international espionage expert (it felt a bit like the second series of Heroes, where everyone got superpowers). Likewise I didn’t buy Sherlock having a sister. They felt like a step away from the source material that wasn’t in keeping with the rest. I also found it frustrating that each episode spent three quarters of its time laying out a riddle, and then wrapped it up far too quickly and neatly in the final quarter. I also felt cheated that unlike earlier shows, we didn’t see how Sherlock put together the clues to reach his conclusion. It was presented in an abstract way, a bit like magic. Viewers were left to assume that the song combined with some numbers in the graveyard could be rearranged to lead to a sentence that unlocked the location of the well. But why those graves, and how did it unlock the location – we were short-changed in the explanation.

As ever, huge amounts of trauma were included in the plot, without an appropriate scale of emotional response. The repeated prompts to be soldiers wasn’t sufficient to carry the uneven emotional responses (smashing the coffin because he had upset the pathologist, whilst being unmoved by four murders and recovering from feeling responsible for a suicide in less than a minute). Likewise later scenes showed the repair of 221b Baker Street to its former state, indicating that the explosion that would have supposedly killed Mrs Hudson in the flat below, and threw them out of the windows in bursts of flame had not only caused them no injuries, but hadn’t even penetrated the floor boards of the flat.

However, my main grumble was with the character of Eurus and the plot that surrounded her. The actress playing her was good, and the twist of her being several characters was fun, but the story and back story they gave her was appalling. This woman was supposed to have been born a dangerous psychopath, and to have spent her entire life from the age of around seven in solitary confinement as a result. She was supposed to be lonely, anxious and delusional but to express that by doing nothing for two decades and then engineering plots that skipped continents and killed multiple people without emotional response. Well I call bingo on the theme of propagating negative myths about mental health, with zero points for reality.

First, it reinforced the association between mental health problems and risk of committing crime, when people with mental health problems are much more likely to be the victims of crime. Second, it gave the impression that mental health problems are things that you can be born with, and unrelated to your life experience. For example, we didn’t see that Eurus had been emotionally and sexually abused to create her distress and anger. We saw a highly intelligent child in a highly intelligent family that felt a little left out when her brother had a friend, and as a result decided to kill the friend, then burn the house down, and wanted to kill her brother. She was portrayed as a petty and jealous child, whilst presumably nobody in this highly intelligent family was able to show her affection or to help her regulate her emotions. And nobody recognised the risk or tried to intervene in a supportive way.

Eurus was supposedly unable to tell the difference between laughing and screaming, and was portrayed as being entirely without empathy, yet she had the subtle social insight to see (from her minimal observations whilst supposedly secured in a prison island) that her brother was unable to communicate any affection for the woman who was in love with him. Then, despite the lack of normal human interaction for most of her life it transpired that she had developed sufficient mind control to reprogram others within minutes of conversation. She had never done so as a practise, or in a way that was unsuccessful or aroused concern, however. But after 20 years she had suddenly taken over the entire prison/asylum island sufficiently to get people all over the place to transport her to and from the island, to set up her murder scenarios, to dangle three men in front of the window and cut the ropes to make them fall off the cliff to their deaths. No single person in the entire staff of the island failed to fall under her thrall, or had any moral doubts about her plans that were sufficient to breach her conditioning enough to raise an alarm (whilst the prison governor was able to disobey her to commit suicide in his attempt to save his wife). And she was able to set explosives, procure sedative darts and transport Holmes and Watson to an entire set created at her old family home. And this frightened, lonely girl who had supposedly only killed a child once in a failed attempt to play was suddenly killing many as experiments to test her brothers.

Sherlock, despite his intellect and his “mind palace” of perfect visual memories, was supposed to have entirely erased the existence of his best friend being murdered by his sister, or even of having a sister at all. When he spent the evening with the daughter of the famous serial killer, he could notice the drips of water and the line on her dress from her exit from the taxi, but not the fact that she was his own sister in disguise, putting on a false accent. Likewise he could predict that Watson would be at a particular location in two weeks time, but not see anything suspect in his flirtation with the woman on the bus. Meanwhile, despite the whole of MI6 and the intellect of Mycroft being involved in her supervision, Eurus could come and go from her prison island enough to make a therapy practise that both Watson and Holmes thought to be bona fide. And in the finale, Sherlock could believe that the voice of an adult woman he had been interacting with, communicated from an attic in the rain or a prison island, was that of a small girl in a crashing aeroplane.

