Author: ClinPsy: Dr Miriam Silver

ClinPsy: Dr Miriam Silver http://clinpsyeye.wordpress.com I'm a Consultant Clinical Psychologist working in the UK. After 17 years in the NHS I left in 2011 and set up my own company. We have subsequently taken on the challenge of introducing tools to help parents, carers and profesisonals identify track and support the psychological needs of children (see www.BERRI.org.uk). We hope that regular use of outcome measurement can improve the quality of services and the life chances of children who are neurodivergent and/or have experienced adversity. I have written a book called 'Child Trauma and Attachment in Common Sense and Doodles' published by JKP, which tries to make current scientific and therapeutic knowledge about attachment and chronic developmental trauma accessible for adoptive and foster parents, residential care staff, professionals and anyone who wants to know more about this topic. I'm a Senior Research Fellow at UCL/Anna Freud Centre, but have collaborated and supervised research in many other universities (Birmingham, Sheffield Hallam, Canterbury Christ Church). My research predominantly relates to BERRI and children in care. I train health, social care, legal and other professionals about attachment and the impact of abuse, trauma and poor early care. Over 1000 people have attended my two-day training for residential care staff, and I’ve trained hundreds of adoptive and foster parents to "manage behaviour with attachment in mind”, as well as training other professionals to deliver this content as a group program. I’ve also done a number of keynotes, workshops and plenaries at conferences. In my spare time, I run www.clinpsy.org.uk/forum which is an internet site and forum for aspiring and practising clinical psychologists. I use the same name on social media to comment on psychology, politics and other topics. I have also done a lot of expert witness work for the family courts sat on various committees and been involved in lots of policy work. However, I am trying to reduce this element of my work to focus on doing more research, training and consultancy. I have been experimenting with blogging and social media as means to disseminate psychological thinking.

Not seeing the wood for the trees: A blog on progress and setbacks

After 3 days of feeling overwhelmed with depression about the referendum result and rise of racism, to the point of being immobilised and pessimistic about the future, I went out for a walk in the sunshine this afternoon.

I looked at the trees that have grown for much longer than I’ve been alive, and will still be growing long after I am gone. I noticed the way that rivers travel through the landscape making imperceptible changes that can cut through stone over time. And I thought about how evolution means that current species of plants, birds, animals and insects can make better use of their environment than their predecessors.

It made me think how much progress there has been in the last century in terms of human society across the world. We’ve made massive steps forward in science. We’ve cured diseases and developed more effective treatments and means of prevention. World poverty has reduced, infant mortality has fallen, and life expectancy has increased. We’ve seen the world from space, and started to map the universe and the genome. We’ve become a more secular society. War and violence are reducing enormously over time. Our tolerance of prejudice has reduced massively. Human rights have been championed in more and more countries. Gay marriage is now enshrined in law in most western democratic nations. We are more aware of finite energy resources and more mindful of the environment. Through increasing internet connectivity, many more people have access to information than ever before.

I realised that by the time our kids are adults the world will be very different to how it is now. They have grown up in a different age, with more awareness of the environment, greater opportunities for travel, and much wider access to information than any generation before them. They are world citizens, born into an age of technology and opportunity. I hope they will build a kinder and more tolerant society because of that.

It is easy to focus on the depressing headlines in the news, and the latest murders or racist incidents – but they make the news because they aren’t everyday events that we turn a blind eye to. We might have just taken a massive step backwards in the UK, but progress marches onwards, and despite all the skirmishes and set-backs, good triumphs in the end.

I believe the UK is mostly full of decent people who care about each other. Sure, much of the British media is full of poisonous propaganda, that blames the vulnerable rather than letting us look upwards at the wealthy and powerful who are siphoning off our rights and resources for their personal gain. And yes, the ideological choice of austerity has increased the wealth gap and made many people feel they had little to lose. And yes, a lot of people feel disenfranchised and were so used to being ignored that they voted for change without knowing what the change would mean. But I think the proportion of people who are genuinely racist and hateful is smaller than it appears. And the rest of us want to find a peaceful, progressive way forward.

So we need to stop being overwhelmed, stop the collective messages reinforcing our learned helplessness, and put our heads together and push for the most positive outcome possible. We need to all engage in the political process. Let us stop mourning the loss of the country we had and work together for a better one.

Terrorism revisited

I feel very very sad about the referendum results, but not entirely surprised given the previous election results.

I think the campaign has been fought on dishonest ground that didn’t represent what we were voting for, and the referendum and the Brexit campaign were the culmination of a particular message being pushed by vested interests in the media and politics for many years. It is part of a bigger problem of politics becoming ever more a game of the super-rich, corporate lobbying and propaganda, and less about representing what the majority of the electorate actually want. I think it is a sign of big trouble with the democratic process when two thirds of the cabinet are millionaires, and that demographic represents only 1% of the population, whilst they are supposed to speak for the breadth of the UK.

I’m not convinced that concerns about immigration are the unspoken elephant in the room, so much as one of a number of targets that keep on and on getting vilified and scapegoated for all of society’s ills. To paraphrase the metaphor: An immigrant, a voter and a millionaire politician are sitting at the table with 10 cookies. The politician takes 9 to give to his chums and then tells the voter “watch out, the immigrant is going to steal your cookie”.

What is unspoken is the responses we need to challenge these poisonous messages and to remind us that there but for fortune we could be in the shoes of an economic migrant, an asylum seeker, a single mother, a person with disabilities, a parent of a child with special needs, someone who loved that child that died because we didn’t have proper health and social care services, someone without legal representation, unemployed, the victim of racism/sexism/homophobia, the generation that live through war, etc. We should want to protect human rights and public services, legal aid, benefits and victims of crime, and to prevent war because we are them and they are us.

But somehow the talk was all focused on the money, and the immigrants, and the pointless bureaucracy of the EU. Maybe I am naive or cynical, but I think that a group of people have been actively driving that narrative for a long time, I don’t believe it is an organic grass-roots concern that has spontaneously bubbled up. I think there are vested interests pushing us towards greater income disparity, blaming of the vulnerable, and encouraging prejudice, selfishness and nihilism. I don’t think people are stupid, I think people have been drip fed right-wing propaganda for many many years, that blames all ills on “immigrants” and “benefits scroungers” so that we don’t look too hard at austerity politics and see all the vested interests. If there was a credible alternative, they’d as easily target that rage against the bankers, the corporations dodging tax and using zero hours contracts, and those using tax havens to hide their cash – all of which I consider to be much more legitimate targets.

As this article in the BMJ eloquently explained, the less people feel they have to lose, the more willing they are to take a gamble on a potentially risky outcome. And the results of austerity politics mean that large swathes of people are suffering financially, and feel powerless, hopeless, disenfranchised and exploited. At the same time as the referendum we have seen an even more tragic set of events unfolding that I think have the same underlying cause.

With the Miami mass shooting and the murder of Jo Cox (and longer ago, the shootings in Paris), I think that we have seen the ugly underbelly of what happens when people feel desperate and voiceless, and are radicalised by hearing poisonous messages blaming particular people for their unhappiness or lack of success in life. Both were horrendous acts, targeting people who had done absolutely nothing wrong in order to convey some kind of political message. Both were incredibly distressing to hear about, let alone for those who were personally involved.

Jo Cox was my age to within a fortnight and had a similar family configuration, so it has really hit home that her husband and kids will never see her again, just because she spoke out for compassion and inclusiveness. She is someone I had never heard of before she was attacked, but the more I read about her the more I like and admire her. She was taking action for the good of others, and she was a great example of our democracy. I have donated to the fund in her memory, and the fact it topped a million pounds in just a few days, suggests that I am not alone in wanting to take some kind of positive action in the face of such awful news.

