Wisdom and reflection

Every now and again I stumble across something that makes me think “yep, that’s true, that explains something really profound”. I want to record that bit of wisdom, and hang on to it, and pass it on to others. So this blog is partly to fulfil that desire, as well as to meander through some of my own experiences and ideas, which are less well-formed and still open to the process of being improved through constructive challenge. There is a certain vulnerability when expressing ideas that are not yet thought through from every perspective, but I think that reflection and feedback is an important component of personal growth. I believe that beliefs can and do change according to your knowledge and experiences. If you look at life as a journey towards wisdom, then each interaction and experience is an opportunity for reflection and learning.

One example of a simple piece of wisdom I like comes courtesy of Michael Specter’s TED talk about the danger of science denial. He says “everyone is entitled to their own opinion, but they are not entitled to their own facts”. It is a helpful thing to remember, because people believe all kinds of disagreeable things that make them prejudiced, intolerant, selfish and lead them to act against their own best interests. As therapists, we are taught to give our clients unconditional positive regard, but what do we do when people have harmful behaviour and offensive beliefs? Do we just ignore them and try to work as normal? Do we pass the client on to another therapist? Do we try to find (or fake) respect for them despite the parts that are uncomfortable? Or do we challenge their beliefs? And what if we as therapists have our own prejudices, or see them in colleagues?

The first step is to recognise and acknowledge the underlying beliefs that are at play. We can then formulate to understand where such beliefs might come from. That will increase our empathy for the individual, but it isn’t an excuse. It doesn’t make the beliefs or behaviours acceptable, just as we can understand why a person might learn to use violence or abuse substances, without endorsing that choice. Sometimes our job as a psychologist is to go back to the facts, and then explore how they fit with the opinion, and what the costs and benefits of maintaining that opinion are. This can true be from the typical inward-facing cognitive distortions of depression or anxiety, to the outward facing generalisations behind racism, misogyny or homophobia, or the poor choices that lead to substance misuse, offending or aggression.

When a colleague of mine declared some of the narrative techniques I was using with a child to be “one step away from tarot cards and the work of the devil” and a non-judgemental discussion about a young person’s self-identified sexuality and gender to be “encouraging an abomination”, it was somewhat mind-boggling to try to understand where those beliefs came from and whether or how to challenge them. Had I known Specter’s quote then, I think it would have given me some guidance. She was entitled to her beliefs, but the service needed to operate on the basis of facts. The facts were that the therapeutic technique I was using had been used thousands of times before causing outcomes ranging from neutral to positive, and had published studies of efficacy. And it is evident that large numbers of people identify as LGBTQ, and that this occurs across the animal kingdom, suggesting it is an innate drive (although the evidence suggests that early experiences do have some influence). It is not a choice. There are enormous risk factors in not accepting that and responding with empathy and compassion (including appalling levels of self-harm and suicide where such identities are rejected/devalued, or there is pressure to act like they are heterosexual and cis-gendered).

I found the beliefs that colleague expressed repugnant, whilst I was also trying to respect her culture and choices, which included the right to participate in a charismatic Christian church that held these beliefs (and no doubt many others) as doctrine. Thankfully I had a wiser supervisor I could take the issue to. Fifteen years down the line, it might be that I would be the person who had to address such a concern about an employee in my company or line management. I think that where beliefs get in the way of facts sufficiently that they interfere with your work, this raises issues about competency to fulfil the role. This should be dealt with much the same as if the person was failing to do their paperwork, or wasn’t dressing appropriately for the job – with feedback about the requirements of the role, an offer of support to develop new skills, and a timescale in which change is required. This might lead to recognition by either or both parties that the person is not suited to the role.

A past supervisor once told me another wise thing: “It is easier to grow the things you like than it is to shrink the things you don’t like”. Whether that is in terms of the balance of fun and frustration in your job, or the way your children behave, a focus on growing the good can lead to more positivity, progress and creativity.

Another piece of wisdom that I have found helpful is the serenity prayer: “Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference”. This is helpful as we lose a lot of energy trying to change things that are immutable (or at least moaning about them), when we would often make more progress by focusing on the things we can do, even if they seem much smaller. We only have finite time and emotional/physical resources, so we have to prioritise. As Dave Allen said, “you can do anything, but not everything”.

On the other hand, Emma Watson’s powerful questions “if not you, who? If not now, when?”, Ghandi’s instruction to “be the change you want to see in the world” and Nelson Mandela’s observation that “it always seems impossible until it is done” are reminders that we each have responsibility for progress and the power to make change. We shouldn’t be overwhelmed by big challenges and can’t rely on other people to get things done, so we need to stop procrastinating and take action to step up to the plate for things that we care about.

I’ve ended up making a website and forum that get 10 million page views per year because it seemed like a good idea and I was in the right place at the right time for that to be a possibility. I am active with my professional body and contributing feedback to national policy, because someone needs to do it and I can just about eke out the capacity. I’ve supervised Assistants and Trainees, and done personal and professional development coaching for early career stage psychologists for many years, because it feels like a helpful thing for me to do. I’ve left the NHS and set up a company and a social enterprise that have survived through a recession. I sometimes get to hear how little things I have done have rippled out and influenced people or events in ways I didn’t expect, and there are people who cite me as influential on their lives personally or professionally. Yet when people ask how I manage to do all these things, it seems like a strange question, as I feel like they are all things any of my peers could equally have done.

Duncan Law, a Clinical Psychologist who has been instrumental in setting up CYP IAPT, said recently (in the context of successful bids for service development) that it is only looking backward that things look like a straight line, because when you are doing them it seems like you are just trying lots of options in the hope of finding a path forward. I feel that about my career. Looking backwards it seems that every component of my experience has culminated to prepare me for the things I am doing now, as if I planned my career methodically. However, at the time I was just taking the most interesting available option, in ways that often seemed to deviate from what I really wanted.

I’ll give the last word to Steve Jobs, who said “the only way to do great work is to love what you do. If you haven’t found it yet, keep looking. Don’t settle. As with all matters of the heart, you’ll know when you find it”. For all its periodic frustrations, I feel very privileged to be able to earn my living doing something that is interesting, worthwhile and rewarding. I wish that everybody had the same experience in their working lives.

All change!

Someone once said to me that, if you can manage the stress, change can be an opportunity. They argued that a time of confusion is a good time to put forward ideas that could be seen as potential solutions, as nothing is set in stone yet. Derren Brown (the skilled TV hypnotist, cold-reader, sleight of hand maestro and showman) said something similar when he talked about how confused and stressed people are at their most suggestible. I think he said it whilst persuading bookies at the races that he had won on losing tickets, which was not something I felt was ethical to replicate (even if I had his skill-set) but I do have some anecdotal experiences of this being true. I remember a few years ago going shopping in early December and queuing up to pay in a very busy clothes store. I had a loyalty card which gave a discount for the event at the store, but when I got to the till I couldn’t find it. The poor cashier was on hold to the accounts department to see if they could find my details when, whilst making small-talk, I asked if the discount was the same as the student discount. The cashier then decided it would be easier to put my purchase through as a student discount (which did not require a card number), so that she could deal with me more quickly. Thus I got the discount without the card, and she was able to move on to the next customer. I could see that my comment had unintentionally introduced the potential for an easy win into her mind. Of course as soon as I left the crowded store I was able to find the card, but it made me think about the attractiveness of offering an easy option when the demands are overwhelming. I find this a reassuring concept to think about when the public sector organisations seem to be constantly in a state of organisational change, demands that exceed resources to meet the need, and a pervasive level of uncertainty and confusion! This idea that sometimes a suggestion with serendipitous timing could influence change in a positive direction offered an interesting alternative perspective to my pessimism about how difficult it can be to get even solid, evidence-based, cost-saving ideas accepted into practise (see previous blogs).

I’ve also been talking about the need for change in how I work in my personal development coaching sessions. I’ve previously blogged about feeling a bit burnt out by the emotionally harrowing content of some of my work, the need for me to get better at prioritising and how I am trying to get a better work-life balance. One of my motivations to start the coaching was my sense that I have so many plates spinning I have almost lost track of why I am spinning them and what my goal is. I wanted to re-evaluate what my goals were, and to find the joy in my work again. As I have begun to clear space in my life to reflect on this, I have recognised that my beliefs about what my career would look like have not really kept pace with changes in the public sector and in my own interests and ways of working.

At some level, my template for a good career in psychology was based on my Mum. She worked in child psychology and CAMHS, and was Head of Child Psychology for a county at the point she retired a couple of years ago. I had always assumed that was pretty much how my professional life would pan out. I had qualified in 2000, worked my way up the bands to make Consultant Grade and be part of the CAMHS management team in 2008, and expected to end up as Head of a Child Psychology service somewhere. In metaphorical terms, that was the train journey I bought a ticket for. But something changed when I had kids and went through a lot of stress related to the organisational changes when the CAMHS contract was won by a competing trust and we were TUPEd over. In the end I left the NHS and did something different. In the metaphor, I got off the train. My early plans for my company were very much based on wanting to replicate what I was doing within the NHS, but without the systemic problems I experienced in the NHS trust that I left. So in the metaphor I caught the bus, but I was still headed for the same destination. At various points I meandered, detoured to explore things I had heard about, joined groups to see the local sights, even hiked across country with my own compass, but underneath it all my destination was still the same.

