ethics

Accountability

On 31st March, a week or so after the coronavirus pandemic lockdown began, I was contacted by the HCPC.

“I am writing to inform you that we have received a concern about your fitness to practise” the letter began. “We will now carry out an initial investigation into the potential fitness to practise issues identified in the concern. This may involve gathering relevant information from a number of sources.
  
In order to assist with our enquiries, I would be grateful if you would provide the following information:
  
– Confirmation that you are the owner and/or moderator of the site ClinPsy.org.uk.
– Confirmation of whether you, or any of the other owners/moderator of the site have received any concerns/complaints about the content of the forum, particularly regarding [celebrity psychologists]
– If yes, please provide a copy of the complaint/s and the site’ s response.
– If not provided above, you are welcome to provide a brief response to concerns raised.
– Confirmation of your current employment arrangement.
– If applicable, please provide the name and email address of your line manager and HR director.

I replied the same evening:

I own www.clinpsy.org.uk I can confirm that I have never had any complaints in any form about any comment on [celebrity psychologists] on the forum – in fact I have never even heard of [the complainant], and can find no reference to him on the forum. I’m afraid you will need to let me know what comment is being complained about to enable me to respond to it.
As to my employment, I am self employed and run my own small business, so there is no line manager or HR involved – but I have to ask why you would think that relevant when a person is complaining about an unspecified comment on social media?

I then contacted my professional indemnity insurance provider and spoke to Mike Wang, chair of the ACP (he was my MSc supervisor and then my clinical course director, and we have stayed loosely in touch since then) who were both reassuring that this wasn’t a legitimate complaint. Later I got legal advice through my membership of the FSB, to check I had fully understood my legal obligations as a forum owner. All of us wondered why the HCPC would launch an investigation at all, given that I had never made a comment myself about any of the individuals named in the complaint, and the forum had been very proactive in ensuring no defamatory content was permitted. The forum does have a thread about “celebrity psychologists”, where legitimate concerns are raised about individuals who appear on television or in the newspapers making comment as “psychologists” who are outside of the scope of HCPC registration. But I could see nothing defamatory in it. In fact the moderating team had carefully checked the content and I had even posted a reply to remind people about our defamation policy and how to raise a concern. So I started to draft a full reply to the HCPC.

Just to be sure, I spent many hours obsessionally trawling through content on the forum and my social media and could find no interaction with the individual concerned, or any defamatory content about any celebrity psychologist on my forum. That isn’t to say members of the forum haven’t criticised such individuals, or that I don’t share similar concerns. Quite the opposite, I’ve been raising concerns about the limited scope of regulation for psychologists and therapy professionals for more than a decade and see this as another example of where the legislation fails to protect the public. However, I have never expressed this as a personal attack on an individual, or said anything unprofessional or defamatory.

At this juncture it might be helpful for me to note what defamation is, what a complainant can do about online defamation, and what the legal rights are both of the individual who believes they have been defamed, and the established defences against claims of defamation, as they will set this complaint in context.

Defamation is the action of damaging the good reputation of a person through the oral or written communication of a false statement about them that unjustly harms their reputation. The important part of that definition is that the statement must be false, and it must cause them harm (which must be demonstrable within 12 months of publication). Being rude about someone or insulting towards them would not normally be defamatory, though it might be unprofessional. As a website owner I am technically the publisher of the content shown on the site, and whilst I cannot be held legally accountable for other users being rude or insulting (though we have worked hard to create a professional culture and to have policies that prevent personal attacks or unprofessional behaviour), I would be accountable if something defamatory was published – if I was aware of it and failed to act to remove it when requested to do so by the individual it affected.

The problem here was that the HCPC did not share any details of the complaint with me, and the complaint communicated was entirely vague and did not refer to particular comments or even allege defamation. It was also made by a third party, rather than the individual that the complainant said had been maligned – making it rather extraordinary that the HCPC would give it even a cursory investigation.