In short, once you apply any critical thought, this series was a woeful disappointment, despite the stellar cast, impressive budget and stylish delivery.

 

Disappointment

I have been let down by someone I trusted again. In fact, in the last three months I’ve been let down by four separate people that I have trusted, in three different separate sets of circumstances, and two of them have been clinical psychologists. That feels like an unpleasant cluster of disappointment. In each case they made me lots of promises and didn’t deliver. I was relying on them and now have to pick up the pieces. I was assuming that my ethical values would be ones that we commonly held, but in fact each person turned out to be entirely self-serving, despite the high cost to others. In each case the other party has taken what they wanted and left me to deal with the fallout.

Being exploited by others always makes me very sad, and it erodes my faith in people. But this time it has coincided with me being physically unwell. It may even be the cause of my health problems. If so, that is something new, and something I need to address robustly and never let happen again. But as ever in real life the picture is complicated and hard to unpick.

I’ve normally been a pretty resilient person, and hardly ever take time off sick. However, the minor road traffic accident in which I was rear-ended by a lorry 18 months ago transpired to have cracked three of my teeth*. One cracked wisdom tooth was removed soon after the accident and the second patched up with a filling. However the third was a visible tooth that had already had a root canal, so it needed to be removed in a way that would allow an implant to be fitted to fill the gap. I paid for expensive specialist dental work to preserve the bone and fill the gap with collagen to encourage regrowth. Unfortunately, removal of the tooth root was harder than expected and involved half an hour of brute force, breaking off a piece of my jaw bone in the process. That led to dry socket pain. I then required bone grafts along with a pin to support the implant, and six stitches to pull my gum back together. I’m not normally anxious about dental work, but it was stressful enough to make me shake before subsequent appointments and involved several weeks of painkillers and a course of prophylactic antibiotics whilst I recovered. So I suspect I was already somewhat physically depleted.

Then the interpersonal disappointments started to compound things. After a particularly unpleasant bit of news in early December I had to go home from work due to what felt like a migraine starting. I’ve subsequently been off work for six weeks with a “severe otitis media, probably herpetic” written on my sick note. The GP was concerned it was a variant of shingles due to the blistering inside my ear, so I was prescribed antivirals as well as antibiotics, but thankfully it didn’t develop into the full shingles presentation and has just felt like a prolonged ear infection. Subjectively I’ve mainly felt like I’ve been underwater, with periods of more marked earache, dizziness, fatigue and a kind of general malaise. Driving in particular has been difficult (as acceleration and even small hills tend to trigger pain), as has going outside (perhaps due to the changes in temperature) but it has also stopped me from playing with the kids in the way I normally would (as spinning, chasing or sudden movements can bring on earache/dizziness), thrown my sleep out and confined me to the sofa for much of each day.

It seems it has also reduced my ability to weather stress, and made it express in a more physical way than I’ve ever experienced before. I’ve had stomach cramps and waves of nausea that appear when I read emails from certain people. I can’t tell how much of the overall problem is a somatic expression of stress, and how much is my resilience being depleted by physical illness and making it hard to cope with the emotional stuff. But it has been an interesting learning experience. I’ve had to stick on an out of office message and binge watch TV serials. It is a big behaviour change for me to disconnect with my work, but I have to accept my own limitations. If it is shingles, then it can do lasting damage to the facial nerves or lead to hearing loss. No contract, colleague or past employee is worth that.

So I’ve made a pledge to myself never to let this happen again. Work is going to be a smaller part of my life, and I am going to make more time for art and music and going out into nature. Within my work I’m going to follow my heart more. I will only work with people I trust, who share common goals, and a sense of fun. I’m going to focus on doing what I enjoy, and what makes me feel I am having the most impact for those who need it most. I’m not going to bend over backwards for people who wouldn’t do so for me. And I’m going to challenge my inflated sense of responsibility for others.

Maybe it comes from being the oldest child of hippy parents, but I’ve always been a person that enjoys helping others, and giving a leg up, or a treat to people around me. Whether it was spending my pocket money on sweets for my friends at school, raising money for charity, or helping someone else out, I’d always put in a little more effort than other people seemed to. When I look backwards I can recognise that sometimes this has led to other people taking advantage, and me ending up feeling exploited.