Of course once you are going off the beaten track, sightseeing, hiking and choosing your own route, the journey becomes a bit more scary but much more interesting. In turn, the destination becomes less fixed and also less important, because it can continue to change and there may be steps beyond each destination to another. You can also grow in confidence and tackle bigger challenges and find new things inspiring, so you end up setting goals you had not considered at the beginning of the journey. Once I was off the train, I didn’t need to follow the tracks, or try to make my way by other means to where they led. I didn’t need to replicate CAMHS or to try to set up a LAC service outside the NHS, and I didn’t need to be Head of a Child Psychology service. Indeed I was offered an NHS post with this title last year, which was my expected destination, but I declined the offer. I learnt things about the post that made me concerned that I’d be jumping back into a train on a route where everything was running late and all the passengers were unhappy, whilst I was no longer afraid of being off the rail network and doing my own thing – in fact I had remembered how much I could enjoy the journey if my focus was in the here and now and not about trying to get to the destination ASAP. I started to think of myself as being a much more adventurous person and put my skills to use in much more flexible ways.

Sadly, the kind of NHS I envisaged spending the next 25 years in isn’t there any more, and the jobs at 8C and above bear a lot of the brunt of the change by having to take on the new political and financial pressures, whilst the lower banded staff continue to do much the same work (albeit with increased pressures of throughput and whilst hot-desking). There are good services remaining, and some people will still think that is the best career option for them, and I’m glad about that as I love the NHS and want to see it survive and hopefully thrive in the future with more investment. But for me it isn’t the only option any more. There are other opportunities for adventures outside of the NHS that hang on to my core ethics and values, and put my clinical psychology skills and experiences to good use, but without some of the constraints of the NHS. I can write my own job description, choose my own working pattern and be paid for what I do, rather than on a fixed set of salary points for a set number of hours. Perhaps surprisingly to me, I’ve learnt I’ve got competencies and ideas that are useful and marketable in lots of places. Despite the austerity in the NHS, I continue to have more opportunities and offers of work than I can accept, and some of these are quite well paid. In short, I have learnt that I can actually think much more creatively about what options for my professional life will make me happy if I let go of the template of how I expected my career to be.

With that insight, I’ve got a growing desire to start afresh and do the things that have most impact and bring me most joy. That means I need to look hard at all the options in front of me, and all the plates I have been spinning, and figure out which of those I want to focus on, and which I want to pass on to other people or drop. There may also be entirely new projects that I can develop because they are interesting to me, but I can recognise a future market or source of funding for.

There is big change ahead. But my business is small and agile, I’ve got an entrepreneurial attitude, and I’m lucky enough to have some interesting offers on the horizon. I’m in a position where I can embrace the change, so I am seeing it as an opportunity.

How to prioritise

Priority used to be a singular thing – the most important goal. It is only in recent years that you can have several priorities. It seems as time goes on the quantity we have to keep up with increases. At the moment I have a “to do list” that seems to grow faster than I can knock items off it. Fix the boiler, get a present for the kids to take to a birthday party, get the MOT and service booked for the car, catch up with my emails, send an anonymised report to the colleague who is shadowing me on Tuesday, book that meeting with the accountant, follow up the meeting I had last week, book in dates for group-work facilitator training, catch up reading for NICE guidance, vote on new dates for working group meeting, produce invoices for recent work, chase up unpaid travel expenses for interview in spring, write another blog entry, set up webinar for patreon supporters, read book I just bought, update the CPLAAC website system, etc etc.

I’ve been reading a lot and working on trying to improve my work-life balance and to work out which of the many options in front of me I should prioritise. I’ve always had such wide interests in psychology that it is easy for me to get sucked in to new projects: Only yesterday I read a post on linked in about how someone had set up a social enterprise to combat social isolation in older men by setting up groups in which they could attend sports matches and wanted someone else to take it over, and I started thinking “what a good idea, it would be a shame to let that drift, I wonder if I could fit it in?” before I gave myself a metaphorical slap and realised that it was outside of my core areas of professional interest and I have too much on my plate already. But I really need to prioritise, and this blog article explains why (if you can get past the pretentious business jargon). Basically, if you keep trying to keep up with everything, you don’t get the thinking space to work out what is most important, and end up keeping up with everything that is thrown at you, rather than progressing with the most important stuff. The advice boils down to: take time out to take stock, set less goals but do them before letting other demands interrupt, let a trusted other help you prioritise, and declutter your physical and mental space (do one thing at a time, and don’t let email, phone or social media interrupt more important stuff).

The first thing to consider is Maslow’s hierarchy. The top priority has to be to ensure that my family and I have our biological needs met. At the most primitive level this involves enough sleep, regular healthy meals, warmth and shelter – and it is amazing to think how often I work late, or skip a meal, or ignore my physical comfort. The next layer is a sense of psychological safety – a stark reminder of how many of the court assessments I do involve some form of risk assessment in how I set up the appointment. There is then a need for love and belonging – which entails time for family and a social life outside of work. Only the very highest levels relate to the rewards of work – the sense of achievement, success and self-actualisation. So why has the fine tuning expanded to seem so important that it compromises more basic needs?

At its most basic I need to cut down my work and have more time for life outside of my professional role. I have mentioned already that the first mnemonic that was helpful to me in thinking about my priorities was to consider the “4 Ps”: As well as being a professional, I am a parent, a partner and a person. If I don’t tend to these other roles sufficiently I will be missing out on important stuff for my own wellbeing and on prioritising my own needs and those around me. And I think this is wise counsel for anyone, whatever their job or life stage. But I now also have four i-words, by which to compare opportunities. These are specific to my personal values and goals. For me, the measuring stick of whether I want to do something is a combination of whether it presents: An interesting intellectual challenge; the opportunity to be innovative; a way to have an impact on a wider audience; and whether or not it generates income. I also know that I want to apply psychological skills to children and young people who have been dealt a tough hand in life (whether through their biology or genetics, or through their experiences of maltreatment). I’m particularly interested in attachment relationships, and the impact of maltreatment on neuropsychological development.

So when it comes to weighing up potential projects I can look at how they measure up. The project for older people and sports is a clear no, whilst my work to improve quality standards and instil a culture of outcome measurement in residential care for children who are Looked After in public care is a clear yes. I also know that I can’t take on any more unpaid committee work. Hopefully now I have at least recognised the problem and operationalised the criteria,  I can be more discriminating in what I take on in future. And to prove it I am now going to prioritise getting some sleep!

Confessions of a workaholic

Hi, I’m Miriam. I’m a workaholic.

I face that fact with insight that it is somewhat akin to an addiction. But there is no 12 step program for this (and I’m an atheist so it probably wouldn’t suit me if there was) and total abstinence is not an option. There is little around in terms of evidence-based intervention either. This might be due to the lack of stigma involved in working too much, and the way that having a job at all is a mark of relative success. In fact society somehow endorses overwork, and there is almost a culture of humble-bragging about how much we let work take over our lives. Our phones and computers bring us calls, emails and texts 24/7 and it is hard to know where work ends and our lives outside of work begin.

So let me start by describing the problem: I have too many plates to keep spinning. I take on much too much at work. On top of all the psychology work I am struggling to get on top of the invoicing and the finances of the business (I don’t really enjoy doing that side of things, but I haven’t found a successful way to delegate it yet). I bring work home. I work as if its a hobby by running a website, a blog, several twitter accounts and now a patreon service in which I offer personal development support to early career stage psychologists. I am making an app, developing an online outcome tracking system and writing a book. Plus I talk at conferences and do training. And I do court work. I provide supervision and personal development support. I sit on numerous committees and working groups. I fill my diary chock full of commitments and let the admin spill outside working hours. And I am writing grant applications (I’ve got one, part-written, on my screen at this very moment). But it is not just in work that my workaholism shows. I create little work-like activities to populate my life. We have some investments that I manage. I used to trade on eBay and at sci-fi fairs. Even giving stuff away to charities and freecycle takes time to organise. I do little fundraising activities for good causes. I’ve done up a series of houses (and even helped friends to do up theirs when I have spare time).I grow vegetables. Even the way I shop is influenced by my business brain, so I’m very conscious of relative prices in different supermarkets and I like to get reductions and offers.  There is a half-written novel too (but everyone has one of those, right?).

Since I’ve left the NHS to set up my business I’ve worked many more hours than I did before that. But even in the NHS I’d often stay late to finish admin, and I took on court work outside of my NHS hours. I’d guess I worked 40-45 hours per week then if I averaged it out. Last year I would work from waking up until the kids needed putting to bed, when I’d stop for an hour to chat and then sing to them, then I’d make a meal and eat with my husband before resuming work again until I couldn’t stay awake any longer. I’d fit in bits of work (and catching up on sleep) at the weekend. There were many weeks I probably clocked up over 70 hours of work. And that leaves very little time for anything else.

I’ve come to think of the space that work takes in my life being like that expanding foam filler you can use to fill the gaps where pipes enter your home. At its worst, every minute of my time that isn’t taken up with something else gets filled with work, or work-like activities. The only spaces that are protected are for the things that I value more than work and have defined really clearly – the hour in which I put the kids to bed is sacrosanct. As is an evening meal with my husband. If I have made arrangements with friends or family then work has to fit around. On the times when we go out for meals or do things as a family, I try to make sure work does not impinge. I’ve also tried to carve out time to get to the gym three times a week, and only miss this when working away from base or where there is an immediate deadline. Some things that waste a lot of time for other people, I have simply chosen not to do (for example, I haven’t watched any live TV in over five years now). But many things that should be prioritised are not. I stay up late and sacrifice my sleep pattern far too often. I work through meals. I miss out on relaxation time. I haven’t found time for my hobbies in years. I don’t take a full quota of leave. Nor do I have as many holidays as I would like. Plus I’m embarrassed to say I’ve taken reports to finish with on several UK short breaks with my family. Once we went somewhere without wi-fi and I ended up driving around and using the BT hotspots from domestic customers to work in my car for 3 hours to get a report in, because a colleague had sent me their contribution 2 days later than planned and it didn’t meet my standards without substantial editing.

