Pushing upwards

When I was an undergraduate psychology student, I found parts of the course curriculum kind of boring. I was interested in human behaviour and experiences, because I wanted to understand how to alleviate distress and increase wellbeing. Unfortunately I was not so interested in the neurochemistry or neuroanatomy that is the underlying mechanics for those emotions and behaviours. I was interested in behavioural ecology, like the evolutionary/survival value of altruism to vampire bats, and its parallels in human behaviour (eg why we have developed a system of rules and punishments to enforce the social contract). But I wasn’t so interested in animal perception and cognition. I found some of the early psychological experiments on both animals and humans to be really cruel and distressing, though I was aware that they helped to progress our understanding of brain and behaviour, and helped us to recognise the need for the ethical considerations we apply to experiments now.

Because I didn’t love the whole course, during the second year of the course I began to wonder whether I had selected the subject on autopilot, because my Mum is also a clinical psychologist (now retired).  A few other life events compounded this lost feeling by lowering my mood generally* and I developed an increasing existential doubt about whether I was making the right choices in my life.  I also wanted to test out my values and the options available to me, so my focus drifted to my social relationships and activities outside of psychology. I became less motivated and didn’t attend all of my lectures, and (despite having previously been quite successful in educational assessments) I got a 2:2 for one module that I hadn’t enjoyed. It was a mark that fairly reflected my effort/interest level, and in any other context it wouldn’t have been a big deal. However, I was gutted because I felt like the whole course would be pointless if I didn’t excel academically, as I was aware of how competitive the path into clinical psychology was. I considered changing course or dropping out, but I couldn’t think of anything I would rather do.

One of the images that helped pull me through that time, was from the I Ching – an ancient Chinese book of wisdom, also known as the book of changes. The basic gist is that you throw coins to point you to one of 64 readings, which can be generated with various variations and additional comments, and (like a horoscope or cold reading or fortune cookie, but perhaps with a bit more zen wisdom) the resulting text is ambiguous and non-specific enough for you to draw relevance to your life situation. The page that I was sent to was called “pushing upwards” and the hexagram was of wood below the earth. The image it described was of a seed below the surface, using all of its stores of energy to push a shoot upwards in the hope that it would reach the light and conditions in which it could grow and thrive. The text explained that to do this is an effortful process, in which you are gambling that this investment of energy will be worthwhile in reaching a goal that might still be out of sight. It describes the heaping up of small efforts to create the conditions in which future success is possible. The seed takes time to unfold into the tree: Although the results are not immediately visible and gratifying, “that which pushes upwards does not come back”. The reading tells you to put in a sustained effort if you want to achieve great things. It reassures you that if you are driven by a deeper sense of purpose (rather than wealth or glory) and willing to learn from wise people around you, you should not fear the path ahead. It implies that in time favourable conditions will help you along. In this way, it says, a person can rise from obscurity and lowliness to power and influence, provided that you make your efforts in a humble, flexible and authentic way.

This was a good metaphor for needing to put in more effort to achieve my goals, and it also reminded me of my core values and my drive to in some way make the world a better place, by improving the experience of other humans who had been dealt a tougher hand in life. Thankfully, as I entered my third year I got together with my husband (who has continued to be a supportive and stabilising influence for more than two decades since) and entered a much happier phase in my life. I also found the modules in the final year of undergraduate much more relevant to my interests, because they were much more closely tied in to the theory and practice of clinical psychology. As a result I started to put in more effort and get higher marks. I also started to gather work experience, and to seek out advice from qualified CPs. Gradually, those efforts paid dividends – I secured an AP post on a research project straight after graduating** and then worked incredibly hard to do that job, write up papers for publication and complete a masters degree by research at the same time, before gaining wider experience in a more clinical role with a different client group and then securing my place on clinical training.