And with that in mind, and the clear indications that this was politically motivated terrorism with a far-right agenda, I wanted to say something about all the references to mental illness. Being mentally ill doesn’t mean you kill people and killing people doesn’t mean you’re mentally ill. Doing something awful that we can’t understand is not the same as being mentally ill. One in four people has a mental illness, a characteristic as widespread as blond hair. The vast majority of them will never hurt anyone, and are at no greater risk of doing something awful than anyone else (although they are disproportionately the victims of violence). It is abhorrent to stigmatise all those people because of the actions of one person, even if he may have had mental health issues. He didn’t kill Jo Cox because he had mental health problems. He killed her because he wanted to promote his repugnant fascist beliefs.

I posted on Facebook about the causes of terrorism earlier in the week when the discussion was about the Miami mass murder, and this is exactly the same. This was what I wrote:

Just a reminder, but mental illness is not a cause of terrorism. There is pretty good research that has disproved this popular myth. People do awful things. We can’t understand that and we want to feel like they are different from us, so we assume their mind is broken. In fact the research says that it is a combination of a strong need to belong, coupled with a sense of marginalisation and injustice, dehumanisation of enemies, group processes where beliefs get hyped up into extreme actions and strong religious beliefs. Intelligent men who underachieve are particularly at risk for this radicalisation. That is, ordinary people with no genetic or mental abnormalities get pulled down a particular path by their experiences and social networks.

From a paper by Silke after 9/11:

“It is very rare to find a terrorist who suffers from a clinically defined ‘personality disorder’ or who could in any other way be regarded as mentally ill or psychologically deviant (Silke, 1998). Ultimately, the overwhelming majority of terrorists (and this significantly even includes suicide bombers) are average, normal individuals who in other circumstances would be quite unremarkable. Their involvement in terrorism is not the result of psychoses, inner traits or aberrant personalities. Rather, in most cases it is an understandable response to a series of life events.

The causes of terrorism need to be focused on – not just the actors. Once you are forced to throw away the ‘terrorists are different’ model, then attention must be given to other areas. An important realisation here is that becoming involved in terrorism is a process. Nobody is born a terrorist. Neither does anyone wake up one morning and decide abruptly that on that day they are going to start planting bombs in public streets. Becoming a terrorist is in the first instance an issue of socialisation. Any given society will possess some minorities or disaffected groups who rightly or wrongly perceive that the world is treating them harshly. In some cases there are genuine and very substantial causes for grievance. Individuals who belong to or identify with such disaffected groups share in a sense of injustice and persecution. It is from such pools that individual terrorists emerge”.

Western politicians will easily condemn muslim extremists, but in America in particular they find it much harder to look at terrorism fueled by prejudice, in this case racism (but previously by homophobia and religion) – because, like the gun lobby, it has so much popular support. I don’t have any solutions for that, but we do need to name the problem, and the problem is the rise of right wing regressive ideas, fueled by prejudice and religion, blaming every vulnerable minority whilst turning a blind eye to the rich and powerful exploiting the rest of us.

I want my country back from all this hatred and fear-mongering. We need to stop blaming the vulnerable, and start looking at the political system that has created an increasingly divisive and selfish society.

Is empathy finite? Part Two: Brock Turner

This is the second of two blogs about recent sex offences that have made the news, and is about Brock Turner. The prior blog was about prolific child abuser, Richard Huckle and can be found here. In that case, my ability to have any empathy for the perpetrator was severely tested. In this case, it isn’t my empathy that is under question (because I don’t have the same discomfort in trying to understand the position of all the different parties in this case), but that within our whole culture.

I’m sure you will all have read the story about how Brock Turner sexually assaulted an unconscious woman outside a frat party and her eloquent response to his six month sentence.

What was notable was that the case polarised the world into two camps. Either this was the fault of one individual who did something awful, or he was just the unfortunate example that got punished of a problematic culture of drinking and promiscuity amongst young adults at American universities. Here is how the two alternative stories are framed:

1) Everyone was drunk at the party and coupling off with strangers for casual sex, and that was part of what is expected at frat parties, everyone knows that. The guy was very drunk and paired off with the girl by mutual agreement. They were kissing and she consented to go back to his dorm, but they fell over and were kissing and fumbling on the ground mutually enjoying the sexual activity and he didn’t notice that she lost consciousness at some point before vigilantes interfered. He was a promising scholar and sportsman who has lost a prestigious place at Stanford and will serve six months in jail and be on the sex offenders register for life. He has been an unfortunate example of taking accepted culture one step too far and the poor guy will be paying for that for his whole life in the change in his career trajectory.

2) The victim was really really drunk whilst the perpetrator was just a bit drunk, and he had a pattern of being sexually aggressive to women in similar circumstances. He had made sexual approaches towards the victim’s sister and was knocked back, so he tried it on with her and realised she was too drunk to resist (despite having a long term boyfriend she was committed to) so he led her off and she fell down unconscious by some bins on the way out. Instead of calling for help for her he sexually assaulted her injuring her genitals and would have raped her if not for the intervention of two passing cyclists who noticed her being obviously unconscious. She regained consciousness three hours later with no memory of what had happened, injured and bleeding in a hospital where she then had to be forensically examined for evidence of rape, whilst he expressed no concern for her during several hours of being questioned by police, claimed she gave consent and denied she was unconscious. She then had a year of stress building up to the trial, where she was cross examined and blamed for what happened to her. She has been traumatised for life, and this sentence sets a precedent of rape culture on college campuses being not such a big deal.

I think the evidence best supports the latter version, and the conviction suggests that the court agreed. But I think there is some truth in both stories, because as I have often said before, behaviour almost always reflects the person’s experience and the context as well as the choice that they made. There is a massive problem in modern western culture, particularly amongst young adults, in which sexual coercion is normalised and blamed on alcohol, which is consumed to excess. It is also scarily prevalent. You might call it a rape culture. About 20 million out of 112 million women (18.0%) in the United States have been raped during their lifetime. Only 16% of all rapes were reported to law enforcement. In 2006 alone, 300,000 college women (5.2%) were raped. Among college women, about 12% of rapes were reported to law enforcement. There are similar figures for the UK. And it makes me wonder – why do we not have basic empathy and respect for each other, even when we are intoxicated and disinhibited?

The culture of deifying talented sportsmen in American universities and the tendency for athletic teams to spend a lot of time together and sometimes live together also appears to have contributed to the answer. A recent study shows that male intercollegiate athletes accounted for 19% of all sexual violence cases reported but only comprised 3% of the student populations. Amongst these groups, attitudes to women are problematic. The researchers found many more “beliefs and situational definitions that excuse rape or define assaultive situations as something other than rape” in athletes. Amongst sportsmen there were also distinctive narratives. The researchers reported that amongst athletes “hypermasculine discourse includes war-like, misogynistic, and sexually violent analogies” and that this was directly related to the difference in attitudes towards sexual coercion. 29.5% of college men in the study sample had insisted on having sex when their partner did not want to, and 5% have used force and 5% have used threats to get a partner to submit to sexual activity. Attitudes toward women were less progressive and rape myth acceptance was more prevalent amongst athletes. You can see echoes of this in the letter from Turner’s father, which blames a culture of drinking and promiscuity rather than his son’s actions and displays no empathy for the victim. Likewise the same theme is present in Turner’s testimony, and in the (repugnant) letter sent to the judge by a childhood friend of Turner who claimed that the accusations levied against him were down to “political correctness”.

The truth is that whilst we can take actions to help reduce the availability and vulnerability of potential victims by helping to educate teens and young adults about the dangers of binge drinking, the main problem is in the attitudes and actions of those who use coercive sexual behaviour. In the words of an infographic from facebook, the causes of rape are 0% slutty clothes, 0% alcohol, 0% college culture and 100% rapists. And in the words of another infographic:

“She was drunk, what did she expect?” “A hangover, that’s what she expected.” Drinking isn’t a crime, rape is. Stop victim blaming.