So, given there was no risk of getting fired or not being able to pay the mortgage, why would I give work such precedence against everything else in my life?

I keep asking myself that, and its a tough question to answer. I am not hugely motivated to maximise my income and I’m not competing against someone else. I’ve never had ambitions to drive a porsche or own a huge house with a swimming pool or any form of status symbols – in fact I hate ostentatiousness. I don’t have a goal for turnover, or numbers of employees, to win a particular contract, or to take over the NHS. I just want to do worthwhile work that improves life for people who have been dealt a bad hand, in a way that is delivered to them for free and according to need. I want to spend my working time with people I like around me, and to have shared goals and achievements.

I think the things that motivate me to work hard are complex and interwoven. Part of it is my heritage, and the stories about the importance of work that have carried through the generations in my family. My dad rebelled against expectations to be a doctor, and has always been creative, which is a much harder niche in which to find success (he has written many children’s books and has latterly become a skilled photographer). He spent much of his working life as a house husband, dealing in antiques or doing jobs he didn’t like, and had a lot of time off with ME like symptoms when I was a kid. My mum has always been a hard worker and the main provider in my family. My maternal grandmother was a hard working single mother in an era and cultural group where there were not really single mothers, and remarried unhappily but wished she hadn’t (and probably impressed upon my mum at some level the value of supporting yourself and marrying for love). Plus my heritage is as an immigrant squared – my great grandparents/grandparents were persecuted Jews who earned their way up from nothing when they fled from Russia to South Africa, and then my parents came to the UK and built a new life here from scratch. There is a high value placed on taking advantage of the opportunity for a good education that people take for granted in the UK, and there are many examples of the value of hard work. The family is very well educated (my dad is the only one who didn’t finish his doctorate) and has implicit ethical rules about the kind of work that we do. I’d think about these as stepping up to the challenge, and seeking to advance knowledge or make people happier, rather than maximising profit or power. There is a definite drive to achieve, though no-one would explicitly want to pass this on to me and I know they would want me to prioritise happiness.

Another part is my moral values, approach to life and personality. Being a psychologist is core to my identity, but so is a sort of entrepreneurial view of the world. I approach everything with curiosity and a desire to problem solve. When it comes to issues that lead people to be less happy or achieve less than optimal outcomes, I genuinely love the process of formulating what is going on, designing innovative solutions that might be effective, evaluating whether they work and disseminating the results. I gain satisfaction from the intellectual challenge, being able to influence practise. I like getting positive feedback for good work, feeling that I have been helpful to others or had a positive impact on systems or decisions. I like the fact my reputation means I am constantly in demand – interestingly in the public sector a waiting list feels like a sign of failure, of not keeping pace with demand, whilst in the private sector it is a marker of success as people are prepared to wait to see you, and the demand for your services exceeds your capacity to supply them. I also feel that people who are gifted with the resources of resilience, intellect, empathy and knowledge should put them to good use, and that the value of my life and the legacy I leave behind will be the impact I have had upon the happiness of others. I’m not a perfectionist, but I do set myself high standards. Finally, it is hard to turn down work that is so badly needed or that you feel might be done poorly in your absence. I know that sounds grandiose, but I’ve seen really bad examples of court reports that led to ill-informed decisions, and it adds to my sense of responsibility to do things well.

I also think that the nature of being self-employed, and of feeling responsible for employees has added to my pressure to work. I feel like I need to put the effort in to establish the business, to ensure we have enough cash flow to pay everyone, and to feel I am pulling my weight. I also feel there is something difficult about turning down work that pays amounts of money that seem almost obscene when compared with what some of the population have to live on. Doing this kind of work is such a privilege compared to having to work in a factory or doing hard physical labour or monotonous office work, or having to do voluntary work experience to claim their benefits. I compare myself to someone trying to eke out £150 of job seeker’s allowance to pay for a fortnight of food and fuel and think how bizarre it would seem to them that I had turned down work that would earn that in just a couple of hours. Or I compare what I earn now to myself as a graduate psychologist earning £9500/year and self-funding an MSc from it. I think about how that extra money could keep on the assistant who really needs the work, or pay for us to have a holiday, or a cleaner, or how far it would go if donated to a charity.  It just seems so ungrateful and lazy not to be willing to do the extra work in that context.

It is also to do with how I think about my own work. I always try to help others and say yes to requests unless I have a reason to say no. I’m dreadful at thinking “oh it will just take me a couple of hours” and taking on new responsibilities without being realistic about my existing commitments. I don’t put sufficient value on my time. And I hide the amount of work I do from others (and myself) by flexing my working pattern. I’m a night owl. I can work until I get things done, into the small hours of the morning taking advantage of the quiet solitude that gives me, and being self-employed and having a sympathetic partner I can often work a late start into my week or lie in at the weekend to catch up. But it makes me tired/hungry/cold (which are all very connected for me) and sabotages my daytime activities if I do it too much. From lying in rather than being up with the kids in the morning, to being grumpy and half-focused during interactions later in the day, there is always a price to pay on those nights that I’ve worked too late. But my tendency to put things in to this quiet time, or to need it to catch up with things I have taken on means that I don’t stop at bedtime, and I certainly don’t stop in time to wind down for bedtime. I don’t think it makes me a very good role model. My kids ask why I am up late at night, or sleep in during the morning, and I feel embarrassed that I haven’t organised my time better. My colleagues are used to me taking work home and end up adding things to my calendar to fill up all the gaps, reinforcing the pattern that the 10 hours it takes to write a court report is outside of my working hours, and that no admin time is scheduled for writing bids, contributing to committee work outside of meetings, catching up with email or making calls.

Ironically perhaps, my internal sense of myself is of a lazy and disorganised person. It has been interesting to me to have friends, colleagues and online folks reflect how they perceive me as hardworking, organised and successful. The contrast between my sense of self as never doing enough, and the external perceptions that I do more than is necessary is something I have been increasingly reflecting on. I recognise that my pattern of work is quite masochistic at times. I’m also aware that my expectations of myself are unrealistic and can’t be sustained. Overworking means I end up feeling like I end up with no down time, or at least very little that is entirely disconnected from my professional role or being a mum. I sometimes hit a kind of gridlock where there are so many demands I don’t know where to begin and end up doing none of them! And, like the emotional burnout I wrote about in an earlier blog, this has to stop.

A previous supervisor once talked to me about needing balance between multiple roles as a professional, a parent, a partner and a person. I’m trying to take stock and to chase work back into working hours so that I can focus on the other roles. I think they get more and more neglected as I go down the list. But kids grow up fast, and time with loved ones is precious and shouldn’t be put on hold for some imaginary future point at which there is more time. And I need to also find better ways to care for myself, so that I am happier and have more emotional resources to share with those around me. No more postponing going to the optician or physio. No more working through lunch, and no more super-late nights. I need to set aside time in my diary for all of my work commitments, including those that are currently invisible, and to prioritise better amongst what I take on. Instead of being pulled in all directions I need to work out where my highest point of contribution and greatest enjoyment are, and concentrate more of my efforts in a single direction. I need to have firmer boundaries and say no more often.

I read an article recently about a man who was diagnosed with cancer and given a very poor prognosis who then made a very positive response to treatment. When his cancer was treated and doctors said he had returned to a normal life expectancy he said that the experience had given him an unexpected gift – the insight that time is a precious and finite resource. He recommends that everyone thinks about what they would do if they had only a week to live, or only a month, or only a year, or only five years and identifies their priorities for this time. He points that at best we only have the remainder of our lifetime to live (in my case, probably another 50 years) and that now is the time to do the things that are the most important. So many people on their deathbed look back wish that they had recognised what was really important while they still had time, but we have this time ahead of us, and the option to choose to use it wisely. So whilst I have time, I am going to work out how I want to spend it. And that doesn’t involve work filling up all the gaps in my life. I suspect it involves more cuddles, more singing, more making things and cooking. More time socialising. More walks in the countryside. More holidays and travel. Regular exercise. Relaxation. Going to watch gigs, films, comedy and shows. Finishing my Adventure Diver certification. Making a mosaic. Laughing.

Work isn’t really so important. It doesn’t have the right to crowd out all the fun.

Sifting through the hoard

Over the years I have watched “a life of grime”, “my hoarder mum”, “life laundry” and “how clean is your house?” and saw hoarders on TV whose homes were filled from top to bottom with the detritus of their lives. The homes were unhygienic and bursting at the seams. Some were infested with insects, mice or rats. It was obviously problematic. I’ve read http://inheritingthehoard.wordpress.com/ and been curious about how some people reach the point they just can’t throw anything away.

I’ve done assessments with families who live in dirty cluttered spaces, filled with what is perceived as rubbish by outsiders but to them are mementos of loved ones who have died, have some intrinsic financial worth, or are imbued with sentimental value (or in the case of one or two people with more unusual thinking, with feelings that would be hurt if they were discarded). I’ve wondered why they can’t see the risks this is causing for them and their children, and realised how habituated we become to our own environment.