From the moment I entered that third year with that mindset, I enjoyed the rest of my journey into clinical psychology. No matter what the client group or type of work, I felt like I was doing something worthwhile and I was also constantly learning and being challenged. I had some inspiring supervisors, both as an AP and as a trainee. I didn’t love every placement (they were all good learning experiences, but my enjoyment varied depending on my interest in the client group, the style and context of the work, and the amount of travel involved to get there). Likewise I didn’t click with every supervisor equally, but I did learn a lot from each of them. In my first AP role my supervisor was a role model of the true scientist practitioner, who secured grant funding to push forward the evidence base of the clinical work, and constantly published papers and disseminated findings. She pushed me to participate in that world, and with her support I co-wrote six peer reviewed journal articles during those two years! She is still my role model of embodying the link between research and practice in psychology, and I would love to emulate Esme’s energy and influence in my own field of work. I then worked in a project that trained student social workers, and assisted with expert reports on parenting – something I continue to have an interest in to this day. It gave me a much more practical grounding, and an awareness of social care systems that I have subsequently built on.

As a trainee I gained a basic grounding in brief CBT-based interventions in an adult service, and learnt more about the structure of mental health services and working as part of a multidisciplinary team. I also worked in services for people with intellectual disability, where I learnt about the value of indirect work, and gave more explicit consideration to issues of capacity and consent. I loved my core child and family placement, and the warmth, pragmatism and commitment of my supervisor, Patricia, set the tone for the kind of psychologist I wanted to become. I returned to her for a specialist placement to pick up the cases that were more complex, transgenerational or involved child protection issues that I had avoided the first time around. I was lucky enough during that second specialist placement to also have the opportunity to work one session a week into an NCH Action for Children project for child and young adult survivors of sexual abuse. There I was reminded of the value of human connections over any academic knowledge, as well as having the opportunity to use Cognitive Analytic Therapy for the first time. I also did a specialist placement in a child development service, with some work into a sexual abuse team – including working with children who had survived abuse and co-facilitating a group for mothers whose partners had sexually abused their children. I learnt more about complexity and systems, and some healthy cynicism about organisational change. I still remember the chart for the new tiered model of services pinned up on my supervisor’s wall, with ovals that widened at lower tiers, entitled “the shape of future services” to which he had added a handwritten subtitle “is pear-shaped”.

When I qualified I was torn between a post with the favourite supervisor I had spent two placements with and one that several people warned me was “burnout waiting to happen” working in child protection. After a long discussion with a good friend I concluded I wanted to continue to challenge myself, and also to put myself where I was most needed. I therefore took the latter post, and worked in a split post across CAMHS and child protection. I learnt from a fantastic supervisor how to work in complex systems and services. David also taught me how to be an expert witness for the family court. The balance between being down-to-earth, approachable and yet grounded in knowledge and theory, as well as the clear communication under pressure gave me another role model of the type of psychologist I wanted to become. He taught me to ask the uncomfortable questions, and to balance holding empathy for parents with speaking up for the best interests of the child. Then in my longest standing post, I learnt from another fantastic head of service to think about process in supervision, how to bring fun and creativity into my work, and also to pick my battles! I also did a lot more collaborative work, and got involved in service development and audit, as well as gradually stepping up to greater supervisory and management responsibility. In that post I had the benefit of working with an inspiring social work team manager who had been doing really innovative work to increase access to permanent placements for older and more complex children. I also went out to America for a couple of weeks to train with Dan Hughes, where I learnt about the power of being present in the intersubjective space, and became more willing to show my own vulnerability and emotional reactions.

I have also learnt from less positive experiences – the times where I got it completely wrong, or unintentionally triggered negative responses in others. For example, I remember an AP I supervised feeding back disliking that I had introduced her to colleagues as “my AP”, intending that to be as supportive as I had perceived it being when I had been an AP myself, rather than as indicative of any claim of ownership. I remember crying when criticised in a multi-agency meeting about the autism pathway, and realising too late that it had been a bad decision to come into work that day whilst my house was flooded and I didn’t have enough emotional resources for work. I still cringe looking back on one time I tried to be supportive to a junior colleague who had to give evidence in court, but ended up making myself look stupid and inhibiting her ability to impart her observations in a useful way. I recall the challenges of having to raise concerns about how a colleague’s homophobia might have a negative impact on service users, and how they justified this being part of their cultural and religious identity. I remember the camaraderie, but also the pressure of working within a big system, feeling responsible for protecting more junior colleagues from organisational changes, worrying about waiting lists, and defensively managing referrals.

