Grand ideas

I recently filled in an application to speak at an event about children in Care. The form asked me to summarise in a limited number of characters what I would bring to the table as a speaker. I wrote:

We have collected BERRI data on the psychological needs of over a thousand children in residential children’s homes over the last five years, and surveyed and trained over a thousand residential care staff to provide care that is tailored to those needs. We can present what this data shows us, and how we have used it to improve the services that are offered, and commissioning decisions made about children. For example, we have learnt that the level of challenge presented varies remarkably little by age or gender, though the types of needs are slightly different. Some types of needs (eg behaviour, risk) are affected much more by proximal stressors (eg exclusions from school, gang involvement, substance misuse, sexual exploitation) whilst others (eg relationships) are affected more by historic adversity and the nature of early attachment experiences. We can present how staff variables (demographic factors, burnout, empathy, ability to formulate) affect the care they deliver, and how the price and types of services commissioned relate to the needs of the child and the impact they make on the life of the child – if at all!

The government spend a billion pounds a year on these 7000 children, and we have good evidence that by better targeting the psychological needs of individual children they can improve outcomes whilst saving costs.

It struck me when I looked at that paragraph that this was simultaneously a grandiose claim and underselling the potential of the systems we have developed*. I think that tension between over and under-selling what we can do reflects one of the big challenges of being an entrepreneur – seeing the potential, whilst being realistic about the frustratingly slow steps it takes to achieve it. I can see so much that we can achieve, and the way that collecting the right data can help put children’s needs in the heart of commissioning decisions, improving outcomes whilst saving substantial amounts of money but it is very hard to get this information in front of the right people. I’ve tried to speak to politicians, policy makers, experts in the field, commissioners, clinicians, funders and the media. I’ve spoken at conferences, written a book, contributed to policy documents, delivered service improvement programmes in major providers in the sector, I’ve even given evidence before a select committee. But because I try to answer the questions that are asked, I don’t always get the chance to promote the products and services that we provide. And it isn’t my personality to aggressively sell what we do.

Looking back, I think that I believed that if you work out a better way to do something, a technique that saves time or money or improves outcomes for people, then once people knew about it then it would start to gain traction until it became the established way of doing things. I figured that was how we had progressed from horse-drawn carts to steam engines, cars and now electric vehicles, or from papyrus to paper to typewriters to computers to the plethora of voice-activated, photo-capturing, text and graphic app laden smartphones – finding iteratively better ways to solve problems. I knew that sometimes there were two simultaneous steps forward that competed (like VHS and Betamax) and that variables like marketing, networks and budget could influence the choice, but I generally thought that the best solutions would win through. Maybe it is my left-leaning political bias or my hippy upbringing, but I think in my heart I have held onto a naive idea of fairness in which everyone should be motivated to solve social problems, and people should be rewarded for their effort and insight.

I suppose the concept that we live in something of a meritocracy is quite a widespread belief, and entrenched in western cultures, that good ideas will surface and the best people will rise to positions of power. That’s taken a bit of a crushing for me over recent years, as I’ve seen the covert influence of the super-rich and we’ve had several prominent examples of terrible people rising to the top of systems that have failed to keep up with social and technological change, but somehow I am still hoping for the system to right itself, because it feels like society should be a functional meritocracy.

I think it is particularly well articulated in the USA, because they started as a nation of immigrants who created their own society. To quote the American Declaration of Independence, “all men are created equal”, are entitled to “the pursuit of happiness” and will rise to their natural position in society. That sounds like a fair way to run a country, but of course the reality has never quite matched the headlines, given the theft of land and resources from native peoples, the decimation of the natural environment and the evils of the slave trade. But somehow the myth of the American Dream has persisted. First described by James Truslow Adams in 1931, it describes a culture where anyone, regardless of where they were born or what class they were born into, can attain their own version of success in a society where upward mobility is possible for everyone. The American Dream is achieved through sacrifice, risk-taking, and hard work, rather than by chance or the privilege of your pre-existing connections. In Adams’ words it is:

a dream of social order in which each man and each woman shall be able to attain to the fullest stature of which they are innately capable, and be recognized by others for what they are, regardless of the fortuitous circumstances of birth or position

Whilst I can see so many places where people are not starting the race from the same starting line, because of geography, race, gender, religion, socio-economic adversity, sexuality, age, or so many other variables I have clung on to my optimism that if you can work out a solution to a big social problem, or have an idea that can really work to make life easier (and/or make lots of money), then it should be possible to gain traction with it, get key people to support you, and get it to happen. The reality is that so many people who think of themselves as examples of a working meritocracy have in fact been handed a huge head start by their privilege. As we joked the other day on Twitter, all the wrong people have imposter syndrome because it is mutually exclusive with entitlement. It seems that private schools in particular train people to expect to be leaders and wielders of power, as we see in the preponderance of Prime Ministers educated in Eton (and in the irritating arrogance of Lottie Lion and Ryan-Mark in the recent series of the Apprentice). Having attended an ordinary comprehensive, and never having been aware of any negative repercussions of my gender or heritage, it has been quite eye-opening to see that maybe the playing field isn’t as level as it appears, even for someone ostensibly white and middle class**.

One figure that has stayed with me is that of all the money invested into fledgling businesses in the UK, 89% is given to all male founder groups, 10% to founder groups containing men and women, and just 1% to all female founders. I couldn’t find any UK numbers, but the figures look even worse if we consider race, with black women only receiving 0.0006% of the of the $424.7 billion that has been invested into startups globally between 2009 and 2017 by venture capitalists. Those white men probably think they simply have better ideas, but the evidence doesn’t support that, whilst the statistics say they are 89 times more likely to be funded than all female groups, whilst a white male entrepreneur is thousands of times more likely to be funded than a black woman, and will have the confidence to ask for much larger sums of money. Only 34 black women have raised more than a million dollars of investment in the last decade. This doesn’t reflect the quality of the idea or the work ethic of the individuals involved (as meaningfully empowered women on boards increase corporate social responsibility and may have a positive impact on the profitability of the business, and diversity increases profitability). It reflects the stereotype of what the (predominantly white male) funders think successful entrepreneurs look like – and they imagine young geeks from silicon valley who are predominantly white and almost always male. And that sucks.

It might also explain why men in suits with glossy patter are able to sell systems they have pulled out of the air for eight times what we charge for properly evidenced tools that do the same job better. Or maybe that’s just a coincidence. But whether or not the playing field is flat isn’t something I can solve alone, and it is unlikely to be resolved within the timescale that is critical for me to make a success of my business and to maximise the impact I can make on the lives of vulnerable children. That means that, despite how discouraging it is to realise that we are not living in a meritocracy where the strength of the idea is enough to sell it to those who matter, I need to find ways to shout louder, communicate what we do better, and get our message in front of the right people.

Because we are tantalisingly close to having all the data we need to understand the critical variables at play in the psychological wellbeing of children and young people in Care, and which placements and services can help to address them. We have an exciting partnership growing with a group of local authority commissioners that will couple our data with commissioning data, and we are applying for grants to help us to gather and analyse that data across much wider samples. We are also scaling up the previous project we did looking at whether BERRI can help to identify suitable candidates to “step down” from high tariff residential settings into family placements with individualised packages of support. These larger scale projects mean that we will be able to show that the model works, at both the human and financial levels. And with a little bit more momentum we can start making the difference I know we are capable of. The trick is hanging onto the vision of what is possible and celebrating what we have already achieved, whilst having the realism to put in the graft that will get us there. I need to keep pushing upwards for longer than I ever imagined, in the hope of reaching the fabled sunlight of easier progress – even if so many variables skew us away from the meritocracy that I imagined.

 

*I think that’s why I used the pronoun “we” and shared credit with my team, even when I was asked to describe myself as a speaker, rather than taking full credit on my own. This transpires to be a common female trait, and part of the double bind for women where being assertive is seen as aggressive whilst being collaborative is seen as lacking leadership. In fact, many words are used exclusively towards women and highlight how pervasive these biases about women in leadership roles are.

**albeit a second generation immigrant to the UK, with Jewish heritage

Can you make things better for children and young people in Care whilst saving money?

That seems to be the critical question in an age in which there is no money in the budget to try anything innovative just because it will create improvement. To be able to try anything new that involves spending any money we have to evidence that double win of also saving costs. A few years ago when I was in the NHS, I found that really frustrating – I had so many ideas about how we could do things better by creating new services or better collaborations with other agencies, or reaching out to do the proactive and preventative work that would save money down the line, but it was almost impossible to get them off the ground because the budgets were so tight. Since then I’ve tried various things to unlock the spend-to-save deadlock, but it was only once we started looking at the economic impacts of some projects using BERRI that we had clear evidence that we could save money whilst making services better, and on a fairly substantial scale. Our pilot in Bracknell Forest saved £474,000 in the first 12 months whilst making services better and improving the outcomes for the young people involved. And that was just a small scale pilot within a single local authority.

After so many years of being told that improving outcomes whilst saving costs would be impossible it sounds unlikely, but it is true. We made life better for the children involved – in some cases in ways that entirely changed the trajectory of their lives – whilst reducing costs for the local authority. The savings generated would be enough to fund services to address the mental health needs of all Looked After Children whilst still lowering the overall cost of Care. I’m not prone to hype, but that feels pretty extraordinary! Importantly we did it whilst also making life easier for the carers, professionals and placement providers involved. So it is no great surprise that we are now working with many Local Authorities to scope out and deliver wider scale projects.