And each time I empathise because I can see some of those traits in myself. I collect things like art deco pottery and art nouveau metal or glasswork. My husband collects vintage Star Wars toys and retro video games (along with containers overflowing with consoles, cables and controllers). I have boxes and jars filled with ribbons, buttons, shells, stones. I have various hobbies that accumulate future materials (from pyrography to mosaics, silk painting to silver polymer clay, to making glass jewellery and other small items in a miniature kiln). More than that, I don’t like to throw things away if they could potentially be of use to someone.

I justify some of it with intellectual rationale. I loathe wastefulness, and the disposable consumerism that characterises the modern age. I can’t bear that everything has become disposable, is burning up the planets resources in manufacture and then going into landfill at an ever greater rate. I’d much rather reuse, repair and recycle whenever possible. I want to teach my children about being frugal, and about finding enjoyment in creative activities rather than consumption. The dress that tore has such pretty fabric that could be used for another project. Last year’s Christmas cards can be clipped with pinking shears into this year’s gift tags. The pretty wrappers from these chocolates could go in the making box to use in craft projects. The trousers you’ve grown out of should go to the charity shop.

I was also an early fan of eBay and Freecycle, and realised that almost everything has value to someone else. So I would sell items worth more than the hassle of posting them out to the buyer, and freecycle everything else. From the extra items of pottery I picked up at car boot sales, to clothes we grow out of, to the wood flooring that came up after we had insurance work done in the house it would find new homes. We’ve sold books, toys, video games, collectables, antiques, electronic items, pushchairs, car seats, cots, jewellery and furniture. We’ve given away spare fence panels, a lawnmower, a microwave, two TV’s, a hi-fi system, bags of used jiffy bags, metal car ramps, two sofas, carpets, even 56 baby fish from our pond. We take clothes and toys to the charity shop every 4-6 months. And the amount that went into the bin reduced. I also changed my shopping patterns to include reduced items to prevent them ending up going to waste, and to try to reduce the packaging used. We also try to recycle as much as possible of our rubbish (our council collects paper, card, plastic containers, metal, glass and garden waste and we compost food waste in a “hot bin” to fertilise our home grown vegetables).

The problem is that my heap of clothes for taking up, taking in, letting out or repairing outpaces the time available for me to sew. The collecting of the hobby items exceeds the time I give myself for creative projects. The piles for eBay and Freecycle grow when I don’t have enough time to spend on that kind of internet busy work, and we haven’t quite got the hot bin working optimally (by which I mean that in the year we have owned it we are yet to produce any viable compost, perhaps because we have not added enough shredded paper and chipped bark to keep it aerated). And I end up keeping things I love even when they are pretty much worn out and we can afford to replace them, from a favourite top where a hasty encounter with a door handle punctured the sleeve to comfy but scruffy shoes. My disposal threshold has become too high.

Steadily over time the amount of stuff we aren’t using in the house has increased. But we are lucky to have a fairly big space to live in, and plenty of hidey holes for storage, so this hoarding has not been so obvious. We also have high standards of hygiene and the wealth to supplement our own tidying up with weekly professional cleaning, so this doesn’t feel like the kind of hoarding that I’ve seen on TV. We just have places in the house that are filled with stuff. There is a heap of slightly or un-used hotel toiletries in the upstairs bathroom because I don’t like the idea that they would be binned by hotel staff if I didn’t take them home. I have various repositories of lovely smellies and candles that seem to accumulate whilst we use more pragmatic alternatives. There is a chest in my bedroom of fabric, and boxes of threads, buttons, ribbons and beads. There is a filing cabinet in the garage filled with art glass, and an old sideboard filled with items for my future mosaic project, along with the tools and junk that garages usually accumulate. The extra bedroom has become a den filled to the brim with video gaming stuff. There are boxes in the loft with art deco pottery item that don’t quite fit the collection I display in a cabinet in the front room. There is a collection of StarWars toys in what used to be the airing cupboard. I have a box of my old school work in the loft, and boxes of the art work the kids have made. We have seven bookcases full of books, plus half a cupboard of activity books and magazines that haven’t been completed. The dining room holds piles of items we are planning to sell on eBay or Amazon, or give away on Freecycle, along with craft materials and books we haven’t found a place to put away. And in the lounge there are heaps of paperwork that need filing and things that need taking to work, or returning to the place we bought them.

Its too much. And it is beginning to feel contrary to the logic that made it accumulate: Things need to be useful, not kept for the sake of it. So, starting this weekend, we are going to go through the whole house top to bottom and clear out the clutter. This time, to make sure we do it properly, all the contents of each room are getting heaped in the middle and then put away. Each item can only stay if we use it or love it and it has a place to go. Things that we love but that need fixing can only stay if they will be repaired before Xmas. Everything else needs to go in the bin, or on freecycle, or to the charity shop ASAP.

Its another reminder of how the dividing line between pathological and functional is blurry, and often a matter of socio-economic status and which side of the table you sit. In a tiny home without the help of a cleaner this would be a problem level of hoarding, in my lifestyle it isn’t, just as the hedge fund trader can fund a drug habit without the pitfalls so common amongst users of the same substance in poverty. It seems to me that hoarding is a basic human survival instinct (to store what might be useful if next season is not so abundant) that doesn’t translate well to the modern context, where supplies are available 24/7. Perhaps some people have stronger triggers to hoard, like not wanting to let go of a loved one who has died by dealing with their possessions, or have different perceptions of the standards that are normative in terms of clutter and cleanliness in the living environment. But it is clearly another trait that exists along a spectrum, with a somewhat arbitrary threshold at which is is considered a problem or symptom of poor mental health. And it reminds me once again, that there but for fortune I could be receiving rather than providing mental health services.

So here I sit, overwhelmed by the chaos that is normally hidden in the storage holes of my life. I’m already embarrassed by the sheer volume of stuff involved. Crates of excess coat hangers, hundreds of elastic bands, pens and mouse-mats promoting medication, heaps of recyclable packaging from parcels, toys related to developmental stages the kids have long since passed. But its a therapeutic process to sort it out, and I think it will be a psychological as well as physical weight lifted when it is all gone.

The battle isn’t won yet: Why feminism still matters and is relevant to everyone

It is easy for me to be complacent about equal opportunities. I’ve never personally been held back by discrimination. I mean, I’ve had people think it is their right to comment about my appearance, and I’ve even had a few individuals who have bordered on stalking because of my internet presence, and my gender has certainly been a factor in that, but I’ve never not been able to do anything because I’m a women. Likewise, although I’m a second generation immigrant and my heritage is from a cultural minority, I’ve grown up as a white British atheist and have never experienced discrimination (even if there have been occasional incorrect assumptions about my religion or politics). I’ve had a broad social network, but I’ve never witnessed my friends or colleagues experience overt discrimination either.

I’ve always seen gender stereotypes as something of a challenge, in fact. I was one of three female students who did A-level physics, compared to about 50 males, and got good marks in maths and hard sciences before I went into psychology. As a student I bought a Haynes Manual and replaced the starter motor of my Vauxhall Astra along with an oil and filter change, because I couldn’t afford the quote from the garage. Likewise I have learnt all about the construction of houses, and was involved in the design and manual labour of various home improvements. I’ve been an early adopter of technology and a fan of video games as an emergent art form. And now I lift big weights at the gym, defying the gender pressure to lose fat through cardio rather than build muscle. I’ve encouraged my daughters to be brave and strong as well as kind, and to want more to the story than for the main character to marry the prince and live happily ever after.

So from my position of relative privilege it is hard not to assume that the battle for equal opportunities has already been won. However, as soon as I look a little more broadly at the world this is clearly not the case. So many different examples illustrate how my experience is the exception rather than the rule.

In the UK women on average earn 21% less than men per hour. This is the case in most of the developed world and the disparity is much worse in less developed nations. Although there has been significant progress over the last 50 years to reducing this disparity, economists admit the gender gap in wages is likely to take at least the next 100 years to close. Even in the most conservative figures, when all the variables that affect wages, such as lower experience due to career breaks and lower levels of qualifications for some population groups are taken into account, women still earn 5-10% less when equivalently skilled and doing equivalent work. In the most senior roles there are far fewer women, and those that are present earn substantially lower salaries. The earnings gap is larger as people get older, and in the higher earning percentiles of the population, suggesting that choosing to care for children does sacrifice status and earnings for the remainder of the woman’s career. These are figures I find appalling.

Thankfully there are movements and books containing advice about how to counter this effect. Cheryl Sandburg’s “Lean In” movement encourages women to take a seat at the table where big decisions are being made in big companies. The excellent “Give and Take” by Adam Grant advises people who are natural givers to advocate for their dependents when making decisions and entering salary negotiations, if they are not assertive/demanding enough when arguing for themselves. And many women and men are advocating helpfully for the value that women bring to senior positions.

In psychology and therapy professions we hit another facet of gender politics, with the dominance of women in the workforce reflecting the idea that empathy and caring are perceived by much of the public as feminine qualities. This message that facts are the male domain and feelings are the female domain is seen to be natural and innate, because of the typical division in gender roles between hunter and home maker in the origins of our species. However, since industrialisation and the invention of effective contraception, these roles seem to be transmitted more as a story based on past experience than in terms of reflecting the current reality (in which we can purchase food by selling other skills, and few of us would be very good at hunting or gathering our own food if this involved strenuous physical activity). After all, women being naturally suited to be the home-maker was ‘true’ in a time that it was also ‘true’ that the earth was flat, bathing frequently would have been seen as a wasteful fad, nobody understood the connection between hygiene/sanitation and disease, and very few people stayed alive beyond their 40s.

