Communicating the value of evidence

I presented at a couple of conferences over the last few weeks about my BERRI system. And I was struck, once again, by how little weight is given to evidence when it comes to services that are commissioned in the social care sector. Various glossy marketing claims and slick consultants were successfully persuading commissioners and service managers that it was equivalent to use their systems and “metrics” (in which people gave entirely subjective ratings on various arbitrarily chosen variables) to using validated outcome measures. By validated outcome measures, I mean questionnaires or metrics that have been developed through a methodical process and validated with scientific rigour that explores whether they are measuring the right things, whether they are measuring them reliably, whether those measures are sensitive to change, and whether the results are meaningful. A pathway that then leads to an established scientific process of critical appraisal when those studies are presented at conferences, published and made subject to peer review.

But outside of the academic/scientific community it is very hard to prove that having a proper process is worth the time and investment it takes. It means that you are running a much longer race than those who work without evidence. At one event last week, I asked a question of a consultancy firm making hundreds of thousands of pounds out of “improving children’s social care outcomes”, about their basis for what they chose to measure, how they measure it, and how they had validated their claims. The answer was that they were confident that they were measuring the right things, and that having any kind of scientific process or validation would slow down their ability to make impact (aka profit). My answer was that without it there was no evidence they were making any impact.

They couldn’t see that their process of skipping to the doing bit was equivalent to thinking that architects, structural drawings, planning permission and buildings regulation control slow down building houses, and selling houses they’d built without all that burdensome process. Thinking anyone can build a house (or a psychometric measure to track outcomes) feels like an example of the Dunning-Kruger effect, the idea that those with the least knowledge overestimate their knowledge the most. But the worst thing was that those commissioning couldn’t see the difference either. They find the language of evidence to be in the domain of academics and clinicians, and don’t understand it, or its importance. We are in an age where expertise is dismissed in favour of messages that resonate with a populist agenda, and it seems that this even applies when commissioning services that affect the outcomes of vulnerable population groups. I don’t know how we change this, but we need to.

For those who don’t know, I’ve been working on BERRI for 12 years now, on and off, with the goal of being able to map the needs of complex children and young people, such as those living in public care, in a way that is meaningful, sensitive to change and helps those caring for them to meet those needs better. For as long as I’ve worked with Looked After children, there has been a recognition of the fact that this population does worse in life along a wide range of metrics, and a desire to improve outcomes for them for both altruistic and financial reasons. Since Every Child Matters in 2003, there have been attempts to improve outcomes, defined with aspirations in five areas of functioning:

  • stay safe
  • be healthy
  • enjoy and achieve
  • make a positive contribution
  • achieve economic well-being

A lot of services, the one that I led included, tried to rate children on each of these areas, and make care plans that aimed to help them increase their chances in each area. Each was supposed to be associated with a detailed framework of how various agencies can work together to achieve it. However, whilst the goals are worthy, they are also vague, and it is hard to give any objective score of how much progress a young person is making along each target area. And in my specific area of mental health and psychological wellbeing they had nothing specific to say.

As with so much legislation, Every Child Matters was not followed up by the following government, and with the move of children’s social care into the Department for Education, the focus shifted towards educational attainments as a metric of success. But looking primarily at educational attendance and attainments has several problems. Firstly it assumes that children in Care are in all other ways equivalent to the general population with which they are compared (when in fact in many ways they are not, having both disproportionate socioeconomic adversity and disproportionate exposure to trauma and risk factors, as well as much higher incidence of neurodevelopmental disorder and learning disability). Secondly it limits the scope of consideration to the ages in which education is happening (primarily 5-18, but in exceptional circumstances 3-21) rather than the whole life course. Thirdly it doesn’t look at the quality of care that is being received – which has important implications for how we recruit, select and support the workforce of foster carers and residential care staff, and what expectations we have of placement providers (something I think critical, given we are spending a billion pounds a year on residential care placements, and more on secure provision, fostering agencies and therapy services that at the moment don’t have to do very much at all to show they are effective, beyond providing food, accommodation, and ensuring educational attendance). Finally, it masks how important attachment relationships, and support to improve mental health are in this population. I can see that strategically it makes sense for politicians and commissioners not to measure this need – they don’t want to identify mental health needs that services are not resourced to meet – but that is significantly failing the children and young people involved.