Most of all, when I think about negative experiences, I remember how gutted I was when my wonderful employing organisation lost the competitive tender for our service, and how horrible the initial meeting with the new service directors and managers at our new employing trust was. It started with a gloating talk from the new clinical director, and him taking digs at our senior staff about how some people in the room might think they know how to run CAMH services, but clearly he new better as they had won the tender. The jokes about how nobody need worry about their job security, except the consultant grade psychologists, as “you are quite expensive and we haven’t figured out what to do with you yet”. And the patronising response of the service director to my questions about whether the plan for my service section in their tender specification was fixed: “If you think you can do better, cheaper, love, knock yourself out”. I remember the pressure to rewrite the service specification and job plans for my team whilst my kids were in neonatal intensive care, and to take on various tasks to compensate for the fact they hadn’t appointed a locum to cover my absence. I remember my team being left out of the accommodation plan entirely whilst I was on maternity leave, and after protesting, returning to an undecorated, unfurnished office without internet or telephone points (or mobile reception) that could only be accessed by swiping out the fire exit across two flights of stairs, then swiping into another wing of the building and going down to the furthest end of the corridor. I remember being told to income generate or face temporary staff on my team being made redundant, and then being told that I was allowed to neither quote nor invoice as I wasn’t a budget holder. I remember being promised time off in lieu for all that I did during my maternity leave, but then being denied this on my return as “we can’t pay you full-time pay for part time work, no matter what you did in the previous financial year”.

I remember the day I walked out of a meeting with an operational manager, out of the building, out of the car park and down the road, and felt like I could keep walking forever and never go back. In the end I walked across town to my previous base and talked to the directorate manager there, who made it feel less personal. Over the following weeks I sought out some personal therapy through Occupational Health, and picked apart what was me and what was the toxic system around me. Then I decided to take a career break and spoke to HR to confirm that I would be able to continue my self-employed activities during a career break without this being considered “taking up alternative employment” and blocking my right to return. I also wanted confirmation that I would return on the same grade to the same client group. I always joke that the HR lady I spoke to should never play poker, because as I told her my reasons for leaving her face gave away too much. I watched her non-verbally say something along the lines of “oh shit, we’re in trouble here, pretend we’re not, pretend we’re not” before casually raising the option of redundancy and a gagging contract***.

So I had to uproot and push upwards into new an unfamiliar soil. Initially I applied for other NHS jobs, but ended up withdrawing before interview for one and declining a job offer for another, because I wasn’t prepared to work in another toxic culture. In the end I used my expert witness work as my parachute, and figured I would work it out as I went along. I changed from being a sole trader to a limited company so that I could employ an AP. I felt like I had been gradually dehydrated by the conditions I had worked in until I was just a husk of myself, and as I started doing my own thing I found some rain I started to find my own shape again. At first I used my own business to try to achieve what I had hoped to in my NHS career independently. As I have said in previous blogs, I helped set up a parenting charity, but felt the political agenda of the founder wasn’t consistent with the clinical goals. I secured funding for, designed, managed and evaluated a service to support people with diabetes, but ultimately it wasn’t commissioned. I set up a psychology service within a social care provider, and trained staff all across the country, but whilst I enjoyed the work I didn’t enjoy spending so much time away from my home and kids.

The challenges have continued, as I have had to foster my entrepreneurial side and learn the skills to run a business, hold a budget and manage staff. I’ve found new ways to disseminate knowledge – through being on committees, doing policy work, and writing for different audiences in my book, practice journals and on social media and this blog. I’ve developed ways to use technology to improve services, and I’ve returned to doing research. I’ve had to be flexible enough to try new things until I’ve been able to find a way to work that feels authentic. This blog documents much of that journey.

Through it all I have never been bored or complacent about my work. I’ve always enjoyed finding new challenges, and new ways to apply psychological knowledge. I have always found that my work provides moments of flow – that sense of deep and satisfying immersion in the present moment to the exclusion of everything else, that you get when you have sufficient agency and skills to meet a challenge, and feel a sense of reward from doing something well or contributing to something worthwhile. By comparison with so many people who do repetitive, boring or physically challenging work, I feel a great deal of gratitude that I earn my living doing something that is so varied, with so much autonomy and opportunity for enjoyment. Thankfully I have always been able to find sufficient challenge and novelty in how I work, along with sufficient freedom to satisfy me. And there have always been new human puzzles that intrigue me, and the varied settings and ways of working that I have experienced each involve looking at what I have to offer afresh and customising what I do for the new context.