So, what are we doing that is different? And where do the savings come from? Using BERRI we are identifying psychological needs effectively, and then addressing them early. For some young people that leads to significant change in their behaviour, risks or mental health, that then opens the door to different placement options, and for a small proportion of children the placement costs are substantially reduced. I’m not talking about forcing children in residential care to move to foster placements for financial reasons. I’m talking about better identifying the types of placements and services that young people need. For some, that will mean that they get to access residential care without having to break down a long series of foster placements to do so. For others it will mean that they get access to much increased mental health input, or specialist services. For many it will mean helping their carers to better understand their needs so they can make minor adjustments to the day to day care. But for some children it can open (or reopen) the doors to a family placement.

It may also have an impact on their longer-term trajectory, as it is well known that addressing mental health needs in childhood is easier and more cost effective than trying to address the difficulties they go on to develop in adulthood if these needs are not addressed. Using the BERRI helps carers to see behind the presenting behaviours and to recognise emotional, relational or attachment needs, or feel empowered to support these more empathically. Importantly, it can evidence the impact of the great work that many carers and organisations are doing already to support children by showing the changes they are making over time. It can help to set goals to work on, and to monitor what is and isn’t working effectively to create positive change. BERRI also helps to pick up learning difficulties, neurodevelopmental difficulties and disorders, so that children can then be more thoroughly assessed and care and education can be pitched appropriately.

We are also learning from our increasing data set what scores are typical in different settings, how individual children compare to the general population, and which variables are important in preventing negative outcomes in adulthood.

I sometimes use the metaphor of the cervical cancer screening programme. At a cost of around £500 per woman each 3-5 years, the screening programme prevents 2000 deaths per year. About 5% of women screened have abnormal cells, and 1-2% have the type of changes that are treated to reduce risk. As a result women who are screened are 70% less likely to get cervical cancer, which has an enormous human cost, but also costs £30,000+ to treat. Screening has saved the NHS £40 million. Most importantly it has led to the discovery that the human papillomavirus is significant in the development of cervical cancer. This has led to preventative treatment programmes with 10 million girls in the UK receiving the HPV vaccination. This has reduced the rates of cervical cancer (with 71% less women having pre-cancerous cervical disease), as well as preventing genital warts (by 91% in immunised age groups). It also has the potential to reduce other forms of cancer, as HPV is responsible for 63% of penile, 91% of anal, and 72% of oropharyngeal cancers, with this and the importance of herd immunity leading to the decision to immunise boys as well as girls in many countries.

I would argue that the case for psychological screening, particularly in population groups that have experience trauma, abuse or neglect, is even stronger. More than half of children in Care have a diagnosable mental health condition, and half of the remainder have significant mental health need that doesn’t reach diagnostic thresholds or doesn’t fit into a diagnostic category. They also go on to higher risks of a range of negative outcomes than the general population, including having a higher risk of heart disease, cancer, strokes, fractures and numerous other health conditions, as well as more than fifty times higher risk of homeless, addiction, imprisonment, requiring inpatient mental health care, or having their own children removed into Care. Like cancer, these have an enormous human cost on the individual and their network, and they also have a huge financial cost for the public purse (some estimates suggest £2-3 million per young person leaving Care, when including lower contributions to tax, increased benefits and the cost of services). If we can understand and address the issues that lead some young people down these more negative paths, and address those needs as early as possible in their lives, hopefully we can increase the proportion of young people who survive difficult early lives and go on to healthy happy adult lives.

If you want to learn more about BERRI and the impact it can have on your services feel free to get in touch. Or you can come and learn more about the pilot in Bracknell Forest and the larger scale projects we have started to expand on it, as I am presenting at the NCCTC next month with Matt Utley from the West London Alliance.

How not to apply for a job in psychology

I’ve been shortlisting for a new post today, as we’ve already received 43 applications for the advert I put up yesterday morning*. For a profession in which there is a narrative that prestigious Assistant Psychologist posts are almost impossible to get, the quality of applications is surprisingly poor. I don’t mean that the applicants themselves are surprisingly poor, as they seem to generally be alright, but the way they have applied for the post is, for far too large a proportion of those applying, pretty disappointing. It isn’t going to affect the outcome of the process, as there are some really good applications so we won’t have any trouble finding enough to interview, but there are far too many people who rule themselves out of the running unnecessarily. Many of these applicants might be quite good, but their applications fall far short of my shortlisting criteria for really obvious and easily avoidable reasons. That means that for people who do follow a few simple tricks** you greatly increase your chance of successful applications – not just in my post, but in any application within the field of psychology, and probably most of the advice will generalise to other job applications too.

Before you think that I’m a control freak with unreasonable expectations of applicants, please remember that the context is that 70+ candidates will apply for my vacancy before I close it, and NHS posts will typically attract 100-200 applicants within a short period of time, leading some to close in just a few hours. The balance of supply and demand here means that it’s a shortlister’s marketplace, and only the best applications from the best applicants will lead to an interview. That means that qualified CPs selecting for AP posts have to set high standards to let them narrow down the number of applicants quickly to a manageable amount that they can then shortlist in more detail. And having spoken to many other people who have been responsible for shortlisting similar posts and seen the posts on the thread on this topic on the clinpsy forum, my expectations and frustration with candidates who fail to do the simplest things to present their application properly are echoed by many of my peers.

Whilst these posts are particularly competitive and the application process has some sector-specific features, like the nature of GBC, and the relative values given to particular kinds of experience, what I am talking about are basic job seeking skills that should be taught by every career service or recruitment website. Not only that, but if you do a search on clinpsy you will see that the expectations held by people shortlisting for AP posts are clear, and there is a lot of advice available on this topic in the public domain. We are not expecting people to crack some secret code or have access to hidden insider information: Most of the things that would make the difference are things that require common sense and a bit of effort. My main grumble is as simple as people not reading the instructions on how to apply that are given in the job advert and firing off applications that aren’t specific to the post or don’t contain the required information, or that are really badly presented.

When it comes to my current post I’m not even asking anything too onerous. I haven’t set a task or asked anything unusual. I just want candidates to send a short CV and a covering letter saying how you fit the requirements of the post, with details of two referees. Surely that’s the minimum expectation when applying for a job, and pretty parallel to the NHSjobs expectation of giving education and employment history and then writing the supporting information and references? Yet a significant proportion have submitted applications with no covering letters, no references, or no information about why they want the job or are suited to it. To me that’s like going fishing but not taking a rod or a net.

In terms of essential criteria I’ve asked for a degree conferring GBC at 2:1 or better (or a degree level qualification in statistics or research), along with a driving license (or a transport plan for candidates with a disability to be able to complete the job). Yet many applicants have told me they will complete their undergraduate degree this summer, or don’t have a driving license. There are international applicants who haven’t shown me they can lawfully live and work in the UK. There are then applicants who haven’t given me information I need in order to see they meet my essential requirements. Perhaps they qualified abroad or with joint honours and they haven’t told me that they have GBC. Several haven’t given me a degree grade. Others might tell me that they had a particular job, but not give the hours or the dates so I can’t see how much experience they gained.

The process has really taught me how NOT to apply for a job in psychology, and I thought that might be expertise worth sharing. If you follow the advice I’ve numbered below, you too can be confident that you will maximise your chance to not secure a post!

So my first set of tips on how not to apply for a job are:

  1. Apply for jobs where you don’t meet the essential criteria
  2. Do not read the instructions on how to apply
  3. Do not write a covering letter (or supporting information section) at all
  4. Do not specify your degree grade
  5. Do not mention if you have GBC, even if you have an atypical qualification
  6. Apply from abroad but don’t worry to mention that you have the right to live and work in the UK
  7. Don’t tell me whether posts were full time or part time or the dates when you worked there

The next issue is that many (and in fact probably most) applications don’t tell me why you want this particular job, or how you meet our person specification. They fire off information that tells about their experiences and skills, but does nothing to show how they meet our shortlisting criteria, which are spelled out in the person specification. Few have told me why they want this job in particular as opposed to any job with an AP title or a CP supervisor. Some tell me about their aspirations to gain a training place and/or to have a career in clinical psychology, but (whilst I am aware that the post is a good developmental opportunity and I’m happy to support the successful candidate to develop) I’m not recruiting someone to help them achieve their aspirations. I’m recruiting to get a job done within my team, and their aspirations don’t tell me why they will be better at that job than the other 30+ people who have similar aspirations.

A significant proportion of applications consist of just a CV, perhaps with a very brief generic covering note. Many look like a mass mailing that the candidate sends out to every job listing that contains particular keywords. The result is that they feel like someone reading me a script to try and sell me double glazing or PPI claims without knowing anything about me – they have invested minimum effort but hope that if they apply to enough posts one might bite. In fact, many applications feel like they’ve taken less time to send out than they would take for me to read, and the impression given to the short-lister is that the person doesn’t care about the post at all.

Maybe it’s something about the internet age that people expect to be able to apply for a post with just a couple of clicks, like putting an item on an online store into their basket and then clicking to check out. If you had to invest the effort in phoning up for an application form and then filling it in by hand, as you did when I applied for my AP post in 1995, it might seem more obvious that you needed to make that effort count. But even then not every candidate would explain why they wanted the post. However the internet age also makes it easier to cut and paste the right chunks of information or to edit existing text. So it also makes it easier to tailor an application to a specific post.

So my next set of tips on how not to apply for a post are:

  1. Don’t read the job advert – the job title, pay and location are all the information you need
  2. Fire off a generic CV with no information about why you want the post or how your skills are suited to it (for bonus marks express interest in a different client group or service)
  3. Don’t even worry to read the person specification, that’s not important
  4. Don’t tailor your application to the job, just send the same application out to every post, regardless of the context or population.

The other big advantage is that the internet lets you check spelling and even grammar, so you really don’t need to submit applications that are peppered with typos and spelling mistakes. If you are dyslexic, get someone else to check it before submitting. If you feel too much time pressure to delay individual applications for proofreading then prepare the content you will need to configure most applications in advance so you can get someone to proofread your main blocks of text in advance. Word processing software also lets you count the number of characters, words and pages before you paste content in to your application, so you can easily follow any specified requirements. Which is why it is so puzzling to get six page CVs when I set a limit of two.