Whatever else contributed to Brock Turner being in that position, let me quote the letter from the survivor of this incident, “we should not create a culture that suggests we learn that rape is wrong through trial and error”. We need to teach every child about privacy and consent from when they are very small to when they are adults. Here is how I explain it to young children: If somebody wants to touch a part of you that is covered by your swimming costume or to put anything in your mouth, then they need to ask you and not do it unless you say it is okay. And if you want to touch any part of another person that is covered by their swimming costume or put anything in their mouth then you need to ask them, and only do it if they say it is okay. You should only say yes to someone doing that if it is someone who needs to touch you to help with an illness or injury and Mummy or Daddy are with you and say it is okay. If anyone does something like that when you don’t want them to or it doesn’t feel right, you should always talk to me about it or someone else that you trust”. Here is how I explain it to a teenager “Don’t ever pressure anyone else or let anyone pressure you to do things that don’t feel right or comfortable to you. If you aren’t sure, you can always talk to me about it. That includes anything about sex or relationships”.

Whilst the mythology of false allegations implies otherwise, and real life is always more ambiguous than it appears in theory, consent is actually pretty simple. If somebody is in a fit state of mind to make decisions and actively says yes and reciprocates, then they consent. If that isn’t the case then they don’t. When this video came out I wondered why they needed to spell out that if a person is unconscious they can’t consent. Now we know why. It is only a basic level of empathy that is required. The golden rule of do as you would be done by. But it involved placing yourself in the other person’s perspective and understanding that the person you really want to have sex with might not really want to have sex with you, and if they did they might want to do so after a gradual progression of the relationship and without intoxication that would impair their judgement.

On the other hand, one bit of empathy is transparently clear from this case. The judge, a former Stanford athlete himself, appears to have had too much empathy for the impact of the sentence on the life of Brock Turner, perhaps because of over-identification. Whilst I respect that he was a prosecutor of sexual offences, and may also be comparing this assault (which was interrupted, and thus never progressed to what we in the UK would define as rape) to other cases from his career that involved violence or threats, and whilst it may well be that Turner has now learned his lesson and will be very clear about obtaining consent in the future, I was not persuaded by anything I have read that Turner accepts responsibility for his actions. In fact, it appears he only accepts responsibility for drinking, and not for any sexual offence. He pleaded not guilty, and amazingly, he is going to appeal even this remarkably light sentence. On that basis I believe it is important that the sentence reflects the gravity of sexually assaulting an unconscious woman, and his lack of genuine insight or remorse, as well as setting an important precedent to show that college culture or use of alcohol is not an excuse for sexual assault.

In my next blog I may talk about my own experiences of unwanted sexual contact. But for now I want to finish by remembering that two students noticed what was happening and intervened. Many people would ride right on by, and it may be that their Swedish rather than American/British norms were part of what protected this woman from being raped, but in this instance two people saw what was happening was wrong and they did something about that. And the victim has not only become a survivor, she has found her voice and used it amazingly articulately to become an advocate for all women who have experienced unwanted or coercive sexual interactions. I think that is a salient reminder that no matter how skew the norms can get within certain small pockets of society, the rest of us can still recognise right and wrong, and protect each other. However dark the world is, we are not entirely powerless. We can prevent some people from being harmed, and can help others to recover from these experiences. We might not be able to change the world immediately, but we are making slow steady progress over time, and at an individual level and at a societal level, things can be better if the rest of us play our part. No matter how overwhelming the rape culture might feel, we can all be part of the solution.

Edit: I have since read that Brock Turner may have photographed the breasts of the victim whilst she was unconscious, and another stranger may have seen him do so, then checked she was still breathing and put her into the recovery position prior to the sexual assault. If this is true, then any pretence that Turner was unaware of her being unconscious is thrown out the window. It would also appear that he had a history of drinking and using drugs prior to attending Stanford, so the attribution of the cause to the culture of drinking and promiscuity at the college seems like even more of a red herring than it did before.

Is empathy finite? Part One: Richard Huckle

There have been two challenging stories in the news this week. In the UK Richard Huckle was given 22 life sentences for sexually abusing around 200 Malaysian children, and in the USA Brock Turner was given 6 months in county jail for sexually assaulting an unconscious woman outside a frat party. Each of them has been hard to read and aspects of each case have brought me to tears. The stories have made me feel grief for the victims and anger at the perpetrators, frustration about the cultural norms that gave them opportunity and in their mind justification for their actions, and vexed at the justice systems that somehow seemed inadequate in the face of each situation. And in each case, it has been really hard to hold on to any empathy for the perpetrator, despite my strongly held belief that people are the product of their experiences and influenced by the context, rather than ‘born evil’.

Because I have read and thought so much about these two cases, and discussed them online, I thought I would write a blog post about each. This is the first of those two blogs, and is about Richard Huckle.

Make no mistake, what he has done is unthinkably awful. Genuinely evil, to the point it is hard to even comprehend. He deliberately targeted vulnerable children and babies in deprived communities for his own gratification, and shared his activities with others for financial gain through the dark web. He even wrote a manual advising other paedophiles how to sexually abuse children in less developed countries. He was clearly without conscience or empathy, or able to override any remaining scraps of either in favour of sexual gratification. The psychiatric assessments were reported to say that he justified his actions and showed no remorse. His ledger and writings on the dark web boasted about his activities. So I can understand why he got such a hefty sentence, and why many people feel he should have been tried in Malaysia where he could have got a death sentence. He has harmed hundreds of children and families, and changed the course of their lives for the worse. No sentence can ever compensate for that.

I found myself thinking that if he committed suicide or was killed by other inmates very few people would be sorry to hear the news. In fact many would argue that the cost of 25+ years in prison is money that will be wasted on an individual that is beyond rehabilitation. Comments on the internet below the breaking news stories said things like:

“Hope he rots in hell he doesn’t deserve to breath air”

“It’s time to bring in capital punishment for paedophiles. Why should we pay for his upkeep? Death is the only appropriate punishment for this creep”.

“How tragic for his father and mother, who were obviously conscientious and committed parents. It just goes to show, you can give your children a good upbringing but you simply can’t control how they turn out. This guy is a slave to his perverted sexuality and his condition is incurable. He really should be locked up for the rest of his life because he will always be a danger to children. What a terrible affliction for any human being to be born with”.

And a woman in the public gallery shouted “a thousand deaths is too good for you” as he was led away from court.

Despite all of my psychology and experience with child protection issues and knowledge that most people who harm children have been harmed themselves, I found myself hating him and feeling no empathy whatsoever. It was as if he had stepped outside of the range that my empathy could stretch. I wanted him to suffer because he had made others suffer. If I’m honest, I’m still very conflicted about it.

However, like the awesome film Arlington Road illustrates, there is rarely a lone gunman. As much as it is an attractive narrative that distances us from responsibility, I don’t think that one person in a million is randomly born evil and will inevitably do things like this. I believe there are things we can do to make such events less likely to recur over time, and it is that belief that stops me feeling hopeless and helpless when the news constantly bombards me with all the evil in the world.

When I took a step back from the emotions raised by the awfulness of what this man did and thought about what I have learned from both research and practice, I found that there are in fact lots of pieces of knowledge that can help us to make sense of what happened and what we can do to reduce the chances of it happening again. In other words, I started to think like a psychologist again, and I wanted a formulation that would help me to reach some understanding of how he got to the position of doing such evil things. Such an understanding would let me sidestep my helplessness, anger and desire for retribution, and instead focus on something constructive; doing something positive to prevent similar cases from occurring again in the future.