 

So here I am, running my small business and trying to establish the use of structured needs assessments and outcome measurements in children’s social care. Once again, those themes of pushing upwards are back, as I have been putting in a big investment of time and effort to nurture this project over many years in the hope that it grows into something productive. Now that I am more established and have a mortgage to pay, plus rent on my office and employee salaries it feels like a bigger gamble than early on in my career where I had little to lose. But I have that same feeling of clarity about where I want to make my impact in the world that I did when I decided clinical psychology was for me after wavering as an undergraduate. I also have the same faith that my cumulative efforts will eventually be repaid with positive outcomes and a move into easier progress. If I go back to the image of the seed growing underground, I’d like to think that the journey through the earth has been completed and the new shoots are now reaching up into the sunlight where they can be replenished by energy from the external elements. I know as a gardener that with good planning and regular nurture the slow growth of seeds sown over winter can quickly turn into the rapid growth of spring and summer. I can only hope that I’ve done enough to establish my new plants and all this effort comes to fruition soon!

*My landlady decided to sell the house I was renting (despite having agreed I could stay on there in my third year), so I had to find an alternative place to live. My Dad was tested for prostate cancer. And I experienced the second incident in this past blog about rape culture in which I felt at risk of rape.
** Before you say “it must have been easier back then” I would note that I got that post against 110 other applicants. So even in 1995 things were pretty competitive, and probably more effortful as we had to find job adverts in the BPS appointments memorandum booklet that was posted out with the Psychologist magazine, phone up for an application pack, and then post in a hand written application, as NHS jobs didn’t exist and internet based application systems had not been invented yet. Which makes me feel very old.
*** A legal “compromise agreement” that included terms saying I would not tell people why I was leaving or speak negatively about the trust from which I departed, and could not take legal action against them – terms I understand are pretty common in that situation, but the government has subsequently outlawed after bad publicity, as they can be seen as an attempt to silence whistle-blowers.

I am not a therapist

I’ve always been someone that likes to keep busy, and has a lot of ideas about places where psychological thinking can make a positive impact. The aspect of my character that I now identify as entrepreneurial and put to good use in my business has always led me to want to try new things and create innovative solutions to problems. I like a lot of things about being a clinical psychologist, and particularly our ability to turn our hand to multiple types and levels of work. However, unlike many other clinical psychologists, I don’t really see myself as a therapist. In fact, I haven’t seen more than a handful of clients for individual therapy over the last decade, and even before that it was a pretty small proportion of my qualified jobs. I’ve always had more of a focus on the other facets of being a clinical psychologist. I think the picture of a clinical psychologist as a therapist is so strong that a lot of people will now be wondering how I fill my time!

So I will answer that question: I have done loads of highly specialist assessments (of neurodevelopmental concerns, attachment, parenting capacity, mental health, life skills, self-esteem, wellbeing etc) and lots of formulating and report-writing – some in collaboration with psychiatric or medical colleagues or within a wider MDT, but more as an external expert or second opinion. I have advised the family courts as an expert in care proceedings and complex custody disputes, and completed numerous pre-court assessments for local authorities to help inform their care planning. I’ve managed teams and services, and supervised from 2-20 other staff at a time, along with sitting in various organisational/management structures. I have designed and delivered training to parents, carers and professionals, and I have done lots of consultancy to various organisations and professionals (mainly those providing health and social care services, or involved in the family courts), and help placement providers to improve their services. I design and deliver group programs (eg Managing behaviour with attachment in mind), but then rapidly cascade train other staff to continue to deliver them. I wrote a book about attachment/developmental trauma, and lots of papers and policy documents about Looked After children, and acting as an expert witness to the family court. I sat on a BPS committee and I contributed to NICE and SCIE guidelines. I’ve designed, managed and evaluated therapy services (but employed others at lower bands to deliver the therapy). I’ve been an expert advisor to the HCPC in a fitness to practice case and to the team investigating a death in public care. I’ve done loads of practice-led research about each client group I’ve worked with, from looking at the psychological and health economic impacts of offering brief therapy to hospital users with diabetes, to commissioned evaluations of other services. So I have plenty to fill my days despite not having a therapy caseload!