There are then other issues with how people present their applications. I get that pasting a CV into a recruitment site can mess with the formating, but you can normally use a preview feature to get the chance to see how it will appear to a recruiter, so it is worth checking. Simplify layouts and fonts and remove massive gaps that appear so that the CV looks neat and tidy. Keep it as short as possible. If I can write my CV on two pages, having worked in psychology for 24 years, managed teams in the NHS and now running my own business, I’m pretty sure that you don’t need six pages by the age of 23. And I’m sorry to break it to you, but I don’t care what your responsibilities were when you worked in that shop, or pub, or holiday resort in the summer before your degree. If you really want to mention it, I’m fairly sure one line would cover it. Otherwise it looks like you can’t prioritise – which is off-putting because being able to pick out the most salient information is an essential skill when deciding what information needs to go into a report.

So my next set of tips on how not to apply for a post are:

  1. Make lots of typos, and ensure to include as many spelling mistakes, punctuation errors and examples of poor grammar as possible (for bonus points, you could spell the name of the organisation or short-lister wrong, or try some text-style abbreviations)
  2. Lay your CV or application out so it is as unintelligible as possible, and definitely don’t check how it will appear in the application system
  3. Don’t worry about any requirements with regard to length, more is always better
  4. Put in lots of information about irrelevant experiences, such as work in retail and hospitality

I hope this blog doesn’t seem like I’m putting people who are just starting out in their psychology career down, or criticising those who have applied in a hurry for fear of the post closing before they have time to submit anything at all. My goal is entirely more positive – to share how simple it can be to make that impossible aspiration of gaining interviews for AP posts come true. There are certain really simple behavioural changes that can remarkably increase your odds of success.

So what can I do to improve my chances of gaining an interview?

First, apply to non-NHS job vacancies. It takes a little more effort to find them, and the quality can be more variable. However, they are a great foot in the door, and much easier to secure than their NHS equivalents as they tend to have lower numbers of applicants and to stay open a bit longer. If an NHS AP post means you have a 1 in 50 chance of an interview, a post outside the NHS might increase your odds to 1 in 15 for a fairly popular post, or even 1 in 3 if the post is only advertised on a company’s website and social media and not on a major recruitment platform. Yup, that one simple trick** can increase your chances by a factor of five!

Second, follow the instructions. Read the advert carefully and do what they tell you to do. If they ask for a two page CV make sure that you send one the right length. A 600 word essay? Well worth the effort, as sending it will double your chance of success compared to applying to a post without this requirement, as fewer other applicants will make the effort, whilst sending an application without it is posting your application straight into the no pile.

Third, tailor every application to show how you meet the person specification for that particular job, and to show you understand and are enthused about what the job will involve. Ideally you need to respond to every point of the person spec in a way that is clear and obvious to the shortlister, and probably in a similar order to that used in the specification. If they want a 2:1 or higher that confers GBC then you need to give your degree grade and specify it confers GBC, rather than assuming that the shortlister will know or be willing to check on Google whether this is the case. If you are applying from abroad or have international qualifications then it is worth stating whether you have the right to live and work in the UK, and explaining the scoring system and/or the UK equivalent of your degree grade.

Fourth, pick your battles. It is better to write fewer applications but to give each one more time so that it is of really good quality and tailored to the particular job than it is to send out hundreds of generic applications. Choose posts that you are enthusiastic about rather than applying to every AP post you see. Think about whether the location can work for you and whether you have relevant experience and/or transferable skills to bring. Make sure every application is up to the highest standards, even if this means they will sometimes close before you submit them***. In such a competitive field it is probably only worth applying for posts where you meet all the essential criteria.

Finally, check your working. Make sure you have spelt names and organisations correctly, and not made any silly typos or cutting and pasting errors. If you can, get someone else to read your text so you can get feedback on how to improve it. Even if that isn’t in time for the application you wrote it for, it will mean you don’t make the same mistakes next time. Preview the application to check the formatting if this is possible.

Then fire it off and cross your fingers!

 

*I’ll be reading more over the coming days too as we normally keep the advert open for a week or 75 applications, whichever comes first. Edited to add: We closed after 5 days and received a total of 86 applications. We invited five people to interview.

**cliche internet phrase

***In this circumstance it is worth sending an email to the appointing officer or point of contact given in the advert explaining what happened and attaching your application. They may consider it anyway, and even if they don’t you risk little by trying.

The misrepresentation of evidence

About a week ago I was involved in a heated twitter debate about this blog post. I felt, as I said on twitter and in my extensive comments about the blog, that it entirely misrepresented the evidence about Adverse Childhood Experiences by implying that because of risk multipliers within particular population groups, certain negative outcomes were almost inevitable for people with multiple ACEs. The author repeatedly asks rhetorical questions like “If 1 in 5 British adults said they were abused in childhood in the last CSEW (2017), why hasn’t our population literally collapsed under the weight of suicides, chronic illness, criminality and serious mental health issues?” Likewise, she asks how anyone can be successful after childhood abuse if the ACEs research is correct. I replied to explain that this simply isn’t what the data tells us or what risk multipliers mean, so the exceptions are expected rather than proof the finding is incorrect. For example the claim that a 1222% increase in the risk of suicide amongst people with 4 or more ACEs meant these people were doomed, in reality means that the odds increase from 1 in 10,000 to 1 in 92, meaning that 91 of every 92 people with 4+ ACEs do not die by suicide.

ACEs are a very useful population screening tool, and have provided incontrovertible evidence of the links between traumatic experiences in childhood and numerous social, psychological and medical outcomes that has been highly informative for those of us designing and delivering services. To me it seems like an example of how a simple piece of research can have a massive impact in the world that benefits hundreds of thousands of people. Yet that blog repeatedly implies ACEs are a harmful methodology that “targets” individuals and to is used to “pathologise and label children, arguing that those kids with the high ACE scores are destined for doom, drugs, prison, illness and early death”. It has been my experience that ACEs are used not to pathologise individuals, but to to highlight increased vulnerability, and to identify where there might be additional need for support. For example, I have used this data to argue for better mental health services for Looked After Children.

I felt that the repeated misrepresentation of the maths involved in interpreting risk multipliers undermined the entire message of the blog, to which I was otherwise sympathetic. (For the record, it is entirely appropriate to highlight bad practice in which it seems certain professionals are applying ACE scores to individuals inappropriately, and making people feel that their life chances are restricted or their parenting under scrutiny purely because of their childhood experiences of trauma). But unfortunately the author took my polite, professional rebuttal of elements of her blog as a personal attack on her – to the extent that she misgendered and blocked me on twitter, and refused to publish my response to her comments about my reply to her on the blog. That’s a shame, as the whole scientific method rests on us publishing our findings and observations, and then learning from the respectful challenge of our ideas by others with knowledge of the topic. But I guess we are all prone to defending opinions that fit with our personal experience, even if they don’t fit with the evidence.

Thinking about how uncomfortable it felt to see someone I considered to be a peer whose expertise I respected misrepresenting the evidence and being unwilling to correct their misconceptions when challenged, but instead trying to discredit or silence those making the challenge, it struck me that this was an example that highlighted a wider issue in the state of the world at the moment. Evidence is being constantly misrepresented all around us. Whether it is the President of the USA saying there is a migrant crisis to justify a wall (or any of the 7644 other false or misleading statements he has made in office) or the claims on the infamous big red bus that Brexit would give the NHS £350 million per week, or Yakult telling us their yoghurt drink is full of “science (not magic)” now that they can’t pretend live cultures are good for digestive health. There are false claims everywhere.

I stumbled into another example just before I started writing this blog, as I (foolishly) booked accommodation again through booking.com, despite the horrible experience I had last time I tried to use them (which remains unresolved despite the assurances from senior managers that they would reimburse all of my costs). The room was terrible*.

So I felt like I should be able to reflect my negative experience in my review. But oh no, Booking.com don’t let you do that. You see, despite seeing that properties appear to have scores out of ten on every page when booking, you can’t score the property out of ten. What you can do is to determine whether you give a smiley that ranges from unhappy to happy for each of their five ratings (which don’t, of course, include quality of sleep or feeling safe). So if you think the location was convenient, the property gets a score above five out of ten, no matter what other qualities mean you would never wish to sleep there again. But worse than that, the Booking.com website forces reviewers to give a minimum length of both positive and negative comments, but only displays the positive comments to potential bookers. So my “It was in a quiet, convenient location” gets shown to clients, but you have to work out how to hover in the section that brings up the review score, then click the score to bring up the averages, then click again to access the full reviews, and then shift them from being ranked by “recommended” to showing them in date order to actually get an objective picture. Then you suddenly see that at least half the guests had terrible experiences there. However, there is no regulator to cover brokers, and fire regulations and legal protections haven’t caught up with private residences being divided up and let out as pseudo-hotel rooms.

But just as Boris has faced no consequences for his bus claims (even though he stretched them further still after the ONS said he had misrepresented the truth), and Trump no consequences for his lies, and the consultants selling contracts worth hundreds of thousands of pounds of public funds to children’s social care departments proudly told me they didn’t care about evidencing their claims, so the world carries on with little more than a tut of disapproval towards people and businesses who intentionally mislead others. Maybe I’m in the minority to even care. But I do care. I feel like it is the responsibility of intelligent people and critical thinkers, people in positions of power, in the professions and particularly in the sciences, to ensure that we are genuinely led by the evidence, even if that makes the picture more complicated, or doesn’t confirm our pre-existing beliefs. To counteract this age of misinformation, we all need to be willing to play our part. That is why I have always placed such a focus on evaluations and research, and have developed my screening tools so slowly and thoroughly, despite the fact that potential customers probably don’t see this as necessary. I believe that as much as possible, we should be promoting the value of evidence, educating the public (including children) to be able to think critically and evaluate the evidence for claims, and stepping up to challenge misleading claims when we see them.