As I mentioned earlier, I believe that people like Huckle are a product of their experiences as well as their innate character, and their offending happens within a context. Of course I still believe in free will, and that people are culpable for the outcomes of the choices they made, and clearly Huckle made very very bad choices again and again and deserves to face the consequences of that. But we don’t make those choices in isolation. Although he was particularly prolific in his offending, Huckle was far from the only person to perpetrate child sexual abuse in the UK. In fact, there are over 100,000 people in the UK who have committed a sexual offence against a child and around 5000 new convictions are made each year. About a fifth of the population have experienced some form of unwanted sexual contact before they reach adulthood. Police recorded 36,429 sexual offences against children in the UK in 2013-14, and estimates suggest that only one in eight offences are reported. So this is a massive problem. (To put it into context, 1600 children per year are diagnosed with cancer, so sexual abuse is more than 20-180 times as prevalent). I believe that when it comes to any form of antisocial behaviour, violent or sexual crime, particularly on this scale, such actions are also an indication something is wrong in our society. It doesn’t surprise me that numbers on the child protection register are rising during this decade of ideological austerity that is widening the wealth gap in the UK. Just as suicide rates, substance use, homelessness and the incidence of mental health problems are increasing as a result of political decisions, so domestic violence and child maltreatment is rising as people fail to cope with the additional stressors imposed by benefit cuts, sanctions and reductions in public services.

There are several likely risk factors that relate to the abuser. First we know that whilst experiencing sexual abuse is neither necessary nor sufficient to create a perpetrator, the chance of sexually abusing children is increased threefold if he was sexually abused in his own childhood, and that experiencing sadistic emotional or physical abuse can also increase risk. We know little about Huckle’s family, but attachment disorganisation and the absence of any secure attachment figures seems much more prevalent amongst abusers. It is known that many sex offenders have sexual dysfunction. Isolation, low mood, loneliness and lack of social skill seems to also contribute, as do neuropsychological impairments – and Huckle was described as a loner who spent most of his time on the computer, as well as “uncharismatic” and on the periphery of things. Finally, the majority of people who sexually abuse children are religious (studies show 93% of abusers to report a strong religious identity, and around 5% of priests have been named in disclosures of sexual abuse). In between trips to Malaysia to abuse children Huckle was actively involved in the church and described himself as a devout Christian. Was that just an act, designed to gain the language and credibility to access children, or was there another motivation? Was he perhaps conflicted about his actions and trying to compensate or seek forgiveness? Or did he believe he was already going to hell, so he might as well do what he wanted in the meanwhile? Or did he have outwardly strong morals as compensation for lacking an internalised moral code? I suspect we will never know.

The part of this picture that is less often a focus of attention is the contribution of online communities to the normalising and even encouragement of abusive activities. However, we know that using the internet gives people an (often false) sense of anonymity and privacy, that brings out certain traits in their behaviour that might otherwise be inhibited because of the social consequences. On top of that certain communities have developed that collect and exaggerate certain types of behaviour. For example, the notorious bulletin board 4chan has boards within which particular patterns of behaviour from trolling to internet vigilantism (such as the hacker group Anonymous) have become the norm. Likewise certain boards have allowed the gathering of gamergaters, men’s rights activists, furries (people who like to role play anthropomorphised animals), bronies (adult male fans of the children’s cartoon My Little Pony), otaku (Japanese nerds), toonphiles (people who want to have sex with cartoon characters), adult babies, truthers (people who believe in elaborate government conspiracies, such as that 9/11 didn’t happen), those trying to give up masturbating to pornography, and many other quirky groups that would not be able to express themselves within a mainstream community. There are groups that advocate in favour of all kinds of risky behaviour from anorexia to suicide, drink-driving to barebacking (unprotected sex between men, which includes “bug-chasing” – having unprotected sex with men who are HIV positive with the intention of gaining HIV positive status). Online people can present with whatever persona they want to create. Instead of being lonely and powerless they can be charming and popular. In that context, it is not surprising that there are websites that normalise and encourage child pornography, and create demand for more content (including a financial incentive, which Huckle had used to seek crowd-funding for pornographic material he had made related to his abuse of a 3-year-old girl).

However, there is much that is unknown about the relationship between use of the internet, viewing child pornography and sexual abuse of children. Does the availability of “edgy” content pull users of legal pornography towards more extreme material that they would not otherwise access? Does the market create an increase in abuse to provide the materials that can be sold? Does viewing child pornography online become a stepping stone to contact abuse? Or does it allow potential contact abusers to meet their needs without harming additional children? Is it related to the grooming of children online? One in eight people convicted of viewing child pornography on the internet had a known history of offending against children in person but it is still unclear which is chicken and which is egg when it comes to a sexual interest in children and viewing of child pornography. But it is clear that law enforcement resources are totally outnumbered by the prevalence of child pornography online.

Finally, there are factors which make some children more vulnerable to become victims of child sexual abuse than others. These include the lack of a secure attachment figure, shame, isolation, neglect, disability, the presence of other forms of child abuse, socioeconomic deprivation, stressors placed on the family (eg unemployment, bereavement, divorce), cultures in which secrecy is encouraged or permitted, prior sexual abuse in the family (particularly if this was not reported and discussed), alcohol or substance misuse, domestic violence, and settings in which there is sexual language, pornography or exposure to adult sexual activities. These same factors make it harder for children to disclose what has happened to them, and for such a disclosure to lead to suitable protective action. Only one in eight children who experiences abuse receives any professional input to assess or intervene with it.

So there are things that we can do to mitigate the risk of future harm. We can protect future children by addressing inequality, providing more support for parenting and attachment, providing more prosocial opportunities for engagement for disenfranchised young people, being more proactive about responding to child abuse, having more investment in policing the internet so that access to child pornography reduces or is perceived as more risky. We can help victims of abuse to speak up early, to the right people, and to be believed. We can encourage the investigation and prosecution of sexual offences against children, and ensure that conviction rates and sentences are sufficient to act as a deterrent. We can specifically develop international policing solutions to address sex tourism. And most importantly of all, we can also help victims to recover from the abuse they have experienced, to feel safe and protected and develop healthy norms about relationships.

Huckle has done evil and unforgivable things. I still can’t find much empathy for the person he is now. However, if I think back to him being born, and the experiences that must have taken place to take him to the point at which he could abuse children, I am able to feel sad for that baby and angry at those who harmed him and failed to protect him or to intervene much earlier to divert him from his path and recognise their contribution to his development and the harm that he then perpetrated. And if behaviour is learnt, then no matter how unlikely, there may be a future point at which it can change. So maybe in 25 years from now it is worth reconsidering whether he still presents a risk, or whether he has gained insight and empathy that he is currently lacking. Perhaps new treatments will have emerged by then to make it possible. It seems hard to imagine that being the case. I’m usually an optimist, but for Huckle, I can’t foresee a happy ending – and I’m not sure I want to.

But there is a note of optimism in the bigger picture. Despite all the evils of austerity, and the massive burden that is creating on the wellbeing of the world population, and a few horrific cases that have been well-publicised in the media there is some progress. Sexual abuse is being talked about more, and more resources are being targeted at prevention and intervention. And there is fairly solid evidence that although there has been a dramatic spike of reports of abuse in the UK over the last two years, the overall prevalence of sexual abuse in the western world appears to be decreasing over time. Hopefully, that decrease will continue to accelerate over time, until sexual abuse really is the one in a million exception, rather than an all too present reality for a significant proportion of children.

Where have all the flowers gone?

This week Liam Fee’s name was added to the list of toddlers killed by their caregivers, alongside Peter Connolly, Victoria Climbie, Daniel Pelka, Ayeeshia Smith and Keegan Downer. And the newspapers have turned their gaze to their favourite post-mortem task of placing the blame. The conclusion, as ever, will be the ‘born evil’ women who killed him, and social workers who ‘failed to prevent’ the death. But that doesn’t tell the whole story.