I have reflected on why it is that I don’t feel drawn to therapy, and reached the conclusion that, whilst I see it as a very worthwhile endeavour, I don’t really have the patience for resolving difficulties one person at a time over sessions spanning many months. I’m always more interested in grappling with the bigger questions of why people are in distress, and what we can do to most effectively prevent or ameliorate those difficulties. When I’ve solved the riddle (or at least, reached a plan that improves upon existing solutions) I like to evaluate its efficacy, modify it if necessary and then disseminate the learning and/or train others to replicate the solution. I try to step outwards from the individual issue to the broader themes and ways that we can intervene on a wider scale. To use a visual metaphor, if dealing with mental health problems is like bailing out a ship, then rather than scooping out water one cup at a time, I am trying to work out how to plug the leaks, and to design boats that won’t have the same vulnerabilities to leakage in the future. It also helps me to avoid feeling hopeless about factors outside my control and demand exceeding supply, or burned out by an accumulation of traumatic stories.

Jenny Taylor, a past chair of the Division of Clinical Psychology, once described our profession as the structural engineers of the therapy world. Unlike a therapist trained in a single modality of therapy, we can survey the landscape and assess the need, then design the intervention that best meets that need – even if we are not always best placed to deliver it. We can base that recommendation on our knowledge of the current evidence base, which can change as new information comes to light.  If we consider the challenges people face as a river they need to cross, a therapist trained in a single model of therapy might be a bridge-maker. A psychodynamic therapist might be a mason who can build traditional stone bridges and claims that this design best stands the test of time. A CBT therapist might be a carpenter with a set of designs for wooden arched bridges that he claims are cheaper and quicker to erect. Each sees their own skill as either suitable to solve the challenge or not, but also has some incentive to sustain their own livelihood by continuing their tradition. A clinical psychologist can survey the land either side of the river, the span length required to cross it, and the materials available in the locality. They can then advise on the various options, including the relative costs and the evidence of how they fare in different conditions. They may or may not feel that bridge required is within their own skill-set to erect, but have a reasonable overview of other bridgebuilders in the area to recommend. If new designs of metal suspension bridges are developed, this is not threatening to the structural engineer, who can adjust their recommendations to incorporate the emerging evidence base.

I really like this metaphor and strongly identify with the role of structural engineer rather than bridgebuilder. I had always thought that this was instilled in me by my first graduate job, where I was an assistant psychologist on a research project about improving quality of life in residential care homes for older people, and I could see how the research and clinical work were closely tied together and built on each other reciprocally. But now I think my love of data and the scientific method runs deeper than that and I can see it infused throughout my whole approach to life since childhood. When it comes to my work I am a scientist practitioner down to my bones, as I always collect data as I go along. Where I don’t feel like I understand the situation well enough, I first look to the literature and then to gathering data and doing my own analysis to try to gain insight. When I develop something new to try, wherever possible I try to evaluate what we are doing, and refine it through an iterative process until we can prove maximum efficacy. I see that process as being part of the USP of a clinical psychologist – that we think like scientists and gather data to inform our interventions.

But I’m not sure that we communicate this mindset well enough, or that it is universal amongst the profession. It certainly isn’t what draws people into the profession in my experience. Too many clinical course application forms I review could be paraphrased as “I want to learn to be a good therapist” with an afterthought of “and do/use research” because they think that is what selectors want to hear – but in my view therapy can be done by lots of cheaper professionals, who might do an equally if not better job of it. I believe that clinical psychologists should be more than well paid therapists. We should know the evidence base and be able to take on the most complex assessments and formulations (even if others then deliver part or all of the treatment) but also to be able to develop, refine and evaluate novel therapeutic interventions, supervise other staff, improve services, consult, train and manage – things that extend beyond the skillset of most therapists. I’m sure it is clear by now that this is where my own interests lie. And I think it shows through in everything I do.