*I booked a room in a property in London which they have euphemistically called “Chancery Hub Rooms” to stay over whilst I delivered some training in Holburn. It wasn’t a hostel or a hotel, but just a small terraced house. This time it had keypad entry to the property and to the individual room, which is a system that I have used successfully several times in Cambridge. Unfortunately it didn’t work so well in London, as they changed the codes twice without informing me. Once this resulted in locking me out of the room on the night of my arrival (and meaning that the beeping on the door as I tried the various codes they sent me woke the lady in the neighbouring room, due to the total lack of sound insulation in the property) and then by locking me out of the property the following evening, when all my stuff was locked inside. It also had glass inserts above the room doors that meant your room lit up like Times Square when anyone turned the landing light on. I then discovered that the building (which I already recognised to be small, overcrowded and not complying with fire regulations) had walls like cardboard, when the couple in the next room had noisy sex, followed by noisy conversation and then a full blown argument that lasted from 3am to 4am – despite me eventually in desperation asking them quite loudly whether they could possibly save it for a time that wasn’t keeping everyone else in the building awake. Of course Booking.com didn’t see it as their problem, and the property management company just blamed the other guests for being inconsiderate.

Holding the buck: Some thoughts about accountability in the modern marketplace

A couple of weeks ago, I gave a talk to the Institute for Recovery from Childhood Trauma at the House of Lords. I decided it would be too stressful to travel down that morning, so about three weeks in advance I booked an apartment through booking.com. I’ve stayed in apartments and rooms through online sites quite a few times before without incident. Normally they send a code for the door by text or email, or instructions to open a key safe. However, this booking was confirmed with instructions to collect the key from a nearby address by 9pm (I was told if I arrived later there would be a £20 late collection fee). So I caught an earlier train and got a taxi to the pick-up address, which transpired to be an office building, locked up for the night. The security guard on site who came out to see why I was loitering had never heard of this being a collection point for apartment keys. So I spent 45 minutes waiting at the pick-up address and checking the apartment address just down the road, with no ability to check my email or find the phone number of the owner due to the o2 outage. I then found a restaurant which let me use its wifi to contact the apartment owner. He answers the phone as Booking.com and says the pickup address sent to me by email was never given (despite me having it in writing on my screen as I spoke to him) and that I had not confirmed the time. He says he will send a man to meet me with a key. But he isn’t willing to send the man to the restaurant in which I am sitting, I have to go wait across the road outside Patisserie Valerie (which is also closed) for a man in a red jacket.

In about 15 minutes that man arrives. He greets me by name, but does not offer me any apologies or identification. I can’t tell if he is the man I spoke to on the phone or not. He does not provide a key to the apartment, but tells me to follow him and walks off in the opposite direction to the apartment. I ask him where we are going, he says “to the apartment”. I say that it isn’t the right way, and I don’t feel comfortable following a strange man to an unknown address. He is short with me and tells me that he is taking me to an alternative apartment, because a cleaner snapped the key in the apartment door 20 minutes previously. I find this suspicious as a) I’ve been waiting at the apartment and just up the road for 90 minutes and nobody has come or gone from it in this time, and b) why would a cleaner be in an apartment at 10pm that is supposed to have check-in from 3pm to 9pm, and c) why did the man on the phone not notify me of a change of address or email me with a change of booking through the site on which I had booked?

He leads me down less busy streets and alleys across Soho. I start to get anxious that I’m in a part of London that is unfamiliar to me, and have no idea where I am going. I will not be at the address I have booked and nobody will know where I am, its past 11pm and dark, and I’m being led by a total stranger who has shown me no ID. So I call my husband, explain the situation and start reading out street names so he knows where I am. He says that I sound nervous, and that if my gut doesn’t feel like this is safe I should trust it and go somewhere that does.

My mind goes into overdrive. I start worrying I’m being taken to an unknown address, where I might be robbed or attacked or anything. I’m thinking perhaps they gave the fake address as a means to be harder to trace, or perhaps they use the photos of one apartment in a good location to put people in cheaper accommodation in less favourable locations. Perhaps he is nothing to do with Booking.com and is just a confidence trickster. Did he definitely use my name? Was he the man on the phone? I have no way of knowing. I can’t just follow a stranger to an unknown address in the middle of the night with no explanation. I find an open wine bar to run into and hide.

Suddenly, all those feelings are right at the surface and I’m sobbing with fear and hiding behind the counter of the wine bar until the man has gone. Then the man who claims to be from Booking.com (I still can’t tell if he is also the man in the red jacket, or someone different) calls me and asks where I am, and I say “I don’t feel safe dealing with you and being taken to an unknown address, I’m going to find somewhere that feels safe to sleep”. It seems like something I should be able to take for granted, that now seems out of reach.

The staff at the bar are super-nice and patch me up, give me some water and use of their wifi. They offer me wine and fancy olives. I take the latter (and they are the best olives ever, as well as thoroughly nice people, so do check out Antidote if you are ever in Soho). When I calm down a bit, I start searching all the usual websites to find a hotel room. I then find out there is nowhere else to stay. And I mean that literally. Even when I increase my parameters to travel up to an hour from my location, nothing is coming up on any hotel booking site that isn’t fully booked. So I’m sat there in a random wine bar in Soho, 200 miles from home, and there are no longer trains to get back there even if I didn’t have to be in London by 9am the next morning to speak at the House of Lords.

At nearly 11pm I find one, very expensive, hotel with a single room available through LastMinute.com. I book it, pay and then pay £20 to get a taxi there only to find it is overbooked and they’ve already turned away 4 other customers. It is a converted Georgian townhouse with a small number of rooms, so I’m sat in the only chair in a tiny lobby. I’m repeatedly calling LastMinute, and it has gone past midnight so there is no longer even a means to find another hotel (as you can’t search for availability for the previous night), and they tell me they don’t have a room. It takes me four calls and 47 minutes on the line to speak to Last Minute’s customer services, who conclude they can’t find an alternative room for me, and don’t see that as their responsibility. At 1.25am they suggest a room is available at the Taj St James Court hotel and they have reserved it for me. I call them, they have no rooms and have never heard of me. It is now 1.30am, and I am making plans to sleep in the bucket chair I am sitting in, in the hotel lobby, as I have nowhere else to go* and it is raining heavily. Eventually at 2am the hotel say that one guest has not checked in yet, and agree to take the gamble and let me use the room. I get less than four hours sleep for twice-the-price-I’d-normally-set-as-my-upper-limit-for-a-room, before having to head out to speak at the House of Lords.

Having given the talk I decided to complain to both Booking.com and LastMinute.com. The response from the former was “You got a refund for the apartment, so it’s all settled” and the latter offered “€20 as a goodwill gesture due to the 2 hour delay checking in”. No recognition of the fact the experience was traumatic, wasted 5 hours of my evening, cost me 3 extra taxis, and left me 200 miles from home without somewhere safe to sleep. I am faced with the realisation that trauma is subjective, and to many men hearing the tale I might have taken fright for no reason and brought the events that followed upon myself. I am forced to say “imagine if your Mum were in this situation” when explaining it to try to trigger sympathy. But nobody really cares. The apartment owner feels he has done his bit by refunding (and the website has conveniently blocked me from leaving a review). The men in the call centres were in another country, abstracted away from the problem. The customer service teams are seeing the facts in retrospect, not the feelings the experience generated, and are motivated to protect their brand rather than genuinely caring about me as a customer. The night manager of the hotel cared, because he met me in person, and saw I was upset. As a result he tried his best, but he wasn’t in a position that could resolve the problem.

And that’s where I finally reach the point. In a system where you book with a middleman who doesn’t actually provide the product you are paying for, nobody really feels accountable for the service you receive. And, to bring this round to being relevant to a wider point for health and social care, this model is being increasingly replicated in public services, where the NHS or local authority commission the service from another provider, who is assumed to be responsible. That split between online broker and real life provider, or the public sector split between purchaser and provider seems like a good model for each of those parties, as the purchaser delegates responsibility whilst fulfilling their obligations (or making a profit, in the case of online brokerage sites) with much reduced staffing and without having to invest in any tangible assets. The provider gains access to a wider market, rather than becoming obsolete. But somehow inevitably, as in my experience, the recipient of the service misses out in the middle, and finds out there is minimal quality control and an absence of clear lines of accountability when things go wrong or aren’t delivered as planned.

For example, there is a level of risk aversion that has made local authorities anxious about providing residential care placements, because of the prevalence of historic institutional abuse and the increasing awareness of child sexual exploitation and involvement in county lines (and the accompanying risk of compensation lawsuits). The result is a marketplace where private providers (many of them owned by international venture capital groups who pay minimal UK taxes) use unqualified, low-paid staff to care for some of the most complex and vulnerable young people in the UK, and it is hard for recipients or commissioners to distinguish them from provision that has different financial or delivery models. Likewise in health (and public transport) private providers cherry pick off the profitable services, whilst the public purse is left holding the can when they don’t deliver. There is a move to entrench this even further with the push towards Integrated Care Providers, where private organisations can manage the entire health and social care services for a particular region of the UK, in a way that is potentially unaccountable for its decisions and not subject to the rules for public sector organisations (like Freedom of Information requests, public consultation, or being subject to Judicial Enquiries if things go wrong, or even their statutory obligations). I think that might be a recipe for disaster, but then, I’m not a fan of corporations and the super-rich profiting from the suffering of the rest of us.