But even with the assumption that someone had said something on the forum that an individual had felt was defamatory – which was far from the case – the law requires that individual (not a third party) to inform the publisher and ask them to remove the content, within 12 months from publication. And in this case most of the comments about celebrity psychologists had stood for 7 years, and no complaint had ever been raised with the forum – despite every post having a button to report it to moderators for review, and a prominent defamation policy that was linked by me in the very thread concerned, in a post giving the forum email address to make such a report.

There are also two main complete defences to defamation allegations; truth and honest opinion. If a statement is true it cannot be defamatory. For example, to say that a celebrity psychologist is not a registered practitioner psychologist or does not have a doctorate is not defamatory if these statements are factually correct. The other defence is that someone is expressing an honest opinion or making “fair comment”. This allows discussion of matters of public or professional interest, and means it is not defamatory to express a view that an honest person could have held on the basis of any facts or anything asserted to be a fact by reasonable sources available to them at the time. That is, if I said “Boris Johnson is a liar” this could not be defamatory because numerous sources have asserted this to be the case. Honest opinion can also be a reaction to something else that has been published, and can even defend someone posting something that is incorrect, if it was an honest belief based on the information available at the time (for example, writing “X isn’t registered with the HCPC” wouldn’t be defamatory if a person had their HCPC registration in a different name, or it didn’t show on the website yet, or the name checked was spelt incorrectly because that was the spelling used in the article under discussion).

As far as I could see, all comments that were on the forum about celebrity psychologists, or made or retweeted by me on social media, involved telling the truth or making fair comment about known or published facts.

On the other hand, my investigations showed me that the complainant was someone who frequently threatens properly registered mental health professionals who criticise his favoured celebrity psychologists with referral to the HCPC. I also found that the individual concerned had used anonymous IDs to respond aggressively to critics of his favoured celebrity psychologists, and to place more flattering quotes and reviews about them into the public domain. I also heard from other colleagues who had been harassed for raising similar concerns. One noted:

“This is one of the perversities about the register and use of the title psychologist; as [celebrity psychologists] are not registered they are able to freely mislead the public about their status and not be held accountable and yet they can put in complaints to the HCPC about those of us that are properly qualified.  The complaint is vindictively motivated [and yet effective as a deterrent/punishment for critics]“

So on 2nd April I sent the HCPC a robust reply:

I have had a better look into this and I am now in a position to reply more fully.

For reference, the forum has run for 13 years and contains 152,000 posts on over 15,000 topics. We have never had a formal complaint about our content, and we have a team of moderators who are all HCPC registered clinical psychologists who help to ensure we maintain a professional tone in all content. Every user has to agree a statement about the rules of the site to sign up (which can be read here: https://www.clinpsy.org.uk/forum/viewtopic.php?f=2&t=16012) and we have written guidance for users that spells out our rules (which can be read here:https://www.clinpsy.org.uk/forum/viewtopic.php?f=2&t=10). The guidance is sent to each user in a welcome message as they sign in for the first time and cautions against personal abuse or defamation. Rules 9 and 11 specifically talk about being respectful of others even when disagreeing, avoiding defamation and ensuring posts do not risk bringing the profession into disrepute. It also explains how any post can be reported to moderators by clicking the small triangle button and stating your concerns. We have a pinned post giving specific guidance about defamation (see here: https://www.clinpsy.org.uk/forum/viewtopic.php?f=2&t=9&p=10) that is linked prominently from that guidance, and note it includes the means to contact us to report any content that is potentially defamatory at the bottom of the page: “If you believe a post has been defamatory about you, or an organisation you represent, please email us at clinpsyforum@gmail.com and we will respond as quickly as possible”. 