Firstly, how can social workers prevent child deaths when their services have been cut back so much that thresholds for intervention have risen ever higher? Social workers are over stretched and morale is at an all time low. When they intervene too much they are demonised by the press as baby-snatchers. When they don’t intervene enough they are demonised as failures who didn’t protect children. Since legal aid was slashed, court proceedings expect them to be both case worker and to cover the role of expert to the court. The social workers I know are amazing people, dedicated to helping make a difference with families, but tell me that some workplace cultures focus on form-filling and don’t allow as much time out in the field intervening with families as they would want.

Personally, I think prevention takes more than reactive services like the current remit of social work. We need proactive screening services to spot where there is need much earlier, when interventions for families are cheaper and more effective. In my opinion we need universal health visiting back, for every birth registered to be followed by mandatory visits twice a year until the kid starts school and for that to include weighing and measuring the child and seeing them in just their pants. It will also see the home environment and the relationship between parent and child. Old fashioned, maybe, but it would hopefully catch malnutrition and serious injuries earlier, and save lives in cases like these.

Secondly, what kind of lives must those two women have had that they were so un-empathic that they could witness and ignore such suffering, let alone create it? There must have been great trauma to end up like that, and a total absence of nurture. Of course no experiences are an excuse for the sadistic things they did to the children in their care. But they can help us to understand what happened, and in doing so to help prevent a future recurrence of similar issues. If we just blame it on innate characteristics of the individual perpetrators there is little we can learn to prevent the same thing happening again (except perhaps chase the fallacy of a genetic marker for evil, which I’m almost surprised is not already being done, given the overly biological focus of research topics that are clearly more influenced by experience).

I’m not convinced that anybody is ‘born evil’. I think people are born with the capacity to be a wide range of things, and their experiences (particularly their early experiences with their caregivers) determine the direction of travel, the types of skills they develop and the behaviours that are in their repertoire. Given exposure to enough trauma, a total lack of safe attachment figures, few skills and loads of dysfunctional strategies, people can end up doing awful things, particularly with a hair-trigger tendency to fight or flight under stress.

This is an evidence based position, not just my opinion as a clinician. We have known for at least a decade that childhood experience is the leading predictor of the health and social well-being, and that this applies on the individual level as well as for the nation. But as well as the self-evident human cost, there is also a huge economic cost to society. Studies show that the financial impact of child maltreatment on the economy amounts to billions of pounds per year, and the impact on lifetime health and employment is equivalent to a diagnosis of diabetes. However, the costs are hard to measure, and occur throughout the person’s lifetime so they are not as obvious.

Violence in society is neither universal nor inevitable (in fact it is almost absent amongst central Thai or Lapp society). Violence is a behaviour that is caused and can be prevented. When it comes to predicting violence, it is clear that the propensity is hugely influenced by experiences in the home before the age of 3. We also know that various interventions to improve care and the quality of the attachment relationship, or the more drastic intervention of removing the child and placing them in a household with better care are highly effective. However, there are also sociopolitical factors at play. Once the use of violence is established in a society, the levels are influenced by many factors, including:

Economic inequality
Unemployment
Alcohol consumption
Violence in the media
Poor housing
Availability of weapons

And yet, over the last decade economic inequality has increased, social housing has been sold off, and more violence has been shown in the media. More hopelessness has been created by the cuts to benefits for people with disabilities, or living in homes with an extra room. Services for people using drugs and alcohol have been cut by austerity measures whilst the need for them has increased. So the government has increased the risk of violence, whilst (as with immigration, single parents or benefit fraud) blame is being directed onto vulnerable individuals and public services.

Liam Fee, Peter Connolly, Victoria Climbie, Daniel Pelka, Ayeeshia Smith and Keegan Downer are the tip of the iceberg. There are many child deaths from maltreatment that never make the news. Best estimates based on serious case reviews suggest 40-80 deaths of preschool children are caused by their caregivers per year. And of course, many more children are injured physically or emotionally every day. For every child experiencing abuse who is known to services, eight more are going unseen. But this is not down to individuals who are born evil, and it is not down to negligent social workers. It is a socioeconomic and political problem. And whilst the media propagates the narrative of individual blame and politicians turn a blind eye, children will continue to die.

Where have all these children gone, long time passing?
Where have all these children gone, long time ago?
Where have all these children gone?
Gone to graveyards every one.
Oh, when will we ever learn?
Oh, when will we ever learn?

How do we know what we need: differentiating evidence based treatments for the public

I am interested in making a website to help direct people at the right kind of sources of support when they are hitting a block or feeling unhappy with their lives. So I started to look at what was out there. I found lots of small silos full of professional jargon that would help people to identify a counsellor, psychotherapist or psychologist if they knew that was what they needed. But I also found lots of sites that point people at all kinds of snake oil that has no evidence of efficacy at all. For example, Findatherapy.org lists the following categories as “therapies”:

Abdominal-Sacral Massage

Acupressure

Acupuncture

Alexander Technique

Allergy Therapy

Aromatherapy

Arts Therapy

Autogenic Training

Ayurveda

Biofeedback

Bioresonance Therapy

Body Stress Release

Bowen Technique

Chiropody

Chiropractic Treatment

Clinical Pilates

Cognitive Behavioural Therapy

Colon Hydrotherapy

Colour Therapy

Counselling

Craniosacral Therapy

Crystal Therapy

EMDR

Emmett Technique

Emotional Freedom Technique

Energy Medicine

Flower Essences Therapy

Foot Health

Havening Techniques

Healing

Herbal Medicine

Homeopathy

Homotoxicology

Hydrotherapy

Hydrotherm Massage

Hypnotherapy

Indian Head Massage

Kinesiology

Life Coaching

Manual Lymphatic Drainage

Massage Therapy

Matrix Reimprinting

Maya Abdominal Therapy

Meditation

Microsuction

Mindfulness

Myofascial Release

Naturopathy

NLP

Nutritional Therapy

Osteopathy

Physiotherapy

Pilates

Psych-K

Psychotherapy

Reflexology

Regression Therapy

Reiki

Relationship Therapy

Rolfing

Sex Therapy

Shiatsu

Speech Therapy

Sports Therapy

Structural Integration

Tension and Trauma Releasing

Thai Massage

Thought Field Therapy

Yoga Therapy

Zero Balancing

That’s a list of 70 “therapies” of which at least 40 are obvious quackery, and very few could be said to have any form of persuasive evidence base for efficacy*. But the practitioners of each are persuasive, and the websites use pseudoscientific rationales that might fool those who are not as cynical or conversant with the scientific method as we are. So how do the public know what kind of help to seek out? How does someone who is feeling miserable, has a job they hate, financial difficulties and problems in their relationship know whether to get financial advice, careers advice, life coaching or therapy? And if they pick “therapy” how do they know whether to get CBT, psychoanalysis, art-therapy or non-directive counselling? And how do they know whether to get it from a therapist or a psychologist or a counsellor or a mental health specialist or any of a hundred other job titles? And within psychology, how do they know when to seek a clinical psychologist, a health psychologist, a counselling psychologist or any of the job titles that the HCPC don’t register?

I think apart from word of mouth and google, they don’t. Most people ask their GP or their friends for recommendations, and then go with something available locally within their price range. They don’t read the NICE guidance or understand the various professional bodies or regulatory systems. They trust that they’ll get a gut feeling as to whether it is going to help or not from the first session, and most of that “gut feel” is probably based on personality and charisma, and whether or not they feel listened to. The decision then rests on whether the therapist wants to work with them and has the capacity to take them on, and the price they ask for (assuming the service is in the private domain rather than the NHS).

Even the NHS itself isn’t very consistent about evidence based practise. For example, the NHS still funds some homeopathy – possibly wasting up to £5million per year on this placebo treatment that is entirely without evidence or credible rationale. Likewise I’ve seen NHS therapists who have done training in models of therapy that are implausible and without evidence (eg ‘energy therapies’ like EFT). Perhaps this is why the majority of clients doubt the efficacy of talking therapies. Yet, despite this scepticism, most would prefer to try therapy than medication yet the use of psychotropic medications has risen much more rapidly than the use of psychological therapies.