In my role as a clinician lead for a LAC service within CAMHS, I kept finding that children were being referred with behaviour problems, but underlying that were significant difficulties with attachment, and complex trauma histories. I was acutely aware that my service was unable to meet demand, leading us to need some system to prioritise referrals, and that there was a lot of ambiguity about what was in the remit of CAMHS and what was in the remit of social care. I wasn’t alone in that dilemma. There were a lot of defensive boundaries going on in CAMHS around the country, rejecting referrals that did not indicate a treatable mental health condition, even if the child had significant behavioural or emotional difficulties. The justification was that many children were making a normal response to abnormal experiences, and that CAMHS clinicians didn’t want to pathologise this or locate it like an organic condition inside the child, so it should best be dealt with as a social care issue.

On the other hand, I was mindful of the fact that this population have enormous mental health needs, having disproportionately experienced the Adverse Childhood Experiences that are known to lead to adverse mental and physical health outcomes. Research done by many of my peers has shown that two thirds to three quarters of Looked After children and young people score over 17 on the SDQ (the Strengths and Difficulties Questionnaire – the government mandated and CORC recommended measure for screening mental health need in children) meaning they should be eligible for a CAMH service, and various research studies have shown that 45% of LAC have a diagnosable mental health condition, but the resources are not available to meet that need. As The Mental Health Foundation’s 2002 review entitled “Mental Health of Looked After Children” put it:

Research shows that looked-after children generally have greater mental health needs than other young people, including a significant proportion who have more than one condition and/or a serious psychiatric disorder (McCann et al, 1996). But their mental health problems are frequently unnoticed or ignored. There is a need for a system of early mental health assessment and intervention for looked-after children and young people, including those who go on to be adopted.

My initial goal was to develop a new questionnaire to cover the mental health and psychological wellbeing issues that this population were experiencing, as well as considering attachment/trauma history and the child’s ability to trust others and form healthy relationships, and the behaviours that these often expressed through. I was also interested in what issues determined the type of placement given to a child, and the risk of placement breakdown, as well as what opened doors to specialist services such as therapy, and whether those services and interventions really made any difference. I therefore ran two focus groups to explore what concerns carers and professionals had about Looked After children and young people, and asked them about what they saw that might indicate a mental health problem, or any related concerns that led people to want my input, or that caused placements to wobble or break down. One group contained foster carers and the professional networks around them (link workers, children’s social workers, the nurse who did the LAC medicals, service managers) and one contained residential care workers and the professional networks around them (home managers, children’s social workers, the nurse who did the LAC medicals, service managers). I wrote their responses down on flip-charts, and then I sorted them into themes.

I had initially thought that it might cluster as behavioural and emotional, or internalising and externalising, but my items seemed more complex than that. In the end there were five themes that emerged:

  • Behaviour
  • Emotional wellbeing
  • Risk (to self and others)
  • Relationships/attachments
  • Indicators (of psychiatric or neurodevelopmental conditions)

The first letters gave me the name for the scale: BERRI. I then piloted the scale with various carers, and then with a group of clinical psychologists involved with CPLAAC (the national network within the British Psychological Society that contained about 300 Clinical Psychologists working with Looked After and Adopted Children that I was chair of for about six years). I then added a life events checklist to set the issues we were identifying in context.

The working group I chaired in 2007 on the state of outcome measurement for Looked After and adopted children (on the invitation of CORC) came to the conclusion that no suitable metrics were available or widely used. We therefore agreed to further develop and validate the various tools that members of the group had home brewed, including my BERRI. There was acknowledgement that it takes a lot of work to develop a new psychometric instrument in a valid way, but a consensus that this needed to be done. So I resolved to find a way to follow that proper process to validate and norm BERRI, despite the lack of any funding, ring-fenced time or logistical support to do so. The first challenge was to collect enough data to allow me to analyse the items on the measure, and the five themes I had sorted them into. But I didn’t have the resources to run a research trial and then enter all the data into a database.