I believe that providing attachment relationships is probably the single most important job in society. That quality of caring about another person, and holding them in mind is essential for each of us to be happy. It is a powerful gift, whether in terms of parenting, friendship or a therapy relationship. However, I have seen no evidence that efficacy in this role is determined by gender. It may be true that in general women have slightly better ‘folk psychology’ and men have slightly better ‘folk physics’, as Simon Baron-Cohen’s research has shown, but apart from the head start that pregnancy and breast-feeding give to mothers, there is a paucity of evidence that the gender of parent who takes the primary carer role affects outcomes for children. Certainly, women feel more guilt about returning to work or choosing not to be the primary carer, but does that reflect a genuine concern about attachment security or the projections of a society where a women is supposed to ‘have it all’ in the form of balancing work, parenting and their own identity, having gained expectations of being an equal provider whilst not having handed over equal expectations of looking after home and family.

By devaluing caring and empathy for men, we lose a significant proportion of the potential workforce for psychological therapies. Those that remain often have less traditionally masculine qualities than are typical for males (whilst women who gain places in clinical psychology typically have more of the ‘masculine’ qualities of assertiveness, ambition and intelligence than are typical of their gender). We also make it unacceptable for boys and men to express their feelings openly, or to seek help for emotional problems without shame. And of course there is the wider issue of devaluing homosexuality, and through association any gentler or more feminine traits in men (for example with the playground taunt of “gay” for disliked characteristics or outcomes). This leads to lower uptake of psychological therapies or treatments for mental health problems, along with greater rates of completed suicide in young men.

More recently social media has provided a new means of networking which have been widely taken up, especially by young people. Mobile phones, text, Facebook, Twitter, chatrooms, Vine, Snapchat, Instagram, Tumblr, forums, multi-player gaming and video chat have allowed people to find those with similar interests and to communicate in new ways, but have also been media in which new forms of bullying and harassment have emerged, along with pockets of rampant prejudice including misogyny. In these contexts sexism, racism and discrimination has emerged in new forms, and some media are better at moderating this than others. Online video gaming spaces, Facebook and Twitter in particular have proved to be free playgrounds for “trolls” (those who gain enjoyment by harassing others online) due to their lack of willingness to intervene about abusive content.

There have been remarkably sad examples of what happens when such media allows the predatory minority to find vulnerable targets, such as the tragic story of Amanda Todd, the teenage girl who was encouraged to flash over webcam and then blackmailed with these images by an adult man until the point she committed suicide. There was also the disturbing video manifesto of Elliot Rodgers, a college student who killed 6 and injured 13 before committing suicide due to the perceived injustice of him not being as attractive to girls as he felt he deserved to be.

In amongst the array of content on the internet a subculture has developed that is profoundly sexist and has disturbing ideas about how to “play the game” in ways that “put women in their place”. Some of the members identify as Pick-Up Artists (PUAs) or Mens Rights Activists (MRAs), but the idea that women now hold too much power, and that men have seized upon feminist and progressive thinking to impress women, seems to be a common strand. There is great anger from members of these groups against men who speak up for women’s issues or social issues more broadly, who are often disparagingly labelled “White Knights” or “Social Justice Warriors” (terms which are intended as insults, despite sounding pretty awesome). Many women have learned to use gender-neutral names on social media, and not to speak when playing multi-player online video games, rather than to risk the onslaught of comments, which range from “get back in the kitchen” to violent threats of rape and murder of them and their loved ones (especially when defeated by the superior skill of a female player).

The latest iteration of this undercurrent has been the harassment of women who have highlighted the sexist tropes within video games, or otherwise become a figurehead of progressive thinking within that culture. Anita Sarkeesian’s highly accessible video series “Tropes vs Women in Video Games” has been a focal point. When her Kickstarter attracted death threats, harassments and attempts to discredit and silence her the community spoke out by massively over-funding her project and giving it a much bigger audience. However, she has continued to be subject to a variety of death and rape threats for merely casting a light on the fact that a small percentage of the content of many popular video games is a set of tired old tropes in which women are the decoration, damsel to be rescued, or die as motivation for the hero’s vengeance, rather than the protagonist of the story. Likewise a bitter ex-boyfriend’s rant about female developer Zoe Quinn led her to be a target of harassment (with a thin veneer of concern about ethics in games journalism that was not evidenced by similar hounding of the journalists who were wrongly alleged to have given favourable write-ups of her work due to personal relationships with her) and games writer Brianna Wu, for writing an article saying that the old stereotype of a gamer has been superseded by a much wider demographic (perceived as a “death threat” to “true gamers”). In each example, the profound sexism of the antagonists is evident, and the impact on the target has included them needing to move out of their homes due to the severity of threats to their safety, after their identifying information has been discovered and released into the public domain (a harassment tactic know as doxxing).

So whilst I observe from the safe space of being a successful female professional, who to date has had very limited personal experience of sexism, I am reminded that feminism is far from being a battle that has already been won, and equality is far from ubiquitous in the hearts and minds of the whole population. The internet has always been a great leveller, by forcing us to judge people on their words and not on their gender, age, ethnicity, sexuality, disability or any other aspect of their physical self, and I think that is an amazing thing and as close to a meritocracy as we will ever experience. So I am saddened by the resurgence of such hate and vitriol into places where these variables shouldn’t even be relevant, and that there are now seemingly topics about which women cannot write without fear of a personal backlash. It shames me that I have a little bit of fear about the repercussions each time I express an opinion online through this blog, or twitter or my forays towards podcasts/videos. We all need to do our little bit to change this, to speak up for equality and against harassment, and to reclaim those spaces in which prejudice is showing – for the benefit of everyone.

Between a rock and a hard place – when friendship and your professional role overlap

I’ve always tried hard to keep a clear distinction between work and non-work stuff in my life. I expect my friends to be able to offer, on balance, a similar level of support to me than they require from me. If the relationship is too skew then it will be meeting one person’s needs at the cost of the other, and that isn’t a friendship. Friendships are reciprocal, and allow me to trust enough to show facets of myself that I might not want to reveal in the context of work. In the safety of such a relationship I can have my own vulnerabilities. I can worry that I am less than a perfect parent, or talk about my relationships with other members of my family. I can joke, swear, drink wine, express opinions, or laugh at the contestants on The Apprentice without fear that this will tarnish my professional reputation. The rest of the time I feel like I have my professional hat on. I am in a position of responsibility and power, and I am bound by a code of conduct. When I talk or post online as a psychologist, I run the risk that my comments will be brought back against me when I’m in the witness box, or be taken out of context and misinterpreted by a present, past or future client or colleague.

I am friends with some psychologists and other colleagues from work and via the clinpsy forum. That’s a good thing. We share common values and experiences. We have shared stressors, and we spend time together. I am also friends with other professionals that know me as a psychologist, like lawyers, paediatricians, psychiatrists and social workers. Again, our work overlaps and becomes a topic of mutual interest. I also have non psychology friends. That’s a good thing, as they bring different ideas and perspectives. They let me relax, share other interests and remind me of the other parts of me outside of being a psychologist. We can cook, eat, play, exercise, explore, talk. We can play video games, make music or art, debate politics and current affairs. As a prior supervisor would say, we are people, partners, parents and professionals as well as psychologists, and we need to pay attention to each of those roles. What marks it out as a friendship is that there is trust, and that the relationship is enjoyable or nurturing.

The difficulty comes when you feel like you ‘click’ with someone who you are seeing professionally and feel that had you met outside work it could have been a friendship, as that makes it harder to stay within a work role and remain within the more neutral and guarded boundaries that a professional relationship entails. A therapist needs to respect their clients, be curious about them, accept them, hold them in positive regard and see their potential. The relationship may be very important for the client, who may idealise you and want to bring you into their life. But that doesn’t make it a friendship. The power balance is different in a professional relationship. Within therapy the client is expected to disclose a lot about their life whilst the therapist discloses little. It is not a reciprocal relationship, and the relationship is not there to be enjoyable or nurturing for the therapist. Having started from there it is not possible to reach a place of reciprocity (at least not without a lot of time and distance after the end of the therapeutic relationship). So if you find yourself acting too casually, sharing too much information, or wanting to step outside of your normal professional role, this is definitely something to discuss in supervision.

Likewise, if someone in your personal life starts to use your professional skills, this needs to be handled very carefully. Parents asking for advice about their child’s anxiety or poor sleep may not differentiate whether you are giving advice as a friend and fellow parent or as a professional. A friend who wants guidance how to access IAPT, or is feeling suicidal and needs to be taken to A&E needs to know you can support them as a friend, but not as their psychologist. We may well know the system and the right things to say, or the right people to approach, but it is important not to end up muddling the role. You can’t ring up someone you know’s treating clinician and say “Hi, this is Dr Silver and I’m wanting to ensure you understand my formulation about my friend Jane”. They are entitled to confidentiality in their therapy and trust within their friendship. But you may also feel a greater obligation to act on concerns about someone’s mental health, or a child protection concern, than a general member of the public.

It is all too easy to get sucked into an uncomfortable place in between. What of someone that approaches you in a way that appeals to both the personal and the professional? They just find you so easy to talk to that they tell half their life story, and next thing you are feeding back a formulation at a dinner party. Where do you go from there? Do you reciprocate and tell the ins and outs of your life, or give them a business card if they want to follow up the conversation with a formal session? Or the friend who just can’t get an assessment for their dyslexia, but is self-critical about how stupid they are, when you have the psychometrics needed in the office and your assistant has a spare hour on Friday. Surely that’s not so personal? Or the friend of a friend that never seems able to access the services they need. Do you step in and advocate for them? Its a very difficult decision to call sometimes. But in my experience it is these situations that are most likely to fall down around your head.