So where do we draw the line? If we only deliver fully evaluated treatments and those where we understand exactly how they work, then the amount the NHS can do when it comes to therapy will be much more limited. Lots of therapeutic interventions in practise are derived from other models or by combining aspects of various models. This allows individualisation of care. Similarly, there are many therapies which are being developed that have promising methodologies and are tightly rooted in scientific knowledge, but have not themselves been subjected to RCTs that prove efficacy yet (eg DDP). And many RCTs seem far removed from actual clinical practise where clients have a variety of overlapping conditions and clinicians deviate substantially from the treatment manuals.

The other confounding factor is that when it comes to talk therapy, it turns out that the modality or adherence to the manual matters very little compared to the relationship between the therapist and client. It seems the key ingredients are listening to the client, genuinely caring about them, giving them hope that things could be different, and giving them the confidence to try doing things slightly differently. Whether we have years of training and follow the manual diligently or whether we are newly qualified and muddling through seems to make much less difference than we think. In fact, therapist variables are much more powerful in influencing outcomes than modality, and even than the difference between treatment and placebo. That is no surprise to me as I’ve personally benefited from physiotherapy that included acupuncture – despite having read studies that show it to be no more effective than ‘sham acupuncture’ where random locations are pricked with a cocktail stick!

In the paper I’ve linked above, Scott Miller argues persuasively that we don’t need to focus on understanding how therapy works, or in using the medical model to work out what works for whom with endless RCTs. He shows evidence that experts are defined by having deep domain-specific knowledge, earned by a process of gathering feedback and focusing on improvement. So he argues that in the same way, expert therapists are those who collect and learn from client feedback. So his answer to the issue of evidence-based practise is for us each to collect our own outcome data to show whether our work is effective according to our clients (and by comparison to other options), and to see if we can improve this by using simple ratings within each session that check we are working on the right stuff and that the client feels we understand them, and that the working relationship is good.

So what does this mean for the proliferation of made up therapies? Does it mean that we should leave the public to buy a placebo treatment if they so wish? Or does it mean we need to focus on the modality and evidence base after all? The ideal would obviously be better regulation of anyone purporting to provide therapy of any form, but given the HCPC remit doesn’t even include counselling and psychotherapy, I think we are far from this being the case. To my mind it throws down a gauntlet to those of us providing what we believe are effective and evidence based treatments to collect the outcome measures that demonstrate this is the case. If we are sure that what we offer is better than someone having an imaginary conversation with an imaginary ‘inner physician’ by feeling imaginary differences in the imaginary rhythm of an imaginary fluid on our scalps then surely we ought to be able to prove that?

And what does that mean for my idea of making a website to point people at helpful places to start a self-improvement journey? To me, it shows there is a clear need for simple and accessible ways to identify what might be useful and to allow the public to differentiate between sources of support that have evidence of efficacy, professional regulation, a credible rationale for what they do, reputable professional bodies and/or personal recommendations. Maybe such a website can be one contribution to the conversation, although I’ll need both allies and funding to get it to happen.

*I’d say EMDR, physiotherapy, speech therapy, CBT and some types of psychotherapy and counselling probably reach that bar. Mindfulness is probably getting there. Art therapy probably suits some people with some issues. Yoga, sports massage, pilates, osteopathy, meditation, life coaching and (controversially) even acupuncture probably have their place even though the evidence for them as therapy modalities is limited. Most of the rest are quackery.

Falling through the cracks – the current state of NHS mental health services

Recently I spent sixteen hours trying to get an acute mental health assessment for a someone. The details of the case are not what matter here, but I want to talk about what I learnt from the process, and to do that I’ll need to give some context. It is necessarily vague and some information has also been changed to protect confidentiality.

However, as a pen picture it is fair to say that there was a combination of a severe deterioration in mental health with risk to others (the person had bizarre beliefs that led them to want to injure/kill people within particular demographics). The person did not want any mental health input, but I felt that the risk issues were so acute that it was necessary to override the lack of consent and request that an urgent mental health act assessment be undertaken. The other members of the household were keen for this to happen, as were various professionals who were already involved from the health, social care and criminal justice sectors. The person was open to a locality mental health service, but after the initial assessment identified various needs nobody had been allocated to undertake the work, so although it was an open case there had been no service for several months.

So, I rang the local service to ask for a psychiatric assessment. It wasn’t an area where I have worked before or a service that I had any prior experience with so I rang the number on their website. I explained I felt that there was acute risk coupled with obvious decline in mental health, but a lack of consent to treatment, so I enquired what kind of urgent services could be triggered, suggesting that the person involved would be difficult to approach and it would almost certainly be necessary to undertake a mental health act assessment and an admission against the person’s will might be necessary to safeguard others. And that is where I hit a brick wall.

The local service told me they were not commissioned to have a crisis service, and that unless the person involved had self-harmed they did not meet the urgent criteria. No amount of risk to others, or deterioration in mental health would qualify for their service, unless there was self-harm, or the person presented at A&E themselves, or we waited the timescales of their routine service (which had no capacity to allocate a worker). Pointing out the NICE guidance required a same-day response didn’t shift their position. Highlighting the risk to others or the individual likewise seemed to go unheard. The Approved Mental Health Professionals team said that the person met their criteria, but they could not get involved unless there was a psychiatrist from the locality team who had seen the person and would identify the bed if it was necessary to use a section. The psychiatrists said they were not resourced to go out and see people, and that they were not prepared to put themselves at risk by attending a person who presented a risk to others, even though I had arranged for the police to be present. They said the only way they would see the person was if the police used section 136 to bring them to the hospital as a place of safety, where they could then provide an assessment. They suggested that we call 999 to ask for ambulance and police assistance. The ambulance and police said they were not there to provide transport, and if the person was calm and inside the house, they did not present an imminent threat that required removing them using section 136.

Deadlock.

The next day I phoned the local mental health team again and asked to speak to someone senior to raise my concerns about the case. The duty clinician called me back several hours later. I got asked “what do you expect us to do on a Friday afternoon?” and “why is this our problem?” and then got talked over loudly again and again as I tried to explain the issues with risk and mental health. I asked politely four times for the person to stop talking over me, without effect and then asked her name. She refused to tell me and ultimately hung up on me. Her service wouldn’t tell me who I had spoken to, or give me any information about the complaints procedure beyond telling me to write a letter to their postal address. I asked to speak to a service manager. Unavailable. To a psychiatrist. Unavailable. I asked for someone to call me back. at 4.45 I got a return call with the same content as the previous conversations. No crisis service. Doesn’t meet their urgent criteria. A&E, the police bringing in under a 136 or nothing. I wrote a report giving all of my concerns to the whole network in writing.

In supervision I talked about my anxiety about a serious incident, and my fear that nothing would be done, and everyone would pass the buck. I was supported that my concerns were legitimate, and made the decision to try to take it up the chain of command. I called the department again. Then I called the directors of the trust involved, and the complaints department. I made calls all morning with no response, having already had no response for over a fortnight to concerns I felt were so acute they needed a same day response. So I called the CQC.

The CQC were very helpful, and made me feel that it was the right place to raise my concerns. I feel that the systemic issues will eventually be addressed because of the CQC having sufficient power to influence commissioning decisions, but that doesn’t help in the timescale of the individual. Likewise someone near the top of the trust concerned did get back to me the next day, and want to learn from the process (perhaps motivated by awareness of the CQC being involved). Hopefully we’ll look at the pathway, and address the various issues that my experience flagged up*. But again, that’s fixing the stable door after the horse has bolted. At the individual level, the outcome was disappointing. The person is moving to a different area within the next few weeks, and the service have decided that means that they don’t have to do anything, whilst the new area will only act if concerns are raised once the person arrives.