I first noticed it in an adult reflective way a long time ago. I remember helping someone with a paper they were writing for a journal submission. Their draft was really very poor, and I made a lot of changes, but they didn’t add my name or even acknowledge my input. A year or two after that I coached someone who wanted to get onto the clinical training course I was on, and let her present a small analysis we had done together on my research project data, only to find out that she had presented the whole study as her own and not credited me at all. I also got her a summer job, from which she was fired for her poor attendance and timekeeping, for which she later attempted to use me as a reference, claiming that the service had subsequently closed and omitting to mention the reason for her departure**.

When a friend of a friend (I’ll call her Jo) sent me an email about being suicidal a few years ago, I cancelled a day of work to go and take her to A&E, and spent 24 hours getting her to attend and waiting for various services. Over the next fortnight I helped Jo sort out problems with her rented accommodation and to get a settlement from her job instead of being dismissed. After a second depressive incident a few weeks later, I brought her back to my house for the weekend rather than leave her alone and unsupported, a visit that subsequently extended to a six week stay.

I tried to be a supportive friend. I got Jo a new job within my network and a week later I agreed to be guarantor on the lease for a lovely flat. However the next day after a clash of opinions with a colleague she decided to quit the job. That left her no means to pay the rent, which would therefore have fallen to me, so I withdrew from being guarantor and the flat fell through. Jo was upset that I prevented her leasing the flat she wanted, but concluded that she would continue live in my house, rent-free, until something else came up. I felt that as well as not being the right choice for our family, this would have been enabling her dependence. There were various problematic incidents, but I still agonised before saying she had to leave and helping her move in with a family member instead. I took another day off and drove a 5 hour return trip to take her and her possessions to a new location. Despite all the efforts I put in, Jo remains angry at me for the perceived rejection and feels that I let her down. She periodically tries to shame me in our social group for “abandoning a vulnerable mentally ill woman”. For me it was all cost and given there was no benefit to Jo it was actually a lose-lose situation, but I did not recognise that until long after it was obvious to everyone else around me.

More recently it has been colleagues and collaborators who have let me down. I’d consider that par for the course if I was unreliable myself, but I don’t think that is the case. I always try to treat people as I would want to be treated myself, and to be really clear about the contract between us (whether that is a literal written agreement or an implicit verbal arrangement). I tend to assume that anyone who has the same profession or client group as me will have the same ethics and the same drive to do the right thing as I do. I always assume that people will care about the quality of the service, prioritise what is in the best interests of clients and keep their word, because that is what I would do in their shoes. Sadly, it seems that is not the case, and lots of other people prioritise their self-interest over anything else.

I don’t think I have unrealistic expectations. If someone signs a contract with me then I expect them to honour it. If someone agrees in writing to deliver a particular piece of work, be it training or clinical work, I expect them to turn up and do that work on the date they agreed. If someone agrees to take on clinical responsibility for some of our clients, I expect them to provide a good quality clinical service for those people rather than nothing at all. If someone agrees to purchase our services for a particular period of time, I expect us to have to deliver those services and for them to pay for them. If someone agrees to buy something from me and I deliver it to them, I expect payment. It doesn’t seem a huge leap of faith to me. Yet somehow these very simple expectations are too much for some people.

I’ve spent too many words justifying why, but I am disappointed by that. And, whether by coincidence or causality, I have been physically unwell in the immediate aftermath. But I am not the kind of person that just rolls over. I might be a sucker and go beyond the call of duty to be helpful when I can, but I don’t let people play me for a fool. I have a very strong sense of fair play and once people cross the line, then I feel obligated to do something about that. Just as I am a demanding consumer who will assert my rights for a refund or compensation when things go wrong (and gave Regus merry hell a few months ago for their terrible service with the office I was going to rent), so I will also take action to ensure that professionals honour their obligations. The way I see it is that many people don’t have the resources to address problems (be that intellectual, time, financial or personal) so those of us that do need to help put the checks and balances into the system.

So my plan is three-fold. Firstly I will address each issue head on and reach a resolution. And secondly I will make plans for the future that mean I am not put in the same circumstances again, gather better allies and do more of what I enjoy. I’ve already got a good team around me and lots of irons in the fire for new projects, and I have had helpful legal and practical advice from a number of sources. So it will all pan out in time. However my top priority is to get well again. And that involves the foreign concept of taking time out to rest. For a workaholic that might be the toughest part of all this!

*I don’t believe this to be a common result of an RTA, but I have brittle teeth due to tetracycline damage as an infant

**I didn’t feel able to provide such a reference, and gave them the contact details of the service instead.