A colleague of mine was concerned that a friend of a friend (lets call her Sarah) was discharged from an inpatient stay without proper risk assessment or follow-up. He spoke to the GP and inpatient team to raise concerns, but nothing was done. Sarah later committed suicide, and my colleague was interviewed in the enquiry that followed. The coroner did not seem able to differentiate between a concerned friend who happened to be a professional, and someone with professional responsibility, and he got given a really hard time. This was on top of the guilt he felt for not having been able to prevent Sarah taking her own life.

Another colleague ended up having to drop everything to collect a friend from various complex situations all over the country as she had psychotic episodes, and would not trust professionals when she was not taking her medication and did not have a good support network.

I ended up writing to the GP of someone I shared an office with early in my career, to report an eating disorder, suicidal ideation and risky behaviour. I felt like there was little else I could do after a supervisor said it wasn’t their problem, because their actions were placing other people at risk. I wanted to be supportive, but at the same time I felt like it was unfair to burden me with the information without allowing me to act on it. I was very clear with the person involved that this was what I was going to do if they continued to confide this type of information, and they chose to write down the contact details of their GP knowing that I would share this information. Thankfully, they went on to get appropriate therapy.

When I first met my husband it was evident he was dyslexic. I did some informal assessments so that I was sure my hunch was correct and then pushed him to get formally assessed at university. This confirmed the diagnosis and enabled him to get concessions made about his spelling and handwriting in exams, and I learnt to help by proof-reading his course work. I felt like the assessment needed to be independent to have any authority, and that I could not take on this dual role.

A decade later, I started at a new post and started talking to the IT guy who covered CAMHS, who was concerned about his memory. It was clear he had a specific deficit that had never been assessed, and I owned the WAIS and WMS that were current at the time. With the consent of the directorate manager and my supervisor, I did a full psychometric assessment. We have gone on to be lasting friends, and he credits me with helping him to understand that he is a bright guy with a specific deficit, rather than a guy of mediocre intellect who has done well for himself. However he has never wanted to use the assessment formally.

More recently I spent 24 hours taking an acquaintance to A&E after they confided detailed suicide plans in the wake of a relationship breakdown. After a long time talking in the waiting room before they were seen, they asked me to be with them in the room and share some of their abuse history with the assessing clinician. I agreed, but I had to be very clear to identify as someone from the personal network. Whilst the assessing clinician was keen to make me part of the follow up plan, I had to set out clear boundaries and decline. I was not a professional to them, and I was not somebody who could take responsibility for this person on discharge as I lived in a different part of the country.

Each of these has been a learning experience and shown the importance of differentiating the personal from the professional, but it is something I will continue to grapple with both personally and through supervising others. The nature of our skills and knowledge mean that there will always be situations in which people want to use our professional expertise, even when we are not wearing that hat. Whether that is the GP that wants advice about a patient when you go in for advice about your own health, or the business coach that wants to talk about their concerns about their child, or the friend who is giving evidence to a child abuse enquiry. We need to find a way to be both compassionate and pragmatic about the capacity in which we can be involved, to keep ourselves and the individuals safe and ensure they get the right kind of support. The role of speaking to other people on the internet is one I will blog about at some future point, and brings with it a plethora of new and challenging ethical issues, not just the way that the informality of the medium makes roles blur more between personal and professional.

The double bind of trying to do research as a clinician

In my first job after university I was an Assistant Psychologist on an applied research project evaluating the impact of staff training on the quality of care in old people’s homes. It wasn’t my natural client group, but I loved the fact that we were measuring whether all our fancy psychology ideas actually made a difference to people when applied in practice. My supervisor, Esme Moniz-Cook was an inspiration in this regard, and set a pattern I have aimed to maintain to this day: innovate, evaluate, disseminate. We wrote lots of papers, and each one worked through many iterations in which Esme would cut up a print out of my latest hopeful draft and stick it back together and/or annotate it in different coloured pens. I developed a ritual to overcome the frustration: I would look at the result, take a few deep breaths and then set it aside. Then I’d move the text around on screen to match the arrows and sellotape. Then set it aside. Then do a few of the suggested edits that felt too trivial to argue about and set it aside. Then I’d look at the reduced number of suggestions that was left and decide which were worth disputing and do the rest. Then I’d send it back to Esme and the process would repeat. It was a challenging process, but the papers were always better as a result, and meant I started training with a set of publications on my CV. My doctoral research felt like a piece of cake by comparison. I developed and evaluated a computer based training tool to help people (especially those on the autistic spectrum) learn to recognise facial expressions of emotions and predict how people would feel in different situations. I published a paper from it, of course.

As a newly qualified clinical psychologist in 2000, I was all fired up about continuing to do research. I put in a bid to two charitable funds to expand my doctoral research to a larger population and to follow up the effects after a period of time. It took me a long time to complete the proposal document and to get all the signatures, references and endorsements from both academic and clinical hosts. Both were declined. The first said the bid was so strong that it didn’t need autism specific funding, the latter said that we hadn’t accounted for poor uptake or drop-out because they didn’t know how keen the kids with ASD had been to have extra computer time. It felt like a Catch 22. In retrospect I should have researched the potential funders better; the former probably wanted research that would relate to their patented use of pig secretin in autistic children, they focused on medical interventions and were not interested in something as ‘soft’ as psychology. I was gutted. In the time I had spent preparing the two bids I could have made significant inroads into the study, but I hadn’t got off the starting blocks.

In my next job, I applied my learning to undertaking small bits of research myself by juggling my clinical time. I explored what it was that defined the young people who challenged multiple agencies. I evaluated how social workers in the adoption support team reacted to having the opportunity for consultations with a psychologist. I measured the Theory of Mind skills of Looked After Children and compared them to children with ASD and a control group. I assessed the cognitive ability and mental health of the children in residential care homes within the catchment. Most importantly, when asked to advise on how to improve adoptive matching, I undertook an audit of factors affecting adoptive outcomes across 116 families. This turned out to be the largest study of risk and resilience factors in adoptive matching ever undertaken in the UK.

I found the answers to my questions, and I learnt a lot of new things that other people need to know. But I had no funded time or academic support to disseminate the results. With the smaller projects, I let my Assistants write up the results for publication in professional newsletters and present them with me at conferences. But with the larger studies I wanted to do them justice, and my NHS role never gave me an opportunity to do so.

Once I left the NHS, I followed up my adoption audit 5 years after the initial data collection because I was determined not to let such interesting findings disappear into the ether. Then I made another bid for research funding, and by fluke or serendipity secured a £75,000 Shine Award from the Health Foundation to complete a one year study of the impact of adding brief psychological input into the local diabetes service (something I have previously blogged about). We reached the end of the year and applied for further funds to spread the impact, but were told that they do not fund follow-up data collection, or time to write up results for publication as this should be done in the course of your employment in the NHS. Of course we don’t work in the NHS, and have no funded time as part of a bigger contract or our contract of employment. So the Assistant Psychologist who was doing our data collection and analysis was only funded for the duration of the project, and has since moved on. The £2500 they did offer towards a editing our service user feedback into a short video, revamping our website, a press release and a small local event, requires a long report to release which is now overdue. I’m still trying to work out how to complete and submit the academic papers, but this takes time and means it has to compete against all the other demands of running a business.

Herein lies the big double bind: you need funded time to write bids and to write up papers to give the credibility to future bids, but unless you have academic tenure this time is not funded. For a clinician it competes with more immediate clinical demands, and for someone self-employed it competes with the tasks that actually pay the bills (in my case training, consulting, and up to 4 court assessments per month). There are also other things that demand my time and mental energy (committees, other forms of writing, http://www.clinpsy.org.uk, etc) and I sometimes even have a life outside work. Not everything can fit into the evenings and weekends, even if I allow work to expand into the rest of my life like gap-fill foam.

But I am not defeated. I am determined that the diabetes results will be submitted to peer reviewed journals by the end of the year. And I’m even more determined that what I have learnt about risk and resilience factors in adoptive matching will make its way into social work practice. I’ve considered all kinds of options including writing it up as a PhD, or a book, or a series of papers, or all of these things seeking funding as a grant, or a stipend, or a fellowship. I’ve tried to use my network to find potential funders. But nothing seems to come to fruition in a way that would allow me to have funded time to write it up with input from a statistician, whilst still having at least half my working week to run my company. Perhaps that is just asking the impossible, no matter how close to fruition the research is or how it will impact on people’s lives. I don’t know.

Meanwhile I keep asking the questions and gathering the data that will answer them, even if I can’t share the results. Innovate, evaluate, disseminate is simply part of what I do. I’ve got grand plans for what the next project will be, but I’ll save them for another blog.

BTW, if you have any ideas where I can secure funding, or want to collaborate with me I’d love to hear from you. Likewise if you can offer an overloaded clinician with big ideas a nominal NHS and/or university home, that would also be very welcome. It is twice as hard to bid for funds when you work in a small company that nobody has heard of!