So the story doesn’t have an ending yet. There wasn’t a happily ever after, because the service I felt was required within a matter of hours hasn’t been provided, despite several weeks having passed. However, there hasn’t been a serious incident either. I’m keeping my fingers crossed the former happens before the latter.

But it was a pretty weird experience for me. Normally, if I raise a concern people take that pretty seriously. I’m a fairly senior clinician with the titles Dr and Consultant by my signature. I’ve been an expert witness in 200+ court cases. And I’ve had 20 years of experience against which to judge risk and after 16 years in the NHS I also think I have realistic expectations of services. I’ve never made a complaint about an NHS service before, and I hope I never have to again, but I didn’t feel like I had any other option. I was genuinely horrified to see defensive service specifications being used to deny a person with clear acute mental health needs a service. I felt like my concerns were ignored and dismissed because they were inconvenient and didn’t fit within existing pathways.

I’m not sure that my involvement did any good at all for the person in the end, despite spending hours and hours on the phone and writing emails and letters. But it made me wonder, what if I wasn’t there? What if there wasn’t someone with a title and qualifications and NICE guidelines to cite to try and agitate for the services to do the right thing? What if a family member or friend of the individual rather than a professional was trying to express their concerns? Why are the barriers so high when it comes to accessing mental health services? Why have services got specifications that exclude people in serious need? Why are the processes to raise concerns so opaque and so slow? Why don’t services join up better? Why are services always reactive and so rarely proactive? Are age, gender, race or other demographic characteristics a barrier to accessing treatment? Why are we still so far from parity between mental and physical health services? Why does mental health still not have the kind of services there are for acute physical health needs? Most of all, why does common sense and compassion get lost in pointless bureaucracy when it comes to referral pathways and criteria?

I used to be so proud to be part of the NHS. Now I wonder about what it has become. Is this just what is left after decades of cuts and reorganisations, or was I always a roll of the dice away from hitting a dead end?

*this was never followed up, so in retrospect it seems it was just platitudes to shut me up

Why is there always a can of worms?

I’ve run http://www.clinpsy.org.uk for 9 years now, and built it up to 6900 members, 600,000 users and nearly 10 million page views per year. I’ve put enough hours into that site to add up to more than two years of full-time work, and I’m proud of what we’ve achieved. It is an informative, welcoming community that allows people to network and ask questions. It also levels the playing field of information and reduces the impact of personal connections within the early stages of the profession, and I hope that this will in the long-term act to increase diversity in the profession. Over those 9 years, members have written upwards of 135,000 posts on the forum, and our wiki of information and answers to frequently asked questions has been viewed millions of times, with some posts about preparing for interviews, the route to qualifying, formulation, writing a reflective journal, and transference proving particularly popular – the latter having been read over 115,000 times.

In all of that time we have had remarkably little need to intervene in the forum as moderators. We remove the occasional bit of spam, and we have sometimes anonymised posts in retrospect on the request of the author, and from time to time we have to explain to service users that this is not an appropriate place to ask for advice, but we rarely have to warn or ban forum users. I think the total to date is seven banned individuals and one banned organisation. Not bad when we’ve had 10,000+ sign-ups, and 135,000 posts! This is perhaps a reflection of our clear guidance about how we expect users to behave on the forum, and also of the large number of regulars who act as a more informal feedback loop. We also have quite a large number of qualified clinical psychologists who log into the forum regularly and often act to provide information and correct misconceptions. This is a very important function, as the pre-qualification arena can often become an anxiety-provoking echo chamber, where rumours are propagated and exaggerated without being confirmed or refuted. It also allows us to have a (hidden) peer consultation forum, which is a very good place to discuss concerns with peers in a safe environment in which every member is an HCPC registered clinical psychologist.

However, the few times when intervention is necessary always tell an interesting story. And the strange thing is, that every single time somebody has been a persistent concern on the forum, this has opened a can of worms that makes us worried about wider ethical issues for the same individual. We had someone who was very unboundaried, and at times threatening to their colleagues and other members in the LiveChat space, and transpired to have caused concern with aggressive conduct in real life. We had a member who was somewhat grandiose and wanted to be a moderator, who attempted to delete and vandalise site content. They later had issues in their workplace, with a similar theme of acting beyond their level of competence. One poster lied to persuade successful applicants to share their applications for clinical training and plagiarised them, and when we identified them it transpired they had plagiarised site content into a publication without acknowledgement and had been unprofessional in numerous other ways. Another odd poster used the same username to post topless pictures on another website. And most recently we have had an organisation recurrently attempt to circumvent payment for advertising on the forum by signing up stooge accounts to promote their service, where it would appear that the appearance of an ethical non-profit organisation instead covers a profitable privately owned tour operator.

It has made me wonder whether ethics and professionalism are the kind of thing people have or they don’t, and that show in numerous domains of their life. Or, is the seeming anonymity of an internet forum a place where traits are exaggerated and played out. Either way, the association between inappropriate use of the forum and inappropriate professional behaviour in other domains seems too high to be a coincidence.

Yet the ethical and professional guidance for psychologists has little that applies in our context. We have had to work out our own boundaries amongst the moderating team (we now comprise ten qualified psychologists and a lay member, although many joined the team as APs or trainees). It makes me realise how much unique our position is, on the technological frontier, and how we are learning case by case. For example, we have had to interpret the balance between confidentiality and risk to apply to our unique setting. We settled on a position that is broadly consistent with what I’d do with clients in real life; we would identify and report a member if we felt they were at risk or presented a risk to others, but otherwise aim to respect the pseudo anonymity of using a posting ID, where only a minority of people choose to be identifiable as a specific professional, or in a way that could be recognised in their workplace. Likewise, we have learnt to log everything typed into our LiveChat space, so that we are able to review the usage of particular members, or read the content if a report is made of inappropriate behaviour. I’d like to think that we’ve reached a good place, and have always been transparent in how we behave. It has been an interesting process though, so I’m thinking of presenting some of the ethical dilemmas and our process at the CYPF conference later this year.

Reflecting back

I’ve been archiving the files for a lot of my past court work this week. I moved office base and I don’t want to be cluttering up my new space with lots of old case information I don’t need any more, when it can be securely stored and eventually shredded. So far I’ve boxed up the files for 115 family court cases for which I completed an assessment and wrote a report, leaving only records that have been updated since the start of 2013 in my filing cabinet. As I check that each of the newer cases has been completed and invoiced, I will put those into storage too, and use my filing space for other things. It is another step in letting go of my role as an expert witness, and the huge weight of responsibility and emotional demand that entails.

As I put each case away, I added the family names to an index in order that I could locate them if it is ever required. I am supposed to keep files for seven years, or until the child is 21, so they stay with me a long time. As I record the names I realise I can remember the stories of many of the families, and I wondered how they were doing now. There were lots of traumas in those stories, that I heard and described in my reports, and felt in my bones. Many parents whose own childhoods meant that they couldn’t parent in a safe and nurturing way. Many of them dealt a hand full of adversity, who had no resources to cope with the stresses of their chaotic lives. Over and over again I saw children who were harmed by the care they were given, both in the children I had to assess, and in the histories of their parents and grandparents. Themes repeating across two or more generations.