My way around this barrier was to get my peers to use the measure and give me their data. To do this I took advantage of some of the technically skilled people in my personal network and developed a website into which people could type anonymous BERRI scores and receive back a report with the scores and some generic advice about how to manage each domain. I tested this out and found my peers were quite enthused about it. We then had a formal pilot phase, where 750 BERRIs were completed by Clinical Psychologists about children and young people they were working with. I then talked about it with some young people and care leavers to check that they felt the areas we were covering were relevant and helpful to know about*. Then I started to use the system in a large pilot with residential care providers and developed tools to focus in on particular concerns as goals to work on, and track them day by day or week by week, as well as creating tools to give managers an overview of the progress of the children in their care. We’ve had a lot of feedback about how useful and game-changing the system is, and how it has the potential to revolutionise various aspects of commissioning and decision-making in children’s social care.

But I really wanted the process to be one in which we were truly scientific and based our claims on evidence. I’ve never marketed the BERRI or made claims about what it can do until very recently, when I finally reached a point where we had evidence to substantiate some modest claims**. But to me the process is critical and there is still a long way to go in making the data as useful as it can be. So from day one a process of iterative research was built in to the way we developed BERRI. As soon as it was being used by large numbers of services and we had collected a large data set we were able to look closely at how the items were used, the factor structure, internal consistency and which variables changed over time. We ran a series of validity and reliability analyses including correlations with the SDQ, Conners, and the child’s story – including ACEs, placement information and various vulnerability factors in the child’s current situation. But even then I worried about the bias, so a doctoral student is now running an independent study of inter-rater reliability and convergent/divergent validity across 42 children’s homes.

BERRI will always be developed hand in hand with research, so that there is an ongoing process of refining our outputs in light of the data. For example, it seems that it might be meaningful to look at two aspects of “Relationships” being distinct from each other. If the evidence continues to show this, we will change the way we generate the reports from the data to talk about social skills deficits and attachment difficulties separately in our reports. We might also tweak which items fall into which of the five factors. We also want to check that the five factor model is not based on the a priori sorting of the items into the five headings, so we are planning a study in which the item order is randomised on each use to repeat our factor analysis. We also want to explore whether there are threshold scores in any factor or critical items within factors that indicate which types of placements are required or predict placement breakdown. We might also be able to model CSE risk.

The results to date have been really exciting. I have begun to present them at conferences and we are currently preparing them to submit for publication. For example, I am currently writing up a paper about the ADHD-like presentation so many traumatised children have, and how we have learnt from our BERRI research that this reflects early life ACEs priming readiness for fight-or-flight rather than proximal events or a randomly distributed organic condition. But the findings depend on all the groundwork of how BERRI was developed, our rigorous validation process and the data we have collected. It is the data that gives us the ability to interpret what is going on, and to give advice at the individual and organisational level.

So you’ll forgive me if I’m somewhat cynical about systems that request a subjective likert rating of five domains from Every Child Matters, or an equally subjective score out of 100 for twelve domains pulled from the personal experience of the consultant when working in children’s social care services, that then claim to be able to map needs and progress without any validation of their methodology, areas to rate, sensitivity to change or the meaning of their scores. Having gone through the process the long way might put me at a commercial disadvantage, rather than going straight to marketing, but I like my houses built on the foundations of good evidence. I can feel confident that the load bearing beams will keep the structure sound for a lifetime when they are placed with precision and underpinned by the calculations and expertise of architects, structural engineers, surveyors and buildings control, rather than cobbled together as quickly as possible, marketed with amorphous claims and sold on rapidly to anyone who will pay for them. After all, I’m not in it to make a quick buck. I know my work is a slow and cumulative thing, and BERRI still has a long way to go before it can create the greatest impact. But my goals are big: I want to improve outcomes for children and young people who have experienced adversity, and I want that impact to influence the whole culture of children’s social care provision in the UK and to continue to be felt through the generations. And to do that, I need to build the thing properly.