Dressing for the job: Presentation and the art of neutrality

Everyone seems to have different ideas of how to dress for work as a Clinical Psychologist or therapist. NHS dress codes are often generalised from nurses on the ward and make exclusions including jewellery, open-toed shoes and nail polish which seem unduly controlling and irrelevant for a therapist. Others argue that diversity is a good thing, and that a therapist can dress however they want to represent their personality and culture, and should not be judged for it. Many settings exclude jeans, whilst others say that jeans are comfortable, practical and come in a range of colours and cuts that are hard to distinguish from other forms of trouser. Are my dark blue velveteen trousers jeans because they have rivet joints, rear pockets and a zip fly? Some employers exclude visible tattoos, piercings beyond a single stud in each ear and hair colourings that are not naturally occurring, whilst these choices are becoming increasingly prevalent in society. Some want staff to dress conservatively, excluding garments that expose the midriff or involve short skirts or low cut tops for women, but is this just sexist? Some make specifications about being clean and tidy, but this means different things to different people. So I figured I’d reflect on my thoughts on the topic of appropriate dress for work as a Clinical Psychologist.

Firstly at a personal level: When I dress for work, most of the time I try to be as neutral as possible. I don’t want my appearance to lead potential clients and colleagues to make judgements about me that form a barrier between us any more than the factors I can’t avoid such as my gender, age, ethnicity, or accent. I want to appear professional but not intimidating, clean and well presented but not ostentatious. I want my clothes to be serviceable if I want to sit on the floor with a child to play, and not to inhibit me if I want to use paints and felt-tips, and not to cause offence to anyone else. Plus I want to be comfortable and not self-conscious about the way I move or sit. For these pragmatic reasons I normally wear trousers, though I do sometimes wear a long skirt or dress. I also like to wear fairly colourful clothes. I suppose I think they are more cheerful than drab colours, and suit me better than paler colours. So you’ll often see me in navy blue, bottle green, chocolate brown, burgundy, purple, turquoise or multi-colour patterned prints.

Of course I have more scope for relaxed dress, as I am effectively the boss, so no-one can tell me off for what I wear! It also makes a difference that I work with children and families, which is generally a more eclectic and casually presented workforce than settings like neuropsychology or forensics where “power dressing” in suits and business wear is more typical. Likewise my clients tend to be younger and more adventurous about what is acceptable than older adults, and I don’t work in health settings where the stronger dress codes apply. Nonetheless I don’t want to be so casual that people think I don’t take the work seriously, and I know that as a senior professional I need to acknowledge the expectations of others who imbue me with status and power. Certainly when I go to court I will always wear a suit to show I take the responsibility of advising on people’s lives seriously, and when I train other professionals I think carefully about my audience and the message I would like to convey. But here I am thinking particularly about client-facing work.

In terms of others, I’ve had to grapple with all kinds of examples of inappropriate presentation over my career. I have had members of my staff wear ripped jeans and trainers to meetings with professionals and clients. I’ve had some who seem to want to look like surfers or a member of an indie band, in slogan T-shirts, bermuda shorts and unkempt facial hair. To me this seems disrespectful towards those who have come to see you. I’ve had staff who have shown too much skin, whether midriff, cleavage, or the dreaded builder’s crack. This can trigger very strong responses in certain people, whether due to their own abuse history, their assumptions about showing more skin indicating sexual availability, or through their religious beliefs about modesty. I once had an employee with significant body odour, and had to have a cringe-inducing conversation in supervision to feed this back. However, not only is body odour unpleasant for those around you, it also creates a bad impression to clients and colleagues, and would put us in a hypocritical position when observing or trying to improve poor self-care.

At the other end of the scale I’ve had staff who over dress. I’ve had graduates who turn up in power heels and suits for everyday work. Or those who look like they’ve just dropped into a session on the way to the catwalk or tea with a Duchess, wearing designer clothing, expensive jewellery and branded accessories. It isn’t very practical to have shoes that you worry about getting wet, or a coat you can’t put down in a dirty environment, and if a client knows you spent more on your handbag than they get in 10 weeks of Job Seeker’s Allowance this may cause understandable resentment. At a more practical level, doing a home visit in a rough area whilst wearing £1400 of accessories, expensive jewellery and talking on a £600 smartphone must surely increase the risk of being a target of crime.

I am acutely aware that many of the families that we see come from high levels of socio-economic deprivation, so I would feel very uncomfortable if I felt that any of my clothes or accessories spoke of excessive wealth. I remember the feeling of visiting a conservative MP at home in a seven-figure mansion full of antique furniture, and a member of the household staff being sent to make the drinks. My mind immediately asked “what can someone who lives like this know of what real life is like for the majority of people in their constituency?” I would hate for a client to think that about me, and to take longer to build trust, or not to be able to confide the whole of their story because of it.

As a result I rarely wear branded clothing, and tend to stick with shopping for most of my work wear in department stores or supermarkets. Likewise I wear quite practical and mid-market shoes. Beyond my wedding ring I wear little jewellery. I rarely spend more than £60 on any item apart from a suit, and I don’t wear things to work that I would be too upset to spoil. My approach is also wider than physical appearance: I try to also be aware of what I talk about  to clients, in terms of whether it reflects my relative wealth and education, or my cultural values. How much of this is my personal taste or my bargainaholic nature and how much is 20 years of cultivating the most neutral appearance possible is hard to separate. Also in the mix are the dress styles of the supervisors and mentors that I have most admired during my career (mostly very down to earth people, of humble appearance) and of my own parents, especially as my mum is also a Clinical Psychologist.

I expect my employees to also find this balance between being themselves and appearing professional and neutral for clients. This includes being clean and tidy, not wearing overly revealing clothes, and being smart but not ostentatious.But beyond that I am happy with some personalisation to reflect their own style and culture. I wouldn’t want a team of clones. I also encourage my staff to reflect on what they bring of themselves to a session or meeting, whether in terms of appearance, body language, accent or content in conversation. We are often unaware of how this would be perceived by others outside of our familiar social circle (which is often defined by similar age, socio-economic status, culture, political values, education or other factors we won’t necessarily share with our clients).

For interview I would always advise presentation that is one step smarter than you’d expect to wear in the job, whilst being something you feel comfortable wearing and not so bland that you are instantly forgettable.

Finally, I wanted to clarify that although I think it is helpful to dress neutrally in a professional role, I don’t consider a person’s dress to be an excuse for how others react to them. Intolerance of appearance or dress relating to someone’s culture or religion is unacceptable and a form of harassment. Using skimpy clothing as an excuse for sexual harassment or assault is likewise totally unacceptable. A person is always responsible for their own behaviour, no matter how others look or what they do. So what I am talking about in this blog entry in terms of reactions to appearance are thoughts and feelings, whether conscious or subconscious, that may have an impact on the therapeutic or professional relationship, not actions that cause harm or fear.

High on scare, low on science: a tale of charity, politics and dodgy neuroscience

In 2011 when I took a voluntary redundancy from the NHS I was asked to help set up a parenting charity* focusing on the period from conception to age 2. I agreed to be the founding Clinical Director and to help them set policies, sort out pathways of treatment and recruit staff. I worked for them one day per week. After less than six months it was clear that there was a divergence between what I felt was most clinically helpful to say about supporting parents in this critical period and the primary goals of the charity**. This was particularly evident in what was being said to promote the launch event of the charity. The title of the launch conference was the dramatic and pessimistic pronouncement, “Two is too late”. This title was cast in stone despite my repeated protests that parents would feel blamed and might think that there was nothing they could do beyond the age of two if they had not had a perfect attachment relationship before this point (when the evidence suggests that there are in fact many effective strategies for enhancing attachment relationships beyond this point, and many therapies for helping children and even adults to learn to emotionally regulate, mentalise and have successful relationships, even where there has been poor attachments, neglect or maltreatment).

The media were given soundbites to promote the event that suggested a baby is born with only one third of their brain active, and the rest relies on the quality of parenting received to grow. The news coverage in the Telegraph*** said that “a failure to help troubled mothers bond with their babies can stunt the development of the children’s brains”. The BBC coverage*** stated “a growing body of research suggests that the amount a baby is loved in the first few months of its life determines to a large extent its future chances” (when love and the quality of the attachment a parent is able to provide are quite different things, the most critical period is usually cited as 6-18 months of age, and the change in prognosis is most impacted by significant maltreatment).

Although our tiny pilot had kept 5 children out of 6 at home with parents successfully, despite them being referred on the edge of care, I had some misgivings about the marketing messages. We had feedback from service users and user groups that they felt stigmatised by some of these messages, but the organisation was unwilling to hear that. I am passionate about the value of improving attachment relationships and I had written a brief literature review on the impact of poor early care to ensure that the project was informed by the evidence. I was also writing a book about attachment and the impact of maltreatment, but I couldn’t match my views up with the politics of the organisation. I felt that to stay would conflict with my professional ethics, and my desire to honour the evidence base and respect the people who needed the service, so I quit before the launch. My colleague decided it would be unsafe to practise in my absence and left at the same time, leaving the charity with no clinical staff. Nonetheless, they decided to make a very big launch event, that I could only describe as one third professional conference, one third stately home wedding and one third party political broadcast for the blue party. It sold 500 tickets to health professionals and other interested parties, and I went along to see the show.

The speakers included a Conservative Peer, Ian Duncan Smith and Andrea Leadsom, along with Dr Amanda Jones (who shared a case study of parent infant psychotherapy). The fantastic Camilla Batmanghelidjh was also present (and made a good job of challenging the lack of empathy from politicians for the people they serve and quipping that this reflects their avoidant attachment styles). I had invited Dr Michael Galbraith (a Consultant Clinical Psychologist who has run community children’s services in Liverpool for many years) to talk about the health economics of early intervention. He did so persuasively and he also challenged the politics that came before his talk (with genuine zeal, as his entire service had been closed in a cost-saving ‘reorganisation’ a few weeks prior to the conference). But the biggest draw was that Baroness Susan Greenfield was invited to talk about the epigenetic effects of early attachment experience on the infant’s developing brain****. As I had not heard of her work prior to this event I was intrigued.