Update: Booking.com fed me some platitudes and agreed to reimburse my costs in relation to the apartment, but then failed to do so, whilst LastMinute.com have not yet replied, telling me they take 28 working days to respond to customer complaints that don’t accept the initial boilerplate response. I suspect that just like in health and social care, the (explicit or implicit) policy is to respond to those who kick up a fuss and have the potential to create negative publicity if things are not resolved, meaning that those who are devalued most by society have the least redress when things go wrong.

*call me a wuss, but I declined the option of having one bed in a bunk room in a hostel shared with 8-12 strangers

Reaching the summit?

For a long time, I’ve had a metaphor in my mind about how it feels to run a small business aiming to change children’s social care. The image is of me rolling a massive boulder up a hill. Progress is slow, it is hard work and I often find it tiring. Even when I rest I have to do so holding the rock in place. At times I feel like I might be reaching the summit, only to see that there is another climb ahead. I sometimes wonder why I’ve taken on this mammoth task, or whether my goals are even possible, but I am stubbornly determined that now I’m so far up the hill I don’t want to give it up. Maybe that is about sunk cost. But I’ve chipped off the worst of the bumps from the rock and got my rolling technique worked out, so I keep telling myself that if anyone can get this thing to the top of the hill, I can. Over the years of my journey I’ve tried to encourage other people to help me to push, so I am not bearing all the weight, but whilst I’ve had good company at times and plenty of encouragement, it has always seemed like the task is mine alone. That has been reinforced by numerous people telling me how I’m uniquely skilled at rock-rolling, even though I know that I was no better than many other people at the start of my journey. In fact I’m pretty sure anyone with some pretty basic skills who rolled a rock for this long could be standing in my shoes.

Of course, that bypasses the fact that I had to be willing to spend a lot of time on this, be resilient in the face of obstacles, and give up other easier opportunities to stick with it. And the fact I had the intellectual, social and personal characteristics to work out how to do this, choose a viable route and make improvements along the way. And it also omits to mention that had I known the real scope of the task would take me over a decade I might not have taken it on at the beginning. On the other hand, perhaps the fact it was difficult enough for nobody else to take on was why I did it. I think those who know me might point out it isn’t the first time I’ve jumped in at the deep end, and that I don’t do things in half measures. I don’t like taking the easy route in life, and if I set myself a challenge I like doing the task properly. I’ve always thought about what I can do to make the most impact, rather than to have the easiest life or earn the most money. I prefer to cut my own path, than to take one that is already well-trodden, and to find a way to enjoy the challenges of the journey.

So here I am, pushing my boulder and feeling like I’ve come quite a long way over the years. I might be deluding myself, but the gradient appears less steep these days. In fact, it feels tantalisingly close to reaching level ground, and I am starting to imagine what it might be like to roll my boulder down the other side of the hill. I’m trying not to be complacent that I’ve reached a point at which the boulder is stable enough not to roll back the way we came up, but people are starting to talk about how this boulder is not just on the level, but given one more push might gain enough momentum to create a landslide that will divert the river to irrigate the lands the local population need to farm. That would be beyond my wildest dreams. I mean, the motivation behind all this is to improve the lives of people who are having a tough time, but to think that it could have impact on the scale some people are now anticipating is mind-blowing. That would mean my big gamble of investing so much time and effort into this project could pay off in terms of impact. In a way that’s the great thing about indirect interventions – that they can make change that ripples out on a much bigger scale. In my boulder metaphor I’m trying to make change not by trying to teach them new farming skills one by one, but by trying to address some of the systemic barriers that impair their life chances, so that they have the opportunity to find their own ways to thrive.

So this blog is a marker of me standing at what I hope might be the top of the hill, and crossing my fingers the gaining momentum part happens. The mixture of hope and uncertainty is stressful to balance. When it’s a bit more concrete I’ll write a bit more, and hopefully I’ll not need a metaphor to couch my cautious optimism in, and can tell you about the actual project and the steps I’ve taken to progress it.

The attraction of small rewards

I went to the Y Not Festival last month. It was a bit of a mixed bag because of the weather, and the terrible app that was supposed to function as a map and timetable was a daft idea on a site with limited mobile in the first place and totally useless in practice as it wasn’t updated when things changed. But we saw some good bands, and ate some good food, and it was only half an hour from home so we also slept in our own beds! But the reason I mention it was because of a trivial but unexpected thing: They had an incentive to recycle the plastic pint glasses that were being used and dropped on the floor. They offered 10p per glass to take them to a recycling point in sets of five. For the most part that wasn’t enough for people drinking to bother keeping and pooling their glasses to cash in. But a small economy developed amongst people who found it worthwhile to go around collecting the dropped cups. There were some sets of kids excitedly supplementing their pocket money by collecting piles of cups during the day, and also a few adults who increased in numbers in the evenings.

At £5 per pint the beer was not cheap, and I joked with my husband that I’d see if I could collect 10 cups to offset the cost each time he drank one. But as soon as we started collecting cups, we realised that there were loads of them, and it was easy to make quite good money from them. In three hour-long collecting binges, and whilst listening to bands I enjoyed, I stacked and recycled well over 500 cups. That was enough to pay for all our food over the weekend, and the couple of drinks my husband had. Of course my legs ached like crazy the next day, after all that walking around punctuated by 500 bodyweight squats. But I felt good about being part of the efforts to clear up the site and recycle the cups.

Of course I’d much rather they used reusable cups as they did at Timber festival, or ones that are biodegradable as they did at Woodside. And it doesn’t really make much sense to pay random people more per hour than they pay their bar staff or rubbish pickers, let alone to pay the people who were simply emptying out the plastic recycling bins, stacking up the plastic cups and taking them to the recycling point like their own little black market scheme. And I wasn’t persuaded that they were actually going to recycle the cups at the end of the weekend. But I was interested in the fact that I somehow found it fun to do a dirty, smelly, physically demanding job earning way less than I can earn from work. Apart from the novelty and fact it filled in the gaps between artists, the reason was as obvious as those demonstrated in Pavlov and Skinner’s seminal experiments: The small but proximal rewards were enough to reinforce the behaviour, and make me want to repeat it over and over again. In fact it became quite addictive. The small payments made it feel like a game in which I was succeeding and earning five to ten pounds per trip to the recycling point made it really tangible that I was being rewarded. I could have spent the entire weekend picking up those crushed and broken plastic cups and straightening them out into stacks to cash in, and my kids were jealous that they’d missed out on the opportunity to earn cash because they had chosen to go to their grandparents rather than the festival.

In another example, I’ve been playing a really rubbish game on my iPad called Hidden City. It is a hidden object game, where you have to find items within a picture of a scene before the time limit runs out. For example, there might be a picture of a greenhouse full of caged birds and exotic plants, and you will then be asked to find a pair of binoculars, a fan, an oil lamp, a walking cane, a string of rosary beads, a bunch of chilli peppers, a pair of shoes, a turtle, and various other objects to click on and collect. Each will be visible within the scene, some in plain sight and others tucked away or masked by being in front of similarly coloured items. In certain quests there are also keys to find in the scene that are smaller and better hidden. Whilst this has some inherent mental challenge and novelty, it really is a very simple premise for a game, and quickly becomes repetitive, so you’d think the game would be very boring – in fact it seems boring to have explained it in writing, so I hope I haven’t sent you off to sleep! You would therefore assume that people would drop out of the game very quickly, but that doesn’t appear to be the case. In fact, the makers are so confident that players won’t be bored enough to drop out that they make you search each scene for objects selected from the same list and placed in the same range of places in the scene many times. In fact, to complete some quests you search the same scene over a hundred times. The task becomes more difficult because you are expected to find more objects in a shorter time interval, and the scene becomes more cluttered so it is harder to pick out the specified items, and you have to alternative with searching other scenes to get the tokens required to go back to the main scene. To compound that, there are multiple locations in the game, and each needs to be searched a large number of times, so to complete the whole game you probably have to complete about ten thousand search quests.

It sounds like an enormous and monotonous task, and the game itself is full of bugs, glitches and poor translations, yet it is the most popular hidden object game in the world. More than half a million people have played it, and there are tens or maybe hundreds of thousands of players active at any one time. They are not only signing up to play in huge numbers, they are choosing to pay for the optional purchases to assist their searching, making this game and the multiple other games by the same company, and the multitude of similar games available, highly profitable.  Estimates suggest that over £3 million of in game payments have been made since the game launched four years ago, and tens of millions of pounds are being spent in in-game micro-payments across all the games by this maker each year. It seems illogical, but many players spend way more than they’d need to pay to purchase a really good game to play this glitchy game that is constantly interrupted by advertising for in-game purchases and other games by the same company.

So why do people keep playing, and why do some of them keep paying? I think it is the same idea of reinforcement through small rewards. As a player you experience a lot of small successes. They make the first few searches really easy. Then each time you search and don’t find all the items you are told to try again. If you find them all you are rewarded by a random selection of small icons, and you can collect these items in sets. Completing the set gets you a rarer icon, with some bonus points or magical powers to boost your energy or increase your ability to find other bonus items. In the bigger quests you might also get tokens to unwrap gift boxes containing more icons. You also get overnight bonuses, daily bonuses and components of a magical piece of jewellery each time you play again after more than 8 hours but less than 24 hours. They compound so an unbroken chain of about a month gets you the finished item, and 12% more items to find for a 10 day period. If you break the chain you either have to use or buy in game currency to restore it, or you lose the components you gained. Something about our psyche likes gaining these pseudo possessions and dislikes missing out or losing them, enough that these games are quite addictive. But they are all just small pictures of random things. Why should I care if I have a magical tuning fork in my collection, or whether I get the apple strudel icon that completes the huntsman set that gives me the Austrian clock? There is no intrinsic value in the drawing of the clock, or the strudel or the tuning fork. They bear little relation to the scenes I search, or to the token plot about the magical city trapping people, or the candy-crush style mini-games. My life is not better in any tangible way if I collect 75 keys and open the golden chest to receive 6 bonus items, or if I play the scene 100 times and get a new avatar of the lady of the manor, or the Samuri, or the gardener. Being at a higher level on the game doesn’t convey any greater skill that would garner respect from other players, let alone in the real world, nor does it teach me anything I can generalise outside the game.