We have a proper process for responding to a complaint, and a team of qualified CPs who act as moderators that I consult with. However, our complaints process has only been activated once (when an approach to purchase the website turned into correspondence disputing our negative review of a travel agency offering work experience placements to psychology students, but they did not register a formal complaint and we did not find any content that was not factually supported when we investigated) and I can confirm that we have never had any complaint from any of the individuals mentioned in your email. We respond frequently to reports on individual posts, which mainly notify us of spam but can also highlight inappropriate content such as potential breaches of confidentiality. These are dealt with within 3 working days. We have never had a report in relation to defamation or to any content relevant to this complaint.

We do have one thread where [celebrity psychologists] are mentioned – you can read it here: https://www.clinpsy.org.uk/forum/viewtopic.php?f=12&t=13708. It was started in 2012 where forum members raised concerns about “celebrity psychologists” who do not have HCPC registration but appear to be giving the public the impression they are regulated professionals. The thread stood for 8 years and the majority of content was posted two or more years before I contributed to it at all. I did review the entire thread at that point and found nothing defamatory. Nonetheless my response includes the following: 

“The issue of psychological therapists who practise outside the scope of professional regulation is one that is important to many of our members who work hard to gain practitioner status with the HCPC, because we believe in the principle being important to protect the public (regardless of the individuals involved).

As with any other thread on the forum, if any of the content of this thread is considered defamatory the the individual involved is welcome to email the site (clinpsyforum@gmail.com) and point this out and we will remove it.” 

The thread was then dormant for nearly six years, before being raised to discuss the way some “celebrity psychologists” were using BPS membership to give the impression of professional qualifications, whilst apparently breaching BPS guidance. I had raised these concerns with the BPS and mentioned doing so on the forum and on twitter. However, as with the content in the thread, the concerns were about the misrepresentation of professional titles and skills, and the role the BPS take in giving credibility to psychologists who are not HCPC registered practitioner psychologists, and their lack of will to intervene or regulatory teeth when concerns are raised about these individuals. Whilst one or two of my posts are critical of specific things that [individual celebrity psychologists have] written or said I cannot see any defamatory content. I have made no direct criticism of [the individuals named in the complaint], and there has never been any mention of [the complainant] on that thread or elsewhere on the forum.

Nobody has raised a complaint about that thread. I have reviewed it today, and whilst there is legitimate concern about misrepresentation of qualifications and the public perception of psychologists, based on things written or said by various unregulated “psychologists” in the media, I cannot see anything defamatory in the content. [Far from being unprofessional, I believe we have gone above and beyond requirements to prevent defamatory or unprofessional content. I posted in that very thread] how to report any concerns about defamation, and have been mindful to allow only appropriate professional concerns about misrepresentation to be raised on the forum, rather than personal attacks or potentially defamatory content.

I do not believe that it can possibly impair my fitness to practice as a clinical psychologist to have hosted or participated in discussion about potential misrepresentation of professional qualifications by “celebrity psychologists”. This has not been defamatory, and I believe it to be legitimate for members of a clinical psychology forum to raise professional regulatory concerns about public figures – especially when these are factually based, shared by many practitioner psychologists and early career stage psychologists, and have been raised appropriately with professional bodies including the BACP and BPS. The posts on the forum that were critical of these individuals were based on the content of their newspaper columns and television appearances, how they are introduced in TV programs, and their stated qualifications and experience on their websites. For example, it is a true fact that Emma Kenny is not a clinical psychologist, despite being introduced in a BBC television series as being one, and this being a breach of the regulations that brought us under the auspices of the HCPC.

I would note that it is entirely lawful for individuals to publish honest opinions on a matter of public interest and based on facts which are true – this is known as “fair comment” or “honest opinion”, and has been tested through the courts by cases such as British Chiropractic Association vs Simon Singh, which led to the Defamation Act, 2013. This introduced a number of protections against allegations of defamation, including truth, honest opinion, public interest, and a defence for website operators hosting user-generated content, provided they comply with a procedure to enable the complainant to resolve disputes directly with the author of the material concerned or otherwise remove it. This ensures that individuals who own or run websites that allow comment are not liable for the content of other user’s comments on it. It requires that the complainant must contact the site owner or administrator to raise a complaint in which they specify the complainant’s name, the statement concerned, where on the website it was posted and explain why it is defamatory, before taking any other action in relation to alleged defamation. These complaints can only be made by the person who has allegedly been defamed or their legal representative.