*I’m still intending to act on the advice to also have a strengths scale to recognise resilience and positive factors, so that it doesn’t feel like we see the children purely as a list of problems. However, I didn’t want to duplicate the work of others, so I am following up a potentially exciting lead in terms of a collaboration with the Mulberry Bush School, who have explored the positive factors they have seen as markers of progress in their environment.
** that carers, therapists and managers find it useful and easy to use, that using the BERRI pathway demonstrated an improvement of 14% over 6 months for the first 125 children placed on the system, and that BERRI has the basic statistical qualities that suggest sufficient validity for use. We also have some testimonials, including a commissioner who used BERRI to map the needs of 15 high tariff children and found four suitable to move to foster or family placements with support, saving nearly half a million pounds per year from his budget – a finding we would like to replicate with a much larger study, given the opportunity.

 

 

What is wellbeing?

A typical GP appointment is 7-10 minutes long. Therefore it was no surprise to me that when I started talking to my GP about my blood pressure a couple of months ago and diverted to talk about my lack of energy, I was referred to the “wellbeing worker” linked with the practise. There was a five week wait for an appointment. I sat in the waiting room at the designated time wondering if this was a new name for a practise counsellor, or an offshoot of IAPT linked to physical health, or whether it was a specific scheme designed to get people eating better and doing more exercise. When she invited me in the wellbeing worker introduced herself and said her remit was to work with people about “diet, exercise, smoking, drug use or to improve your wellbeing”. She asked me to rate my wellbeing on a likert scale for six variables.

So I diligently explained that since being rear-ended by a lorry 2 years ago, I have not been able to make a full range of movement with my left shoulder. This meant I had been unable to continue weight lifting. I also had to have 3 teeth removed and then had a very severe ear infection, causing some other health complications I detailed in an earlier blog. I told her that I have had intermittent earache, headaches, and a feeling of being underwater, which are exacerbated by changes in pressure or getting my ears wet so I had stopped swimming. I have also had ripples in my peripheral vision and a general lack of energy and motivation. I explained that the combination has meant that I had stopped my three times a week gym-and-swim habit and reduced to a fairly sedentary lifestyle with occasional longer walks.

I mentioned that been overweight for my whole adult life, and I had drawn some psychological links to the root of this. I explained that I am fairly comfortable with the idea of being overweight but that stress may have contributed to my more recent problems. I was of the opinion that there is clearly a significant physical component to my health issues, as it has transpired I am anaemic and vitamin D deficient as well as having high blood pressure. But I acknowledged that there is also a lifestyle component, as I had reduced activity and gained weight over the preceding months, and I acknowledged a substantial stress component too.

I noticed that the wellbeing worker had not taken any notes beyond “weight” and “exercise”, so I paused and tried to clarify her role. I asked what professional background she came from, expecting to hear she was a nurse, health worker or psychology graduate. “I’m an admin” she said, and explained that she had taken the job during a reorganisation, having been told that it was predominantly administrative. She said she had initially worried about what she would do if told about problems she didn’t know the answer to, but her manager had been reassuring that it wasn’t her job to solve everything and she could report any concerns to the appropriate person.

It turned out that her job was to identify which pathway to put people onto, from a choice of weight management, exercise, smoking cessation, drugs or alcohol and then fill in the paperwork to make it happen. She booked me in for the weight management group, and gave me a referral to the local council run leisure centre for 12 weeks free membership.