So why is a badly made game with such a simple and repetitive premise so popular? I’d suggest that is intentionally designed to be rewarding to play, and to tap into what we know about reinforcement with the number of small rewards it offers. Our brains are set up to love rewards, no matter how meaningless they are, or what the longer-term cost is. Like scratching an itch, or eating something tasty but unhealthy, using drugs or smoking cigarettes, the immediate rewards are often much more effective as an incentive than the longer-term consequences are as a deterrent. The logical decisions we make about changing our behaviour struggle against these proximal sources of gratification. It doesn’t feel like a big effort or commitment, because we are only playing a three-minute mini-game. We are tempted to take the small action to sample the reward, but this then lures us in to take the next step with another small effort, and the result is that we repeat that for far longer than we planned. Even if this means losing out on sleep, or getting things we objectively rate as more beneficial or necessary done.

The same is true of our online behaviour. We chain from one news article to another, or one social media post to another, or one youtube video to another until whole evenings disappear into a black hole. Even when we are going about our daily lives, we constantly check for the small rewards of messages, likes or responses on social media. For many people this becomes something done obsessively, to the detriment of other activities in our lives. As well as hitting our reinforcement pathways, these small social connections also fire up our desire to feel belonging and acceptance in a group, and to gain the approval and/or attention of others. I’ve blogged before about the toxic aspects of social media. Studies have shown that stopping using social media, whether for a couple of hours per day, a day per week, a longer block of time, or permanently, makes people happier (journal articleanecdotes, article citing studies, more anecdotes, even more). Yet for most of us, we are enticed by the sense of connection (albeit often a much more distant and less authentic connection than we make in real life) and the promise of these small rewards.

It makes me think how despite all the progress of technology, we really are quite primitive creatures in some ways, tied to the way our biology has evolved to reward behaviours that had some adaptive function that had evolutionary benefits. So can we make a conscious choice to use these inherent reward systems for more positive purpose? Possibly. For example, we can benefit by building chains of positive behaviours that we don’t want to break – like a colleague who told me he hasn’t drunk alcohol for 92 days after realising he was drinking almost every night. That challenge of having a dry month, or to do without meat, or caffeine, or cigarettes for a set time period seems an effective way to change behavioural habits. It is less final and impossible sounding to have a break from something than to give it up permanently, but it can give you a chance to see what life is like without it, find alternatives that fill that gap and build up some of these rewards for going without. It then becomes easier to continue that pattern, and there can be a reluctance to break the chain, particularly if there have been social or financial or health rewards for the change.

Likewise we can gamify exercise. When I used to weight lift I would share my achievements with a group of other weightlifters online. This gives a sense of a peer group who can reinforce your behaviour and some social pressure to sustain the pattern (though I was never one to post every gym visit on facebook the way that many runners/cyclists use their apps to, or to post lots of philosophy and photos the way that yoga fans seem to – I just posted to a weightlifters group when I made gains, and could compare my progress to others in the group). But even without this online support I had a sense of achievement each time I went to the gym, or completed my routine, or increased the weight I could lift in a specific exercise. I liked to record my weights in a journal and to feel that I was making measurable small gains. I also liked confounding expectations by being an overweight middle-aged woman who had hidden physical strength. I’ve mentioned my joy in having “ninja muscles” before. I’d like to get back to it, and I’m sure my core strength would return. I’ve still got surprisingly muscular legs, though I wouldn’t risk picking up an 18 stone barbell these days!

So I guess the knack is working out how to make our innate reward systems work for us in a modern world. I’m certainly far from achieving that. Change is hard. But maybe I can at least recognise the patterns better now I’ve thought about it more. Maybe I’ll come back to that theme in a future blog.

 

 

Runway: A blog about whether being self-employed or starting a business is a viable option financially

If an aircraft runs out of runway before becoming airborne then it will have to stop or it will potentially crash horribly. For this reason, runway is used as a metaphor for the relationship between the money available in a business and its running costs. If the business does not generate enough income to keep the cashflow up to cover costs, then it will either come to a stop or come to a horrible end. But unlike an airport, where sufficient runway already exists for the purposes of launching planes, with a new business you have to find or create the money that will hopefully let the business become self-sustaining. And unlike an airport, at which planes get up into the air uneventfully every few minutes every day for many years, most businesses fail within the first three years, often because of not being able to generate enough income to sustain the business in the longer term.

I think a lot of people in employment have fantasies about being self-employed or starting their own business. For clinicians, the fantasy is often about offering therapy in private practise to insured or well-heeled clients with milder problems. Whilst the hourly rates for private practise might seem attractive compared to a salary divided down into an hourly rate, the figures represent something really different. Salary is paid on leave days, bank holidays and when you are sick. It covers maternity/paternity leave and redundancy if you are no longer needed. You get supervision, CPD, equipment to use and premises to work in. You also have a team of other professionals supporting you in the background from admin to HR, finance, operational management, procurement and maintenance. You don’t have to think beyond providing the clinical and associated psychological services. Salary packages, particularly from the NHS, also contribute to very favourable life insurance and pension schemes. When you are self-employed you need to think about premises, insurance, supervision, CPD costs, DBS checks, accountancy, advertising, tax and how you will generate income if you don’t or can’t work. You may also need equipment from computers and stationary to psychometric tests (which are enormously expensive both to purchase and for record forms).

Remember that the bills need to be paid immediately, but clients may not pay you as promptly – and some may not pay at all. This is particularly true for me when doing expert witness work where the timelines from accepting the work to receiving payment for it are amazingly extended. If I accepted an instruction in principle on 1st January, I would typically receive instructions for it 1-3 weeks later. My appointments would take place 4-8 weeks after that, and my report would be submitted a fortnight later, perhaps in late March. There might then be further instructions or clarifying questions, before the case is heard at the end of May. Any invoices will only be processed when the case closes in June, and then sent to the Legal Aid Authority for scrutiny in July. If there are no queries the LAA then send payment to the solicitors, who eventually send it on to the expert in the August or September, though some will drag their heels for several more months. So I have to wait six to twelve more months to receive payment. And about 8% of the work is never paid, because the solicitors closes after the Legal Aid claim is made, or because the LAA determined that some of the work wasn’t “reasonable” or because there was a problem somewhere in the line of communication and one of the parties doesn’t claim a share of your invoice. Meanwhile the work is taxable in the financial year in which it is completed, and the VAT is payable at the point the invoice is issued. I also have to pay any staff who contributed at the end of the month in which we did the work.

Even as a sole trader working from home in a service industry with relatively low set-up costs, most of us need to earn some money to cover our living expenses, and can’t go for months or years unpaid. That means that unless you have a massive inheritance or lottery win to draw on, it might not be possible to give up salaried work to take the gamble of trying something independent. My rule of thumb is to have a minimum of three months living expenses saved before you consider leaving salaried employment. You might get this from a redundancy or mutually agreed resignation scheme, or by putting money aside whilst you are planning. You should also compare your current and projected earnings. My way of calculating this to calculate your annual salary plus 25% (the approximate value of the pension and protections) divided by 210 (the actual number of days an average NHS employee turns up to work). You can then compare this to what you think you could earn in a day if you had private clients, a contract with a large company to deliver training or services, a calendar full of supervision or consultancy, or whatever you imagine doing. You really need a multiple of three between the first number and the second to make being self-employed pay equivalently after costs, though if you really hate your job or are prepared to take a reduction in income (at least in the short-term) you might consider a multiple of two. I don’t believe it is viable to go below this because in my experience people never properly account for the amount of expenses involved, or the for the amount of non-income generating time required. As well as the fact that not all of your available slots will be filled until you are well established, it is worth bearing in mind that most full-time clinicians spend about 15-18 hours per week on direct clinical work, and the rest on work tasks that would be non-income generating in the private sector, such as screening referrals, setting up appointments, phone calls, email, supervision, meetings/indirect work, writing letters/reports, other admin and CPD.

That said, money isn’t everything. I know some amazing selfless people who have earned less than minimum wage for many years, but followed their heart because they cared passionately about what they were doing, and the impact it could make in the world. I’m not quite that altruistic, perhaps because I am the main earner for our family unit and feel an obligation to sustain our quality of life, but I’ve had to learn to live on a much less regular income. I pay myself minimum wage then supplement this with lump sums when the business is profitable. To make this even more unpredictable, I have often had to loan money into the business in order to pay salaries when others have been slow to pay us for work we’ve done. Overall I’d say my income is lower than when I worked in the NHS and did some court expert witness work on top, but nowadays on balance it probably matches my consultant grade salary. The amount I earn feels sufficient for our needs – and probably stretches a little further as some expenses have been absorbed (eg my mobile phone bill is paid by the company, as is the cost of any CPD I want, the costs of my accountant, and some little things like a sandwich and soft drink when I’m away from the office on business).

There are also some things that money can’t buy. I’ve loved the freedom and flexibility of being self-employed, even though there have been times that have been quite tough financially. Whilst it initially increased my workaholic tendencies to quite alarming proportions (peaking at working 9.30am to 6.30pm in the office and then 10pm until 2am at home most weekdays, and fitting in 5-10 hours of work per weekend), more recently I’ve been able to achieve more of a work-life balance. I’ve stopped doing as much consultancy and training that involved staying away over night, and reduced the court work that created so many high-pressure deadlines. I’ve started to cluster meetings in London once a month, arranging other meetings over videoconferencing where possible. I’ve withdrawn from the committee and policy work that was taking up a big chunk of my time. I’ve also recognised the wise advice of a past supervisor that said I needed to fill up life outside work with commitments that would compete with work, rather than expecting to ever be the kind of person who can ring-fence free time. So I’ve started putting social appointments in my calendar, made a commitment to swimming regularly, I’m doing more adventurous things with the children, and I’ve even been able to sneak out for the afternoon with my husband from time to time. Running my own business has also given me a chance to relocate to an area that I love, where my qualify of life and working environment is much nicer.