We have never received any complaint or notification of potential defamation, or any communication from [celebrity psychologists] or their legal representatives, and as previously stated we have never mentioned, heard of or communicated with [the complainant]. Thus a non-specific complaint to the HCPC made by an individual who has never been mentioned on the site seems quite inappropriate as a means to address concerns. I would therefore hope that the complaint can be quickly dismissed.

Yet the case still wasn’t dismissed, despite the fact I had demonstrated that a) I had not made any defamatory comments about the individuals concerned and b) there was no legal basis to hold me accountable for posts made by others on a forum that I own (even had any been defamatory, when none of them had been).

I was then asked on 6th April to provide proof that no complaints had been made to the website. Aside from the fact that it is not my burden to prove a negative, and almost an impossible task, I spent the next 3 hours responding to this request, searching the email correspondence, administrator and moderator report logs for each name or the word complaint, and submitted screen shots of every search. These were acknowledged on the following day.

Yet the case still wasn’t dismissed.

I then heard nothing for 4 months. So I wrote on 12th August to ask whether the complaint had been dismissed. This email was acknowledged, and I was told I would receive a reply within 5 working days, but received no reply. I therefore emailed again on 20th August, which again had no reply. So on 26th August I raised a complaint.


My complaint was that this “fitness to practise concern” was obviously spurious from the start, and should never have reached the point of even a cursory investigation (given the complaint was from a person I had never interacted with, about comments made by people other than me about people other than him). But even if it did, in error, reach a cursory investigation, surely the information I provided within 3 days was enough to say “sorry, it is now clear this isn’t a legitimate complaint” and not keep me under the stress of a formal fitness to practise investigation? How this can still be hanging over my head five months later is very troubling. Surely there must be a process for checking the prima facie validity of complaints, that should have dismissed this? What if I had been employed, and this had led to me being suspended or fired? How you could do this to a person struggling to sustain their business through a pandemic lockdown over such a trivial and spurious complaint is beyond me.

On 4th September the investigation was officially closed. The HCPC informed me:

I am writing to let you let you know that we have now completed our initial investigation into the concerns we received about your fitness to practise.

During our investigation, we obtained information from the Complainant and yourself. We have now assessed the concern, and all the information we received, against our threshold criteria for fitness to practise investigations.

In doing so, we have considered whether this matter may be a breach of the following HCPC Standards of Conduct, Performance and Ethics:
2. Communicate appropriately and effectively
6. Manage risk

The outcome of our assessment is that the threshold criteria for fitness to practise investigations has not been met in this instance. This means that we do not consider that the concern, or the information we have obtained about it, amounts to an allegation that your fitness to practise may be impaired.

The reasons for our decision are explained in more detail below:

Issue 1 – comments of an offensive, bullying or inappropriate nature on social media

Registrants are not prohibited from expressing their opinions on social media, provided the content or language used is not inappropriate or offensive.

HCPC Guidance on Social Media advises Registrants: ‘ When using social media you should apply the same standards as you would when communicating in other ways. Be polite and respectful, and avoid using language that others might reasonably consider to be inappropriate or offensive. Use your professional judgement in deciding whether to post or share something.’

From the links and screenshots provided, the content of the forum appears to be confined to a discussion of professional concerns and information already in the public domain. Regarding the opinions and concerns expressed in the forum, the HCPC would be out of place to prohibit its Registrants from having a free discussion about their concerns or limit their ability to express their opinions. Of the information provided and the search conducted, I am unable to find any statements which amount to ‘trolling’  or bullying.