Don’t get me wrong, those things are good low-level interventions. The weight management group is friendly and non-shaming, even though it is pitched at a simplistic level, and I completely endorse exercise on prescription schemes for improving physical and psychological wellbeing. But where was the space to actually talk about what was going on my life? The website for the wellbeing service says:

‘Wellbeing’ means feeling happy, healthy and content in life. Our wellbeing can be affected by our physical and mental health, the people around us, the place that we live, the money that we have and how we spend our time. Our Wellbeing Workers can help you to identify and prioritise changes you might want to make to improve your overall health and wellbeing. They offer lots of support to help inform, motivate and empower you [including through] … Support with confidence issues and to improve self esteem

They offer services to reduce social isolation and assistance to address issues such as debt, housing and education (though this branch appears to prioritise people who have an intellectual disability or socio-economic deprivation) but the only mention of mental health or psychology is in relation to the specialist branch of the weight management pathway for people with BMI over 45 and those considering bariatric surgery. There are also leaflets linked from the weight loss section of the website which talk about “finding happiness” (helpful habits) and “mastering your thoughts” (basic CBT intro) and “relaxation and stress relief” (mindfulness, visualisation/anchoring, breathing exercises). But I was never even told these existed, and even when on the website I had to use the search feature to find them, and as far as I could tell there was no connection to the local IAPT service.

Six weeks later the wellbeing worker rang me up again, to see how I was doing. But again, she didn’t really want to know how I was doing psychologically in any meaningful sense. She wanted to know if I had followed the pathways she had offered. She asked me to give the six ratings again. It felt pretty hollow giving more positive scores, as I didn’t feel like the services provided by the wellbeing service were responsible for the changes – I had lost 10lb in weight before I joined the weight management group (and 2lb since), and feel better because I have more iron, more vitamin D, lower blood pressure, more energy and less pain.

So I was left feeling that it was a service that I was glad existed, but it seemed to tackle symptoms in isolation to their causes, and didn’t seem to connect physical and mental health. I’m guessing that is because public health is still local authority commissioned, whilst mental health is within the NHS. Wouldn’t it be nice if there was a single point of entry to this kind of wellbeing service and IAPT? Surely that would reduce stigma and mean that both symptoms and cause could be addressed, and patients would be able to tackle the interwoven issues of mental and physical health together.

 

Seeking collaborator to change the world

LifePsychol Ltd is a company with a clear social purpose – to improve outcomes for people who have experienced adversity through the application of clinical psychology, particularly children who are Looked After in public care after trauma or maltreatment. We deliver effective psychological services for Looked After and adopted children by providing assessments, formulations, therapeutic interventions, consultation, training and outcome measurement tools for placement providers. And we are very much in demand. But at the moment we are clinician led, and we really need a COO with complementary business skills as the company scales up, to ensure that we make the maximum impact going forward.

We are at a very exciting time, with the potential of rapid growth and the first evidence of efficacy for our pathway emerging. We have started the process of applying for DfE Innovation Programme funding, and we have great support from key people (Sir Martin Narey, government advisor who just reviewed the future of children’s homes in the UK, described our pathway and tools as “the missing link for the sector”, Jonathan Stanley at the Independent Children’s Homes Association described them as “the new gold standard for our members”, whilst Lord Listowell said the government should fund part of the cost to ensure there is input from a clinical psychologist in every residential care home). Despite having done no marketing, we have more enquiries about joining our system than we can keep pace with. We are already used in over 100 children’s homes, and we have a growing number of local authorities who wish to roll out our pathway across their entire catchment. We are looking at how we train and license other clinicians to deliver the model both in the UK and internationally.

We have a great clinical team, a graduate project manager/admin, a fantastic professional network and a great product set. What is important to us now is getting the right person to drive the business side forward at this critical time. To do that we really need someone with business skills and experience, combined with a passion for making social change to take on a leadership role on the financial/business side of the company. We are therefore seeking an extraordinary COO who will help us achieve extraordinary things.

Who are we looking for?