When weighing up the options, bear in mind that working as a sole trader can be quite isolating. In the NHS or other organisations we usually work within teams, often with the benefit of colleagues to bounce ideas off, or who can contribute to formulations from other perspectives. Working with others also allows you to collaborate or to delegate work to people with complementary skills or interests. It shares the risk of complex cases, and means you don’t feel solely responsible for the waiting list or the stuck cases. It can allow you to prioritise work and manage your workload. When you are the only one doing the work this becomes much more difficult, and the pressures and sense of responsibility for clients can increase substantially. Even though the waiting list might be shorter, you might feel more guilty if there is a delay in starting work with a new referral, or more responsible for ensuring a good outcome for everyone. When your income literally depends on how much work you do it can be hard not to end up over-working to the detriment of everything else in your life. However, on the flip side you can feel pride in positive outcomes, and a waiting list becomes a marker of success (that people are willing to wait for you) rather than a mark of failure like it is construed in the NHS (where there is pressure to meet targets, and services don’t have enough resources to keep pace with need, and are the only available option for most people).

You also need to realistically appraise your business plan. Most people go into business in the belief that they have found a niche in which they can earn a profit, and hope that demand for their services or product will arrive as soon as potential customers know it is available. However, that can lead people to be overly optimistic about how fast they can gain traction in the market, or the level of profit they can make. Unless the plan is to seek external investment, most small business owners need for the business to become profitable fairly quickly, and few would be willing to pour their life savings into a new business in the hope of a return further down the line. When trying to start up a company or expand a sole trader enterprise into a business that employs others it can often feel like a Catch 22 situation, that you can’t afford the things you need to generate the income that will fund the things you need. But unlike on Dragon’s Den or in Silicon Valley, few people have access to capital investment and most professionals (in the health and social care field at least) are wary about taking on loans before the business has the means to repay them, even if they can access lending.

My point is that even if you have a great business idea and an established reputation getting enough money to start and sustain a business is tough. Cashflow is a make or break issue. Generating sufficient working capital is one of several elements that challenge new start-ups. In fact, of small businesses that fail (based on figures from the USA), 82% attribute this to cashflow issues and 29% say that they ran out of cash, whilst 42% said that the issue was a lack of market need for their products or services, 23% don’t have the right team to deliver the business, and 19% can’t match a competitor.

I guess that makes me a survivor. I launched my small business seven years ago this month, and it is gratifying that we’ve managed to weather the politics of adversity to still be trading. However, making money is still something I find quite challenging. I’ve come out of a career in the NHS in which the financial transactions involved were far removed from my daily life, and the idea of making a profit was quite aversive. But I’ve had to learn to make my business financially viable. Whilst there have been times that have tested me almost to my limits, the business is still functioning and financially we are still on the runway. I view that as a success. However, I feel like we have never quite reached the position of being airborne, where the business is self-sustaining without me personally doing income generating work as a substantial proportion of my time – and that would be an enormous issue if I ever needed time off sick.

My penultimate piece of advice is to speak to people who understand business and finance before you embark upon your journey, and regularly as you go along. I’ve had the benefit of great guidance as I’ve travelled outside of the NHS and into the world of business. As well as my fantastic ongoing mentoring from Impact Hub, which has included some work on the financial elements of the business plan, I recently won a place on a scheme sponsored by Barclays bank to help social purpose businesses to scale up. I’ve been attending Judge Business School at Cambridge University with several other small businesses, where we have had a series of days to explore our options and make a growth plan for the business. Having identified gaps, I’ve then taken actions to rectify them. For example, we’ve built a website for BERRI so that prospective subscribers can see what our tools have to offer, and that has brought in a flurry of new subscribers. I’ve also explored the options to help me scale up more rapidly and increase the impact of what we can deliver. Thankfully we have a strong business case, and I’ve been increasingly able to articulate that as a result of the work I’ve been doing. Over the last month I have spoken to two potential sources of investment. That would give me more runway to play with, but I need to work out whether we are fully aligned in terms of the destination and route to get there before I can be sure that is the right move to make compared to continued slow organic growth.

My final advice is to recognise your own limitations, and to find ways to delegate the tasks you are not good at or not enthused about, and spend time with people who share your passions or the skills you want to grow. For me that means having an administrator who makes up and chases up my invoices, accountants who can deal with payroll, tax, NI, pensions etc and advisors who guide me to apply for the right grants, tax rebates and training schemes. I also meet up regularly with other social entrepreneurs to share our progress and plan collaborative projects. I just appointed an experienced Business Development Lead for the company, who I hope will help me to weigh up the options for investment, and help us to grow quickly but in a way that feels right and prioritises making an positive impact on the lives of vulnerable children over maximising profit. I’m hoping we’ll reach sustainability by the end of the year, but there are still hurdles to overcome, and even when we get into the air I can’t imagine it will be a journey without occasional turbulence.

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 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.

 

 

Drama vultures: Some comments on social media

For young people, social media can be a very significant part of their social life. As Mark Brown put it, “Social media went big at the same point that austerity did. We lost our libraries, youth clubs and schools funding but we got smartphones and snapchat instead.” It has also been a means of connection for people who were technologically savvy but socially isolated. This is a surprisingly broad group, including both “geeks” (with subgroups of angry young men who have been radicalised by anti-feminism and the alt-right), those with social communication deficits (who like entirely written communication, as it means that they no longer feel excluded by the pace and non-verbal elements of real life social interactions) and people who are socially isolated because of their geography, disabilities, sexuality, gender identity, culture or more introverted personality, as well as an increasingly broad demographic who have simply discovered the convenience of social media as a means to connect with likeminded others. It can be enticing as a way to gain some social validation, either through “likes” of your content or photographs, or through a sense of belonging to a community of people with shared values or interests. And with so many different platforms, there can be many different qualities to this interaction, and functions that social media serves in people’s lives.

With niche communities, pockets of self-referencing and self-reinforcing cultural norms appear. Whether it is the sensitive niche sexualities of tumblr, or the offensive-as-possible culture on 4chan, the visual memes of imgur, the glamorous selfies of instagram, the endless stream of headlines from twitter, the business focus of linkedin, the many facets of reddit, videos on youtube, livestreaming on twitch or periscope, various blog platforms, an almost endless variety of podcasts, massive web forums on every topic imaginable, or even the comments sections of various publications, each has a different personality and norms. Some are ephemeral, with content disappearing after a certain time. Others stand as searchable archive with a long-term record of past content. Some allow people to broadcast outwards and collect followers, whilst others are focused on more reciprocal relationships. Some allow privacy restrictions that mean you can limit access to friends and family. But most have some means for others to indicate their approval or disapproval. And that means that there can be a sense of being judged or rewarded according to what you post. Sometimes this is based on the quality of the content, but it can also be based on political/group affiliation or appearance – with attractive young women who post photographs or video in particular getting a lot of attention. Some sites allow interesting or amusing content to float to the top where more people will see it, allowing particular posts to be read by remarkably large numbers of people. These can include inspiring content like non-zero days or unintentionally hilarious content like the penis dunking thread on mumsnet (mildly NSFW) that had me failing to contain my laughter during a BPS committee meeting. Some people seek out notoriety by writing controversial or entertaining content. Others who feel they don’t get enough positive attention seek out more negative peer groups, or seek attention in less functional ways. There are also less healthy pockets of social interaction on the internet. There are pro-anorexia communities, and sites that discuss and even encourage self-harm and suicide. There are bullies and trolls, and even people who fake being bullied in order to seek sympathy or justify introspective disclosures*.

One of the great advantages, and problems, with social media is the potential to be anonymous. This is a great leveller because it makes other users blind to your gender, age, race, appearance, physical ability/disability, sexuality, wealth, social class or other sources of prejudice – although many people choose to display these characteristics anyway and seek out similar people for a sense of belonging within specific online communities. However, the very anonymity and ability to create a character for yourself online can be problematic, as anybody can pretend to be anything. As well as the proverbial middle-aged lorry driver pretending to be a teenage girl, there are people pretending to be of different social demographics to infiltrate or undermine these communities. For example, many alt-right trolls attempting to fuel the gamergate conflict signed up “sock puppet” accounts as women and people of colour to pretend that their movement was more diverse or to defend them from criticism for sexism and racism. More obviously there are trolls, who use the anonymity to bully, harass and try to get a rise out of others, safe in the knowledge that social media is functionally a lawless zone, where only the very most serious of attackers, who challenge national security or make repeated overt threats towards targets in the public eye ever see any attempt at identification or prosecution.

By contrast, if you slip up on social media and say something stupid or embarrassing it can be shared with hundreds of thousands of people, your identity can be outed, and the impact can spill out into your real life in unpredictable ways leading to a roulette of inequality in which an ill-judged racist or sexist joke having more consequences than a year-long campaign of rape and death threats.  Or, you can become a target whose personal details are released on the internet (known as doxxing) by someone who dislikes your opinion or feels slighted by you, or subject to “revenge porn” where intimate photographs are published by an ex-partner without the consent of the subject. In America you can even become the target of hoax calls intending to send in an armed response team (known as swatting). And (as in many things) it is women and people of colour who always end up being disproportionately punished.