As our process is evidence based, we cannot proceed with our investigation without evidence to support the concerns. The Complainant was given multiple opportunities to provide evidence that you contributed to and offensive or inappropriate content, but has failed to provide information which supports the concerns.

Issue 2 – hosting comments by others of an offensive, bullying or inappropriate nature on your site

You have provided evidence that you have put multiple protections in place to ensure the tone, language and content of the forum is not defamatory and does not stray into inappropriate content or language. Where members breach these terms, you have a team of moderators who will respond.

In providing individuals the ability to report specific posts and comments, you have acted in accordance with your professional duty to support and encourage others to report concerns(SCPE 7.2). You have evidenced that you have not received complaints on this thread, and therefore have not been in a position to respond to such concerns.

In the absence of any evidence to suggest you have not complied with the relevant obligations, there is no information to suggest that your fitness to practise may be impaired.

We will therefore not be taking any further action in relation to this matter and have closed our file on this case. However, please continue to be aware of our communication guidance when reviewing your forum/website.

We appreciate that this has been a very stressful time for you and would like to thank you for your co-operation and patience during our investigation.

So, to my relief, they got there in the end and the complaint has been dismissed. However, my question is why the complaint got through the starting gates, and why it took 5 months, 2 emails and a formal complaint to resolve.

But more than this, why do the BPS continue to endorse these “celebrity psychologists” and do nothing to protect or support genuine practitioner psychologists against this kind of attack? Despite numerous complaints about “celebrity psychologist” Jo Hemmings in the context of her article about Meghan Markle being manipulative, the BPS sat her down for a chat and took her at her word that she would be more careful in future. And they’ve not replied to any of my emails in the six months since I suspended my membership, saying I would not continue membership until they responded to the concerns I raised about their endorsements not protecting the public.

And more than this, why does the legislation not distinguish genuinely qualified and accountable professional psychologists within the scope of regulation from anyone who calls themselves a psychologist? In Australia it is an offence with enormous financial penalties to misrepresent someone as a psychologist or claim to be a psychologist if not within the scope of statutory regulation. So the public cannot be misled by the media citing quacks or charlatans who claim qualifications, but actually have to check their registration before using them as experts. Here we haven’t even got that protection for who can be called as an expert witness to inform critical decisions in the courts. The scope of current regulation fails to protect the public, yet nobody – not professional bodies or politicians – seems to care.

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 and child protection into the remit of 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 children in Care and adopted within a CAMH service, 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. The first step in that is getting age and gender norms. But the data can also indicate what we need to do to improve the measure, and the usefulness of the output reports. 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 some articles 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.

* 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 a robust factor structure, good reliability between raters, and 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.

 

 

Spreading too thin

In general I’m a frugal person. I buy foods that are reduced because they have reached their best before date and most of my clothes and shoes in the sales. I collect coupons and shop around for good offers. I try to waste as little as possible, and to recycle as much as I can. So I can understand wanting to get good value for money.

On the other hand, I like doing things properly. For example, when it comes to a sandwich, I like a thick slice of granary bread, fresh from the oven, with generous amounts of toppings. As it happens I’m not a big fan of butter or margarine, perhaps a symptom of being overweight in the 1980s and 90s when fat was literally seen as a cause of fat, whilst the carbs underneath were seen as relatively healthy. But whether it is soft cheese and cucumber, avocado and salad, cheddar and chutney, hummus and roasted veg, or toasted cheese and banana, the topping needs to cover the bread, with sufficient depth to make the sandwich proportionate. If the cheese has nearly run out, I’ll have half a cheese sandwich that tastes good rather than a mean whole.

So when it comes to services, I can see the motivation to get value for money, and to ensure that resources are being used in the most cost-effective way. I’ve developed pathways, clinics and groups to meet needs more effectively, and I’m happy to delegate less complex work to less experienced or less qualified staff. I can’t see the justification for paying psychiatrist salaries to deliver therapy, when a member of staff with half the hourly rate can be an equally good (if not superior) therapist. I can see the importance of capping the cost of agency staff, so that this money can be invested in increasing the substantive workforce. And when it comes to staff who are not pulling their weight (my record being a member of staff who had spent a whole year with a caseload of four clients, whilst colleagues in the same job had five times that along with other responsibilities) I can see the need for performance management.