The talk that Prof Greenfield gave was baffling from the off. It massively overran her time-slot, and the program was rearranged to give her a second slot in the afternoon to complete what she wanted to say. My recollection was of a chaotic set of shock images and headlines, with provocative statements which appeared to contradict my knowledge of the literature, despite the fact she claimed they were scientifically founded in hard neuroscience research. Thankfully the pdf of the PowerPoint she used was circulated after the event, so you can see the content for yourself (zip file to download here).

Her title was “The mind of the 21st Century Infant” overlaid on a stock photograph of a baby using a computer. She immediately moved on to dramatic images of a youth celebrating in front of a fire during the recent riots, blaming the riots on the lack of attachment young people have grown up with, which she said had been replaced by technology. She then showed scary images of “artificial intelligence” before trying to define the mind. Then she made a knight’s move to demonstrate that “environment trumps genes” through a single study of rats given genes that cause Huntingdon’s Chorea which had less symptoms if they lived in a more stimulating environment. Then back to human babies, and images of how neurones proliferate during the first 2 years of life. Then a study showing that the Hippocampi of taxi drivers are enhanced, and then some blobs designed to indicate that mental practise of piano also activates the brain like physical practise. Then back to rats, showing more neural connections in a richer environment than when rats are isolated in boring cages. Then a description of how the mind shifts during development, from sensory processing to cognitive experience and gives greater meaning over time, with the view this is driven by experience.

She then claimed the mind might be “changing in unprecedented ways” due to interaction with technology, and showed alarming headlines circled in red, and book titles reflecting her view that internet use is changing our brains.

Prof Greenfield then showed a study counting children’s hours of screen time reported by parents, according to the child’s age. The source cited turns out to be a report saying that children have always used whatever media is current, mostly watching TV (which has been on for 7 hours per day since the 1970s) and although digital media is rapidly proliferating including learning toys, music and phones, total media use by white children had only increased by 38 minutes between 2004 and 2010, though it was more prevalent in low income families and had increased more in BME families. It states there is no evidence yet about how much is too much when it comes to media consumption but states that “media platforms by themselves are neutral; what matters most are the choices made by parents, educators, educational production companies, and other content providers in order to encourage a balanced pattern of consumption” using the metaphor of needing a balanced diet. This was not reflected in Prof Greenfield’s narrative about this amount of media being harmful, and it is unclear how she extrapolated the figures in her table.

Another leap, and we were onto how dopamine is the reward chemical and behind all addictive behaviour. Prof Greenfield said that it changes neural activity, inhibiting the frontal lobes. This is why children are becoming fat, sedentary and obsessed with technology. They are all addictions, and disrupt our frontal functioning. Then a leap to schizophrenia not having sufficient frontal lobe activity, and reverting the brain to sensory processing which is fragmented and without meaning. Another slide full of brains: The prefrontal cortex is not mature until your 20s. Then a claim that schizophrenia, gambling, over-use of screen technology and over-eating have a common pattern of prioritising our senses over reason, due to dopamine making us mindless rather than able to synthesise meaning. It felt very alarming to have schizophrenia and addictions linked to the same pathways as attachment difficulties and technology use. The implication was that parents could cause these difficulties in how they parented babies, or by allowing children to use digital media. These are claims for which I have never read any scientific evidence, despite being a clinician working in this area and trying to keep abreast of the research literature.

Another leap to social media and how it makes us “alone together”. Prof Greenfield told us how real communication is three dimensional, and little of the meaning is conveyed in the words, whilst 90% is in eye contact, body language, tone of voice, perhaps even touch and pheromones. But online we have only the words. According to her, this is why empathy has dropped over the last 30 years (another newspaper headline, not a scientific study, and with no reflection on the socio-political changes that might explain this). The lack of empathy required is why people with autism are so at home with technology and on the internet. People also have reduced identity, so they have to record their existence online. Prof Greenfield characterised the development of online communication as going from describing your cat sneezing on Blogger, to putting up a photo on Flickr, to a video on YouTube, to live Tweeting the action, saying that such activities reflected the author as a disconnected “nobody” who needs to prove they exist. She postulated that a rise in social networking is the cause of reduced empathy and people having a less robust identity, but it seems to me that even if these two things co-occur the direction of causality could be the reverse.

She then skipped on to the evils of video games, inserting a slide with MRI scans to show reduced listening when looking at something else, before blaming video games for the increase in methylphenidate prescriptions. Prof Greenfield claimed ADHD could be caused by video games because they lead to “fragmented attention, shorter attention span and increased recklessness” because they activate the dopamine system. Another headline in a red circle saying children who love video games have “brains like gamblers”. Then she showed us her own work bringing this together: a proposed cycle of how the intense stimulation and immediate feedback lead to high arousal and dopamine release, reward seeking behaviour and this makes brain changes which cause “conditions of childhood, schizophrenia, obesity” and a drive for sensation over cognition increasing the appeal of screen based stimulation in a continuous cycle. Again, I don’t believe any of these claims have appeared in peer reviewed publications or have any evidence to substantiate them, and even if there was evidence of co-occurrence the direction of causality is far from certain. There is however a growing body of evidence that some symptoms that could be interpreted as ADHD-like are caused by early trauma and maltreatment having an impact on neural development. To end that section, Prof Greenfield juxtaposed the “mindless” brain slide with a shot of World of Warcraft and mocked the lifestyle she believed was typical of those who play the game.

Then Prof Greenfield turned her attention to search engines, claiming they give fragmented information but nothing about meaning. By way of example she claimed that you can’t possibly understand what honour is from the search engine results produced by that term. Again, she claimed digital media is all fragmented content, lacking metaphor, depth and meaning. She strongly asserted that nobody could care about a character in a video game like you care about characters in a novel. Again, I would disagree with this. Like any media, video games are very diverse in style and quality and you pick ones that fit your taste, just as you would with a book or a film. If you don’t like violence, don’t pick a violent one. You don’t have the same expectations for the latest chick lit/flick as you do a weighty classic. Some examples are also of better quality than others, some focus on special effects over plot, others are low budget and whimsical. In my opinion if you feel immersed and the story is told well it feels like time well spent and you care about the characters and outcomes, whether the media is a video game, a book or a film. Its disingenuous of her to pick a random game she has probably never played and say nobody could care about a character in it as much as one in War and Peace.

Prof Greenfield then talked a little about the benefits for children of reading with a parent, and how we need to “make up our own minds”. She finished by advertising her books, and claiming that “mind change is the new climate change, the biggest issue facing us in the 21st century”. I’d share the comments on this claim raised here.

The whole felt to me like a mishmash of pseudoscience, headlines and speculation that didn’t even address the topic of the conference. Even if there was persuasive scientific research about the impact of using digital media (which I wasn’t persuaded), it wasn’t relevant to the conference as babies don’t use it. Her talk wasn’t about the importance of relationships between conception and two, which was what the conference was designed to highlight. She had come with a single agenda to sell. And it was clear that she was very much an outsider looking in when it comes to technology; judging it with minimal knowledge of social media, the internet, or video games.

As someone fairly immersed in that world, I could pick out numerous examples of violence in TV, film and video games, particularly violence against women and children. I might even be able to make a prima facie case that we are being desensitised to human suffering (and violence and sexism is being normalised). It is possible that the manufacturers of such products are buying into various ‘exciting’ neurochemical pathways that deal with arousal and reward (cortisol, adrenalin, dopamine), over those that deal with relationships, empathy, love and the ability to soothe (oxytocin and the work of the prefrontal cortex). But I think Susan Greenfield is making a huge correlation-causality error when she blames new media for people becoming isolated and lacking social skills and healthy relationships. I think there is much more evidence that real life experiences of maltreatment prime certain brain changes that make people more sensitive to later triggers and confer vulnerability for later mental health problems (see the work of Prof Eamon McCrory, for example) than that digital media is the cause of the problem.

I do think that if people lack templates for how to do real relationships in a healthy way, and haven’t learnt empathy and self-soothing skills, then these kind of media have a stronger attraction and a different effect on their brain, and can perpetuate rather than ameliorate this pattern. However, in the end I figure that people can always fill their time with something that disconnects them from others, or anaesthetises their pain. In other words, it isn’t the availability of the internet or video games that is the problem (any more than the presence of cheap alcohol, or drugs), it is the unhappiness and isolation that creates the void people want to fill with those things. And that has much more complex solutions, though it might generate less click-bait headlines.

* It is now nearly 3 years on, and I am confident that the clinicians recruited after I left have been able to establish a high quality service, so I would not wish to imply any concern about the services they provide.

** I felt, cynically perhaps, that there was a second agenda designed to promote the MP who founded the project and her political party which was of more importance than our clinical goals, although this was never explicit.

*** http://www.telegraph.co.uk/women/mother-tongue/familyvideo/9273569/New-post-natal-depression-charity-will-address-huge-gap-in-provision.html

http://www.bbc.co.uk/news/uk-england-northamptonshire-18117945

****The promotional flyer for the event said “We are honoured to announce that Baroness Susan Greenfield, Professor of Synaptic Pharmacology at Oxford University, whose speciality is physiology of the brain will bring you up to date on the Science, Neuroscience and Epigenetics”.