It has always felt terribly sad that in order to give their children a chance at a better life, the courts have to intervene in ways that further wound the parents. But an expert’s job is to advise on what is best for the child, and sadly that is often contradictory with what is in the best interest of their parent. And I hope that I have always kept what would be best for the child paramount in my thinking, but whilst holding some compassion for the other family members. I think about the cases where I didn’t do the story justice, and the courts made decisions that I didn’t agree with. I worry about the cases where greater experience or new knowledge from the literature would have given me a slightly different perspective. I think about times I was threatened, or parents refused to talk to me, or I was cross-examined for five hours straight. Then I remember a time when a parent I assessed approaching me after I gave evidence, and feeling wary she was going to be angry that I recommended her child was removed. Instead she said thank you to me. “You were the only person I’ve met in all this that was always honest with me, and understood how I got here. I can see why you said what you did about me, and I think you are right that he will do better being adopted”. I’m still blown away by that. What an amazing gift to give me at a time that was so painful for her. I hope that she got the therapy she needed to put that reflection, empathy and kindness into practise in her life, and get out of the run of destructive relationships that had dominated her life.

I put the files into the box and lock them away. I am glad to let them go. It isn’t just physical space they take up, but mental space. Being an expert witness for the family court is a tough job. The hourly rates might seem high, but there are other ways to earn the same without the emotional burden. There have been pros and cons for me. I’m a different person now than I was when I began doing that work. I’m more observant and analytical, better able to ask the right questions, to deal with uncertainties, and to spot inconsistencies and triangulate sources. There have been rewarding moments too. I have had a lot of positive feedback about the quality of my assessments and evidence, and thanks for the impact of my work. But I’m also more cynical and I’ve seen a very dark side to the world. I’m more aware of the risks, and of how prevalent maltreatment and poor care are, even in our supposedly developed nation. I think I’m less trusting of people as a result of doing this type of work, and my norms for what levels of problems require professional help have shifted towards the more severe end of the spectrum, making me less sympathetic to people who feel very disadvantaged by more minor difficulties. I’ve also acquired the bad habits of work that has a strong pattern of boom-and-bust in demand – working through the night to make deadlines, putting in 80 hour weeks to meet demand, and generally taking on too much to leave enough of myself for other tasks and life outside work. It has also shown me that I can be a total control freak about the standards of work contributed by other members of my team, because my own standards are meticulous and I take this type of work – that can change the course of people’s lives – particularly seriously.

Letting go of court work is difficult, because it glitters. There is always demand, and it is nice to feel needed and held in high regard by other professionals. It feels as if you have genuine influence in the legal process (and I generally hold the UK justice system and public law professionals in high regard). The pay, although much reduced since legal aid cuts, still seems somehow more attractive as an hourly rate than the reality should be (given you can’t charge for much of the time these cases actually take, nor for administrative support such as typing or arranging appointments, nor for venues or materials it actually works out to be less than I make from other activities like therapy, training or consulting). It also has the kind of attraction of rubber-necking at a car-crash, as the cases each have their own grim story, are more complex than most clinical cases seen in secondary and tertiary tiers of service provision, and are often both acute and chronic in nature. I find it hard to say no when my skills are needed. But I must learn to delegate this work to others, or to decline, because I want to have my time and emotional energy back for other things.

And so it is good to archive my files, and to catch up with my invoicing, and to clear the decks of old ways of working to allow myself space for the new. It feels like putting down rocks I have been carrying for a long time….

Bedtime routine: The gift that keeps on giving

Of all the things I’ve done as a psychologist who is also a parent, the one I am probably most proud of is my bedtime routine. As I watch other people struggle to get their kids to sleep, or hear about the struggles of kids that keep getting out of bed or will only sleep with a parent present, I feel very grateful of the fact that mine always go down like magic.

The secret recipe started in infancy. After a difficult start with premature twins born before they had a suckle reflex, and six months of having to spend an hour feeding each of them every four hours (meaning we got a maximum of 2 hours sleep at a time), we turned a corner. At six months, we were told by our health visitor that they no longer needed milk in the night and could manage without a feed from the time we went to bed to 7am. So after a late feed at 11pm or midnight we got back our night. There were a few nights with some crying before the new routine was established. The first night pulled on all my emotional hooks, so I went to check and found they were fine and soon settled with me there, so the next night I was able to resist going for the ten minutes it took for the crying to peter out. Two nights later and it was quiet from midnight to seven am and we got back our unbroken sleep and our sanity. Soon after we saw that they were not taking much, if any, milk at the last feed and we were able to withdraw any room service from 7pm to 7am. By then, my night time routine was already in place.

Once baths are done, pyjamas are on and teeth are brushed, the kids get into bed and we make the room darker by closing the blackout curtains. I used to wish them goodnight using the same little rhyme every night, and then move straight to singing. Now they are older, when there is time, we normally have a little chat about the day and read a story – this is one of my favourite Mummy times, as we talk about all kinds of interesting things. Our conversations range from why some children are mean, to where petrol comes from, to why there is war in Gaza, to whether religious beliefs are true or just stories that some people believe and some people don’t, to how families have different configurations, why their second cousin had a brain tumour, or how flowers come back after the winter, or why some people are homeless. I’ve got a strong belief that if they are old enough to ask a question they are old enough to have an honest answer, no matter how difficult that answer is to articulate in simple terms for me as an adult. They have this insatiable thirst for knowledge, and often bring up what they have learnt at other times.

Whenever we have these discussions, my kids amaze me with their compassion and desire for fairness in the world. I still remember being told by a serious-faced four year old that we needed to “send a load of postcards to people in Israel and Palestine to tell them to look after and re-build schools, so that everybody can learn about how to be kind to others, no matter whether they believe in the Hanukkah God or the Eid God”. They were even younger when they explained how they want us to buy things that create employment in less developed countries, because most people have food and houses in England, but the people in other countries would want jobs that let them feed their families. And I remember how nonplussed they were to hear about gay marriage and how they couldn’t understand the examples of prejudice that kept coming up on the news because “its not right to be mean to people because of the colour of their skin or who they love”.

Then after our serious discussions and perhaps a bit of reading (Harry Potter and Rebel Girls seem to be favourites at the moment) it is time to wind down to sleep. Then quiet time begins. That signals that it is no longer the time to have a conversation and anything except the most urgent questions need to wait for the next day. I sing a few songs that they have chosen and a few old favourites, and within 15 minutes they are asleep. If we’ve had a busy day and we are out late, I can skip right to quiet time and go from active to asleep in the same time-frame. Friends and family members are often amazed, but I say its the best example of behavioural conditioning ever. I can even make the kids yawn by singing the same song in the middle of the day!

Of course it isn’t always perfect. If one of them is poorly, or I have been away too much in the week for work, they might stir and say “don’t go Mummy, sing an extra song” or they might wake in the night and come down for a cuddle or some medicine. But we always meet that need as quietly as possible and then return them to bed. Because when they sleep well, and we get quiet time as adults to wind down and catch up as a couple, the whole household is happier. We can flex the routine enough to stay up late for a special occasion or to give a little extra time on weekends or holidays, but we also flex the other way and start winding down earlier if they are tired and irritable. The kids even say “Mummy can we have an early night tonight as I’m feeling a bit tired and I want to have enough energy for swimming tomorrow?”

I know there is a lot of debate about ‘controlled crying’ but the few nights in which we ignored some crying at six months have reaped rewards ever since, and we have a happier family as a result. Of course, it won’t work for everyone. There are plenty of children who are more difficult to get to sleep than ours, but my advice would be to have a very clear routine, to start as young as possible, to be very calm as a parent throughout, and to persist through the difficult bit as quietly and calmly and consistently as possible. Because sleeping well helps all members of the family to regulate their emotional state better and have more positive experiences throughout the day as well as at night. I know I’m happier and more able to focus when I’ve had enough sleep, and the same is true for all members of the family.

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	Anastasia Delgado on How not to apply for a job in…
	Diagnosis vs differe… on Everyday madness
	ClinPsy: Dr Miriam S… on Give and Take
	Jane Williams on Give and Take
	ClinPsy: Dr Miriam S… on Words Matter: Prejudice, progr…

ClinPsyEye

A Clinical Psychologist's perspective on things