However, there comes a point that too much pressure for efficiency actually makes services less effective. I saw this happen gradually over the 16 years I worked in the NHS. If we cut out all the conversations between cases, all the informal supervision, all the CPD opportunities, the time to bond as a team and to reflect and process information between appointments, then clinicians are less able to be empathic and individualised with clients. If you also give people tougher and tougher cases to work on, expecting faster throughput than with the more mixed caseload that preceded it, and couple this with cuts in admin despite there being more and more paperwork to do, you increase burnout and time off sick. Add some pay freezes, lose a proportion of posts, put people in smaller premises and tell them to hot-desk or become mobile workers and they no longer feel valued. Make it a set of competing businesslike trusts rather than one amazing non-profit organisation, tender out services like cleaning and home visiting to allow them to be done on minimum wage without the terms and conditions of the NHS, allow private companies to win contracts, and keep people in a perpetual state of change, then morale falls. Nobody has any loyalty or job security and it no longer chimes with the ethics of the people who work there.

The sandwich has been eroded down to bread and butter, and then to crackers and margarine, and then to a value brand version of the same that is 30% smaller. It might look like costs have been driven down, but the price is a reduction in the quality of services, and in the wellbeing of staff. It reduces the willingness to go above and beyond that has been the backbone of the NHS, and increases presenteeism – the tendency to feel that you need to be at work longer, and look like you are working harder, without this making meaningful impact on the work you get done. The UK has lower productivity than most other developed nations, perhaps because we have longer working hours, and work expands to fit the time available.

All over the public sector at the moment I see services trying to spread their resources thinner and thinner, and I’m acutely aware that this means they can’t do the whole job. Social Services departments have barely the capacity to maintain their statutory role, so supporting families in need goes by the wayside. Some good staff find other jobs. A proportion of the remainder go off long-term sick, leaving an ever bigger burden on those that remain. Teachers are forced to teach to tests that assess primary school pupils on aspects of English grammar that graduates struggle with that have little relevance to daily life, and squash the rest of the curriculum into less time. Children’s centres, youth clubs and leisure facilities are disappearing at a time when it is clear that parenting support and exercise are critical in improving well-being and decreasing long-term health and social care costs. We’ve been feeling the cost of ideological austerity bite, even before the financial shock of the Brexit vote, so I am struggling to see how things can improve in the foreseeable future, let alone once any steps are made to implement the extraction of the UK from the EU.

It is hard in this climate not to feel overwhelmed by pessimism. Staff are not pieces of equipment that can be upgraded or replaced at the click of your fingers. I can make a plan for how to cover a remit that needs 12 staff with 7, but I can’t then tell you how to do it with 5. I can only tell you that if you want the job doing properly it needs 12, and if you go below 7 it won’t be fit for purpose. If I sticky plaster over the cracks, you can pretend that paying for 5 is enough, and that it is the clinicians who are failing, whilst we burn out trying to do twice the amount of work each. But no matter how hard I work, I can’t be in four parts of the country at once, or do recruitment, service development, supervision and provide a clinical service in a part-time job.

Maybe the problem is that I am stubborn. I won’t just toe the line whilst covering my eyes and ears and going lalalalalalala when it comes to everything that isn’t being done. Like my exit point from the NHS, there comes a time where I’d rather leave than do things badly. And where the only efficiency available for me to recommend that fits the prevailing rationale is to pay two cheaper staff instead of my time. I’m teetering on the edge of the plank they’ve made me walk, and I’m increasingly tempted to jump. Maybe in retrospect they’ll recognise how much was getting done with such limited resources.

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.