Having been on the internet since the 1990s, I’ve had an interesting personal history on social media. I was part of the eBay forums around the launch of eBay.co.uk for several years. As well as giving advice about scams and using eBay to buy and sell, there were lively off-topic discussion, running jokes and fundraising activities. But even within a seemingly diverse and healthy community of strangers there were many interesting signs of dysfunction. There were cliques and factions with marked animosity between them. There were people who claimed to be things they were not, including a “detective” and a “vet” (who was so desperate to uphold the facade she tried to get the Royal College of Veterinary Surgeons to amend a register entry for a genuine vet to match her name). There was a lady who faked her own death and posted as her (supposedly bereaved) husband, but was rumbled by an astute poster spotting contradictions in her story. When I foolishly mentioned being a psychologist in a conversation that only contained four other active users, that information spread much more widely than I had expected. I started to receive disclosures and allegations, messages about distressing feelings and even what appeared to be a suicide note (with the help of moderators I alerted authorities, and the suicide was not completed) so I soon learnt to be much more private and anonymous.

On clinpsy we have also had our fair share of tea-cup sized dramas, despite having very little need to intervene as moderators compared to the large volume of members and posts. I blogged about some examples two years ago, and I can only think of two people we have banned since then (although I did block someone from registering after they were very antagonistic and inappropriate on facebook after we failed to activate their registration between 10pm one night and 4am the following morning). I did recently have the interesting experience of having someone apply to work for me who had been banned from the forum. They didn’t seem to think I’d know about that, despite the fact that they used the same email address in their application as they had when they had been banned. They withdrew their application when I said that I knew and we’d need to have a conversation about it if they wished to progress their application.

It is an interesting thing that social media crosses the boundaries of communication that we are familiar with. The written form seems somehow impersonal and emotionless compared to forms of communication that contain the non-verbals, and yet somehow emotions are conveyed and evoked. The nature of speaking to strangers who may or may not be conveying the truth, and where we know little about them except for what is posted, involves a lot of extrapolation and ambiguity. It is hard to judge the response of the audience or how far information will spread, and deceptive safe feeling that we are posting in our own homes and usually under pseudonyms, yet it can suddenly become very personal and intrusive. On the clinpsy forum we monitor usage quite closely, and have zero tolerance of personal abuse or inappropriate content. In order to avoid knee-jerk responses or being hooked into unhelpful patterns, and to help us keep on top of maintenance and development tasks on the clinpsy forum, we work as a team. We keep a log of moderator discussions, user reports of concerns and reasons for banning users in a hidden moderators area on the forum. We tend to have quite a rapid response time for removing content for moderator consideration, and quite consistent views about where to draw the line, which has made clinpsy relatively drama free.

That isn’t the case on other forums, where much more banter and jokes are let fly, and these can be quite offensive, particularly if the dominant demographic is young white men. Racism, sexism and misogyny are quite prevalent in some online communities. Many women hide their gender to avoid quips about getting back in the kitchen, or banter about rape (which can be a term used in video gaming communities to refer to trouncing another player). But in some places it can even go a step further than that. 4chan, for example, used to ask for topless photos if anyone mentioned being female with the delightful phrasing “tits or GTFO”, and provoked many young women (at least one of whom appeared to be below the age of consent) to share sexually explicit images of themselves. 4chan also had links to child pornography (although I believe that this was eventually prohibited and split off onto another forum). Reddit has subreddits for misogynist men’s rights activists, pick-up artists, and incels (men who consider themselves to be involuntarily celibate – that is, they are too unpleasant to attract consenting female partners but do not recognise this, and turn the blame onto the women instead, with extreme examples like Elliot Rogers and the man behind the recent Toronto van attack), although again some attempts at prohibition and moderation are creeping in after bad publicity following the recent school shooting.

As a female poster in some male-dominated communities it was initially quite a culture-shock, but it is good to socialise outside the same narrow bubble, and there are also very positive aspects of being part of an online community. There is a hive mind of information on every topic that means you can gain immediate and often highly skilled advice on everything from how to rewire a light fitting, or how to distinguish a wasp from a mortar bee, to which model of television has the best features within a certain price bracket, or how to complain if a parcel doesn’t arrive. The community might be a rapid source of news, or entertaining new memes. There can be reviews of films, music, events or games that lead you to try new things, and erudite discussion about politics, current affairs, history, different cultures, religion, sports, science, religion, mental health, relationships and any topic that takes your interest. There can also be mutual concern and support when things are not going well, and shared delight when people experience unexpected success. So there are definite positives. The problem is that they can come at a price, and some people are more likely to pay the price than others.

Anyone who has been part of an online community knows about how they seem to inevitably create remarkable interpersonal dramas. These are like road traffic accidents – as a neutral spectator they both repulse you and make compulsive viewing, but as a participant they have the ability to cause genuine harm. When a person starts posting erratically or there is public conflict, or even when a person or group is bullying a vulnerable member if they do so in a way that is seem as amusing, it is viewed as entertainment or public spectacle. And, like a fight in a school playground, they inevitably attract a circle of spectators who both encourage and influence the unfolding drama, both joining in to sub-conflicts in the audience, and throwing in more fuel if it seems to be petering out. I’ve been in that circle a few times for different reasons, and it isn’t a fun experience. And as it starts feeling more personal and more antagonistic emotions start showing in how you post, and that seems to fuel the aggressor to go in for the kill, and other posters to join in. Our ability to reason and to predict the way that others will interpret and react to our posts reduces, and the stakes start to feel higher, and yet it somehow becomes harder to leave the conversation whilst feeling threatened or misunderstood. So you get drawn in to the battle, trying to clarify your intended meaning, defend yourself from perceived attack, or persuade others to see your point of view. Perhaps you criticise the other person, who then becomes more antagonistic or defensive. By the time you are in the thick of things there isn’t an obvious exit without either victory or shame.

Walking away from an online community because you don’t like how you are treated feels a lot like social exclusion and can have a significant impact on your sense of self, but to stay once you have attracted negative attention can mean the slow attrition of insults and snide digs that someone once described as “death by a thousand paper cuts” (a less severe/more protracted version of the Chinese torture method death by a thousand cuts, in which it is hard to criticise any individual action as being unduly aggressive or breaking any rules). Frustratingly these can often be the kind of microaggressions that align with real life experiences reflecting the casual degradation of disempowered/minority groups. And, as ever, women and minority groups seem to be disproportionately the target for them. Even a phrase like “calm down love” is loaded with patronising layers of meaning about women being ruled by their emotions and lacking the calm logical analysis of men. It implies that caring about anything enough to show some emotion about it is already losing the battle.

There is little time for compassion or reflection online, and it is hard for an onlooker to intervene in a way that is helpful to diffuse conflict. Thus vulnerable people may end up re-victimised, and people with dysfunctional ways of relating often play these out over and over online. I can particularly recall one poster who had a distinct cycle of debate, feeling criticised, rage and then burning out to a final phase of being shamed and apologetic, trying to make amends to avoid rejection – and the community becoming increasingly intolerant of these emotional extremes. At times it felt like observing a digital version of a disorganised attachment relationship, with the forum community functioning as the inconsistent/abusive parent. It came as no surprise to read disclosures about an abusive childhood, use of crisis mental health services and a personality disorder diagnosis. But s/he was far from alone in having dysfunctional ways of relating to others online. In fact it seems that many people with such difficulties are strongly attracted to the accessibility and 24 hour nature of online communication, and can find significant support from strangers there. But it often comes at a high cost, or with significant risk, because of the prevalence of trolls and the way dramas are amplified by having an audience, and the way social media can serve as a written record of whatever unfolds that is hard to erase. There might be the right to be forgotten under GDPR, but how does this actually work in practise when comments are quoted and replied to, or captured in screenshots and posted elsewhere?

There are plenty of examples of how vulnerable people are enticed by the sense of belonging in a group, or the superficial success of social media influencers, but harmed by the messages they are given. This can range from unhealthy roles models such as the one I blogged about previously to being encouraged to harm others or given advice on how to harm themselves or commit suicide (the Daily Mail recently ran a scare piece on a “Blue Whale” game that culminates in telling children to commit suicide, though snopes felt there was little evidence to substantiate this). It would seem to me that the bigger concern is the indoctrination of larger numbers of young, socially isolated people in toxic beliefs such as alt-right ideologies, through writing that blames others for their ills. Whether it is “psychologist” Jordan B Peterson whose 12 rules for life serve as an introduction to his regressive beliefs including “enforced monogamy” in which he appears to advocate that to prevent male violence women should be allocated to partners and forced to remain monogamous to them (which is rightly being called out as sexist/stupid/victim blaming). It might have sold 1.1 million copies, and he might make £80k/month in patronage, but this isn’t a new enlightenment. Enticing simplistic sexist answers are not the cure for angry young men who feel left behind by progress, I would argue they are the very fuel that will convert them into the school shooters, rapists and perpetrators of future violence and harassment. But it is hard to offer up an alternative perspective or contradictory evidence when an angry mob descends on any divergent opinion, claiming that they are the true victims and that the sexist/racist drivel they promote is being censored by sensitive snowflakes (the new version of “its political correctness gone mad”). Ironically, these repugnant views that are allegedly suppressed/unspeakable are getting lots of airtime, whilst stifling free expression of opposing/alternative views** as progressive voices fear becoming a target of the mob.

In short, its a messy and unregulated space, and there are both interpersonal conflicts and large scale culture wars playing out in it. How to protect people in a digital age needs a lot more thought, both at the level of educating children about critical thinking and empathy, and in terms of regulation of social media, and enforcement of crimes committed via digital media. But with middle aged and older politicians doing the legislating it is hard to see how that is going to happen.

*if you find this surprising, consider the bug chasing community, who are people actively seeking HIV infection in order to gain care, sympathy and a sense of belonging
**including me, as I avoid using certain terms on social media or in the tags and category labels for this blog, as I dislike the surge of abusive/antifeminist responses they trigger