You need to genuinely care about making the world a better place, and to share our goal of making a measurable difference to the lives of vulnerable children and young people. As a clinician CEO it is vital for me to have someone I trust to bounce ideas around with, who will ensure that we are on a sound financial footing to enable us to deliver our ambitious plans. You will be familiar with all aspects of the finances for running a business, have a good working knowledge of the UK social care system and be a dynamic manager, but with a willingness to turn your hand to other aspects of the business (from fundraising to recruitment to CRM) until we are large enough to take on a full team. You understand the value of evidence-based practice and you have a good awareness of the financial demands of the social impact sector. You are the kind of person that can nail down complex ideas and grand ambitions into concrete and achievable plans that will make genuine social change.

You will ideally be based in Derbyshire at our new Matlock office and will help to develop a team there, but with some travel to other sites. However, we already have a base in Milton Keynes that I visit fairly regularly, along with existing relationships and use of shared working space in North London (Kings Cross), so if you are the right person then these might be possible alternative locations, provided you are prepared to travel regularly to meet with me in Matlock and are comfortable using video chat in between times.

How to apply

If what we are looking for sounds like you, and you are looking for a new challenge, please get in touch and we can set up a meeting. Or if you know someone that might be the right fit, please pass this information along to them. Email lifepsychol@gmail.com to express an interest. No agencies or recruiters please.

Background information:

LifePsychol currently consists of a small clinical team who provide assessment and therapy services, particularly for children and families, and services commissioned by local authorities to support Looked After Children, adoption or families at the edge of care. Our Clinical Psychologists also provide expert assessments for the family court and to local authorities considering entering proceedings. We provide consultations advice on service development and service evaluations for social enterprise and third sector organisations. Our main specialist area is around attachment, trauma and maltreatment and how this evidence base can inform the care of children who do not live in their family of origin. We therefore provide training for adoptive, foster and residential carers, as well as health, social care and legal professionals, and have a network of associates who provide regular consultation into organisations.

However, our primary goal at present is nothing less than to improve the quality of placements for all Looked After Children in the UK. LAC are a particularly vulnerable group of children and young people because their needs are complex, and often include mental health, developmental difficulties, problems with relationships and behaviour. We hope to achieve this ambitious goal by training carers and implementing a new set of standards for care providers (PRIME) and through regular use of outcome measures (BERRI).

The PRIME standards are about ensuring that strategies carers use are evidence-based, individualised to the background and needs of each child, evolve as the child’s needs change, and are based on a thorough psychological assessment and a multi-faceted formulation of the child’s needs. We believe that having advice from a clinical psychologist to inform the care of all Looked After Children (and other children with complex needs) will both reduce stigma and improve outcomes, whilst helping carers to feel better equipped to meet the children’s needs. We have developed a training program and care pathway as one means to implement these standards for placements.

We have also developed a set of online tools for commissioners and placement providers to use to identify and track the needs of children in their care. The tools are known by the acronym ‘BERRI’ because they explore Behaviour, Emotional well-being, Risk to self and others, Relationships and Indicators of psychiatric or neurodevelopmental conditions that may require further assessment or diagnosis. We want every young person with complex needs to have a service that meets their needs in an effective and evidence-based way. We have therefore developed tools that allow us to gain a more holistic picture of children’s needs, to track how this changes over time and to target particular concerns and monitor the effectiveness of interventions to address them.

Our first data suggests that we can reduce concerns about children significantly within six months of using the pathway and tools we provide, and our services gain exceptional feedback from carers and professionals, but we hold ourselves to tough standards of evidence, and gather data about our effectiveness every step of the way.

Note: The BERRI questionnaire and online tools were developed to improve the outcomes for children Looked After in public care in the UK. However, the system is also applicable to those receiving other forms of intensive or multi-agency input, such as those on the edge of care, attending special schools, placed in inpatient services, secure units or involved with services for young offenders. The system would also be equally applicable in other countries, and could be adapted to other populations (eg adults using mental health inpatient services, people with learning disabilities, or those within the criminal justice system).