For example, when I was asked to lead the CAMHS service providing neurodevelopmental assessments I started with a literature review and current policy and best practice guidance. I then conducted an audit of the existing pathways, then tried to make things better. We set up a new clinic system with more rapid throughput and more thorough assessments, and then re-audited showing a reduction from an average of 18 months of input to five, with increased clinician confidence in the service and higher client satisfaction. I also wrote a booklet to help provide the information to parents whose child received a diagnosis of an Autistic Spectrum Condition. Although it required dedicated clinician time for the multi-disciplinary clinic and for the psychometric assessments generated, overall the new pathway freed up capacity because less cases were being held open by other clinicians whilst waiting for assessment, or kept open for prolonged periods afterwards to help the family understand the diagnosis and connect up to local sources of support.  I also sat on a multiagency strategy group to look at establishing best practice standards for the county.

I had the same approach when I was asked to support the adoption and permanence service. I initially set up a consultancy clinic, where social workers could bring cases to discuss or book in families to see jointly. I found that I was explaining similar information about attachment, trauma and neuroscience to multiple professionals, parents and carers in the consultations. So I designed a group to share this content. I called it “Managing Behaviour with Attachment in Mind”, and developed some “doodles” I would draw on flipchart paper to explain the concepts more accessibly. I evaluated the impact and showed it to be an effective format for supporting parents in this situation. The groups were popular and over-subscribed, so I trained others to deliver the group to keep up with demand, first in my service and then more widely. Many people in the groups liked to photograph the doodles to remind them of the topic, so I decided to write a book to share them and Attachment: In Common Sense and Doodles was born.

But I also wanted to know about how we could achieve permanence for more children. I started by looking at the literature about what makes effective adoptive matches. Very little information was available, so I systematically audited the paperwork from 116 adoptive matches and followed them up over 7 years to see what factors influenced the placement outcomes. I was able to look at whether the innovative adoption project to place children with more complex needs had better or worse outcomes, and was able to explore the impact of different motivations for adopting. Whilst to me this was just a natural process of answering the question as an evidence based practitioner, it transpired that these studies of adoption risk and resilience factors were amongst the largest ever done, and I have discovered unique findings that I really should publish*.

You could argue that I was using a sledgehammer to crack a nut by doing all this research and trying to change process when organisations are notoriously slow to change, and that I could have spent my time more productively working with more individual adoptive families. But that’s not how I’d see it. The research I did helped me to understand what the key variables are when considering whether a child can achieve permanence, what kind of family we need to look for to place them successfully, and what kinds of support might ensure that the placement succeeds. I hope that I have fed that knowledge back through my court work, and into various organisational and policy work over the last decade. I have also disseminated it at conferences. However, I would still like to spread it further, because it is my belief that such knowledge can have positive impact at multiple levels – it can help to inform individual placement decisions, service-wide strategies for helping optimal numbers of children to access permanence, and national policy about adoption.

That work led naturally on to developing our services for Looked After Children when I left the NHS and set up my own company, LifePsychol Ltd. We provide training and consulting to foster carers and residential care staff, the social care organisations that support them, and the wider professional networks surrounding them, including education and health staff, police, lawyers, magistrates and judges. As I started to get more immersed in working with children in and on the edge of Care, it led me to recognise that there was a lack of validated and reliable tools to identify the needs in these populations, no outcome measurement tools that could reliably measure change over time in a way that was sensitive to the context and type of life events these young people experience, and a dearth of clinical governance in terms of the efficacy of both placements and interventions for this group of children. That seemed shocking to me, given their highly complex needs, and massively elevated incidence of mental health problems, challenging behaviour, risk to self and others, and prevalence of intellectual or neurodevelopmental difficulties.

As well as the human cost of not being able to identify the best choices for people, it seemed unacceptable that huge amounts of money were being spent on placements and specialist services for this group without any evidence of them changing their wellbeing or life course for the better. Placements seemed to struggle to identify what to work on and how, and there was little objective indication of what defined a successful placement, beyond annual visits from Ofsted (who were predominantly focused on process and procedure). The high level of need and the lack of clinical governance in the sector has allowed various specialist therapists and services to spring up that are virtually unregulated, and many placements have adopted terms like “therapeutic” without these having a consistent definition or meaning. So I wanted to see whether I could make any headway in changing that.