Tipping points (an unusually optimistic blog about entrepreneurship in delivering psychology)

This is a really exciting month for my business. Things are seemingly reaching a tipping point at which all the effort I have put in to date is starting to pay dividends. Even some things I had given up hope on have come back in a more optimistic way.

1) I’ve been short-listed for a grant, in which I can pilot my care pathway for LAC in a new county, scope the level of need, validate my measure and find out whether my system is effective in causing positive change for young people in Care. I’ve just got to get the full application completed by next week, and get the signatures from health, social care and commissioning in that locality onto the form before the deadline. No problem. Well, actually quite a big problem, judging by the initial application where getting signatures on it in time turned out to be a total nightmare. But worth a stab nonetheless.

2) I’ve been contacted by a social impact investment fund who may want to fund a scaled up version of the diabetes project that I blogged about so bitterly here. (If you remember, it was a pilot of brief psychological interventions for people with diabetes, and we found that it more than covered its own costs in savings from physical health treatment costs within the 12 months of the study. I was immensely frustrated that it wasn’t commissioned after the pilot year and I had long since given up on reviving it). It is unclear what they are planning, but they may want to fund us to deliver the project again, perhaps on a larger scale either geographically or in terms of including other long-term health conditions such as cancer, which would be pretty exciting.

3) As if that isn’t enough, I’ve got a new little venture starting up. Its an internet based business, that has already attracted interest from a venture capitalist who likes seed funding projects from idea to proof of concept. Not something I’ll be delivering personally, or directly related to CP, but nonetheless pretty exciting.

Everything else is ticking over nicely. The therapy service we run at LifePsychol is now full to capacity, and profitable enough to consider taking on another member of staff. I’ve got a contract with Keys that takes just over half my working time, delivering training and rolling out the BERRI as part of a change to the training, culture and care pathways across their residential provision. And we are suddenly getting lots of enquiries and sign-ups to the BERRI from other organisations, and several other psychologists I know professionally are recommending it for work they are doing.

On top of that I’m getting free business development coaching from Shawn Jhanji, who is a really supportive and inspiring guy, as part of winning a place on the Impact Hub scaling program (I’m one of 10 small UK businesses focused on making a positive difference to the world that are getting a year of support to enable growth and expansion into new markets, as part of an international cohort of 100). And before that I had personal development coaching from Andy Gill, who was also awesome. I can genuinely say that I couldn’t have made this happen without them. My investment in personal development coaching over the past 18 months has made a tremendous difference to my clarity of goals and the way I want to work to achieve them. It’s been revolutionary in terms of changing my perception of myself and the impact I can make on the world.

Other positive things are also happening all at once too. I’ve had 2 professional publications appear in the last month – a paper on running a social enterprise in Clinical Psychology Forum, a chapter in What good looks like in psychological services for children, young people and their families. The NICE guidance I was part of developing and the practise standards for psychologists working as experts into the family courts are also nearing publication. This means I’ve been able to step down from various committees and unpaid commitments feeling that I’ve done my share of the bigger picture stuff. Finally, I’ve nearly caught up on my invoicing and have made a concerted effort to chase some of the unpaid invoices that are overdue.

Basically, everything is falling into place with my new line of work, and past work is starting to pay dividends. So rather than feeling small, isolated and just about able to make ends meet to run the business, it now feels like the future is much more likely to be secure. This has let me stop taking new instructions for the emotionally intense and time/energy demanding court work that was making me feel so burnt out.

Hopefully pretty soon, I’ll have some time to focus on home stuff – which is good because we are supposed to be moving house by the end of the year!

All of this change has made me feel much more optimistic. Instead of feeling like I’m thanklessly hacking away at the rock face alone, I’ve got to a point where other people can see the value of joining in with what I am doing, and bringing machinery and tools to help. It is by no means inevitable that I’ll be able to achieve my goals yet, but I’m starting to feel more optimistic. And that has given me much more energy and enthusiasm, which is contagious in itself. I’ve got this feeling of travelling beyond territory I know into the unfamiliar. Who knows where it will take me, but I’m enjoying the adventure.