Meanwhile there is pressure from the government to improve outcomes for children in public Care, because they are seen to fare badly compared to the general population of children the same age. The difficulty is that this isn’t comparing like for like – children in care have many more adversities to face, both organic and in terms of their life experiences, that mean they often deviate from the norm. For example, I found that there was a 20 point skew downwards in IQ distribution in children in residential care compared to population norms, meaning that 20-25% of children in this setting had a learning disability, compared to 2% in the general population. Likewise the incidence of Autistic Spectrum Conditions and other neurodevelopmental difficulties amongst children in Care is more than triple that in the wider population. The same is true of young offenders. If we don’t acknowledge that, then the sector is being asked to seek impossible goals and will inevitably be seen as failing, even if placements and services are performing optimally and adding a lot of value to the lives of the children they work with.

To state the obvious, children in care are not just randomly drawn from the population – by definition their needs have not been met, and this can mean both the presence of additional challenges and exposure to harm or deficits in care. I believe that to look at the needs of this population and the degree to which these are met by placements or interventions, we need to either compare them to carefully matched controls or ensure that outcomes are always considered relative to baseline. The latter seems more pragmatic. Scores for young people also need to be considered in the context of what is going on in their lives – as changes in placement, daily routine, contact arrangements, or the arrival or departure of other children from the home can make big impacts on the child’s functioning.

So I’ve been beavering away exploring these issues and developing systems to measure needs and make the data meaningful for those providing care and services. The impact might not be as obvious as delivering psychological therapy directly, but I’d like to think that over time it can improve services for thousands (or even tens of thousands) of children, and make a greater net change in the world.

 

*Maybe I’ll write more about this in a future blog. But the short version is that I have been trying to secure some funding to complete the statistical analysis and disseminate this information, and would still like to do so, so if you have any ideas or useful connections to assist with this please let me know. Failing that I hope I’ll find enough time to write a book on making better adoptive matches at some point in the future.

Sticking plasters

I realise that this title won’t mean much to Americans or people outside the UK, so let me share a small anecdote by way of explanation before I get into the topic I want to discuss. I was on an American airlines flight back from New York in 2003, having done a lot of walking around the city over the preceding week. When I removed my shoes and straightened my socks it transpired that a burst blister had adhered to my sock, and it started to bleed surprisingly profusely. I asked a member of cabin crew for a sticking plaster, and got entirely blank looks in response. When I explained the situation, a steward showed a sudden look of recognition and sighed “oh, a Band Aid! I keep one of those in my wallet for my kids” and provided what I needed. So yes, a sticking plaster is a Band Aid – an adherent protective dressing for a small wound.

I found it quite an insight into American marketing, as I had also tried to buy antihistamine cream in a drug store to utterly blank looks, until someone realised I wanted “Benadryl”. I had also seen the TV advertising persuading people they had adult ADHD (with a symptom list that seemed to encourage false positives, and a link to a small quiz online that seemed to classify almost anyone as having ADHD), or that they needed Viagra (with the almost comical warnings that “erections lasting more than two hours can be dangerous and require medical attention”). Disease mongering is a pretty interesting phenomenon, and well worth reading about – Did you know that the vast majority of viagra prescriptions are “off label” and written for groups in which there is no evidence of efficacy (including women, when there is not a single study showing evidence of efficacy in this population)? And that the pharmaceutical companies are trying to medicalise “Female Sexual Dysfunction” to create mass markets to address lack of desire or lack of pleasure, with minimal consideration of the context or wider issues, because of the success of such marketing with men? Or that “restless legs” has been marketed to the public as a common condition requiring medication? It made me quite glad for our generics, and lack of medication marketing targeting the public.

But the reason I wanted to talk about sticking plasters is that they are a response after the event. A means of short-term management, and covering up of an injury, rather than preventing it. Like my blisters adhering to my sock, there were many stages at which that bleeding could have been prevented – by covering the blister earlier, or better still byby taking the subway more and/or wearing more sensible shoes to explore New York. The problem is that if we become overwhelmed by demand for the reactive response, we lose the capacity to look at what underlies the demand. And if we spend too much time reacting to distress in health services, it can mean that we fail to do the preventative work that would reduce the need for such services. With austerity politics ensuring that the health and social care sector are too underfunded to be proactive, I think that is where the NHS is heading, along with most of the public sector.

Every single day I seem to read about travesties of social justice, and the lack of thought about the people that bear the brunt of them. Time and time again the most vulnerable members of society are being abused and neglected at a national and global scale. Whether it is the man who has paid UK taxes for 40 years who is being denied essential cancer treatment because he doesn’t have a British passport (due to a paperwork oversight when he arrived as a child with his parents from the Caribbean 44 years ago), or the deportation of a humanitarian/academic couple who are being told to leave because they went abroad for too many days – to complete a government study. Or how about the person that tweeted about having waited for over a year for support after a sexual assault, with rape crisis waiting lists closed for most of London for more than a year due to the scale at which demand exceeds supply?

Perhaps we should look at the rapid rise in mortality in the UK so far this year, falling life expectancy (especially in lower socioeconomic groups) or the rise in deaths amongst mental health patients – despite the falls in smoking and improved outcomes in many health treatments. A man/woman in an impoverished estate in the north of England can now expect to enjoy 32/35 fewer years of life in good health, compared with a counterpart in a wealthy suburb in London or the Home Counties. Or perhaps we can look at the impact of cuts to NHS funding (albeit masked by fake claims of record wage rises) record waits for A&E, the cancellations of operations, and the burnout of NHS staff.

Or look at the increase in homelessness over the last few years (it went up 16% in 2016 alone, with almost 50 000 families living in bed and breakfast accommodation and many more “hidden homeless” living on floors and sofas of friends and acquaintances) with the knowledge that being homeless can worse than halve your remaining life expectancy (homeless women die on average at 43 and homeless men at 47, compared with 77 for the rest of us). As the author of the BMJ article puts it “Homelessness is not an episodic event, but something systemic. It is a neon sign that something is fundamentally wrong with policy across health and housing”. This lack of provision doesn’t even save money as the cost to the NHS of society’s failure to deal with homelessness and other examples of inequality has been estimated at £4.8bn (€5.4bn; $6.7bn) annually.

These same austerity policies have a wider impact on mental health. Psychologists for Social Change have identified five ways austerity policies impact on mental health: 1. Humiliation and shame 2. Fear and distrust 3. Instability and insecurity 4. Isolation and loneliness 5. Being trapped and powerless. They remind us that “These experiences have been shown to increase mental health problems. Prolonged humiliation following a severe loss trebles the chance of being diagnosed with clinical depression. Job insecurity is as damaging for mental health as unemployment. Feeling trapped over the long term nearly trebles the chances of being diagnosed with anxiety and depression. Low levels of trust increase the chance of being diagnosed with depression by nearly 50 per cent”.

So we can’t see mental health in isolation. Whether it is the individual context (for example in the power threat meaning framework I discussed in a prior blog) or in the wider sociopolitical context, we are not brains in a jar, but socially connected beings with experiences that impact on our wellbeing. When we talk about the shortfall in mental health services, too often we are saying that in the context of demand for services exceeding supply, and feeling strongly pulled as psychologists to provide more of the same. That makes sense in at the coal face, where it is hard to have the energy, time or resilience to look at the wider picture beyond the demands hammering on our own door. However, it means that we are discussing the lack of sufficient reactive responses to a problem that could have been dealt with more effectively further up the timeline with proper proactive and early intervention work, and in a lot of cases could have even been prevented with better social policy and provision for vulnerable population groups.

Of course, doing preventative or early intervention work also takes resources, and we can’t take them away from the people currently in need/distress now. But instead of us constantly asking for a little bit more of the same to deaf ears who reply with excuses about finite pots and efficiency savings (and sarcasm about magic money trees), maybe we need to think more creatively about intervening at different levels and in different ways to the set up of existing services. I’d rather be providing sign-posts to avoid hazards than doling out sticking plasters when people trip over them – and best of all I’d rather be fixing the hazards, and helping vulnerable people identify routes that are less risky.

I’ll give Psychologists for Social Change the last word: “Mental health isn’t just an individual issue. To create resilience and promote wellbeing, we need to look at the entirety of the social and economic conditions in which people live”.