experience

Wisdom and reflection

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

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

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

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

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

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

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

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

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

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

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

All change!

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

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

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

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

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

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

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

Confessions of a workaholic

Hi, I’m Miriam. I’m a workaholic.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Slow burn: Reflecting on the emotional impact of working with chronic trauma*

*This post contains vignettes of harrowing material which may upset some readers. Case examples are all anonymised.

When I decided to do work in child protection, people warned me it was the fast road to burnout. Twenty years later I think they are right about the direction, if not about the speed.

Burnout is an insidious thing. It sneaks up on you as a chronic accumulation of many tiny things, rather than having an obvious trigger, like a single life threatening event that causes PTSD. A thousand small examples of vicarious traumatisation. Experiences that I shouldn’t complain about as I’ve chosen a career that inevitably brings exposure to distress and tragedy. It feels like I’ve chosen to wade through the grottiest parts of life, until I’m normed on that 1% of stories that cause the most concern. It saturates me. Pollutes my perceptions of life. It has been building up for a long time.

Fifteen years ago my two specialist placements included post abuse work with survivors of sexual abuse, a group for non-abusing parents of children who had been sexually abused and work with “complex” children and families, such as those on the child protection register. I knew it was emotionally harrowing work then. I talked about it with a good friend, and concluded that my drive was to go where I was most needed, to grapple with the most complex cases, and that I’d worry about burnout when I got there. I graduated onto a clinic for children who were “failing to thrive” and most of my clinical time being with children in care and therapeutic work with those who had experienced trauma or maltreatment. Right from the start, it was an induction of fire, salved only by the fact that it was important work that needed to be done.

It started with individual stories.

The sad silent child who ate 7 digestive biscuits and carefully stowed extras in his pockets during clinic, but whose parents claimed he had a digestive disorder that meant he wasn’t gaining weight despite eating plenty.

The young woman with learning disabilities who repeatedly played out how the daddy bear lay on top of the baby bear and thrust, but said baby bear was a liar and nobody believed her when she told.

The adult relatives who revealed at the last moment the sadistic physical and sexual abuse that their step-father inflicted, after he had charmed the professionals enough to get residence of his grand children, when their mother was unable to cope and had reverted to chronic drug use.

The maps of children’s bodies in medical notes, used for annotating injuries, including one for babies. The paediatricians sharing photographs of torn orifices, injuries, malnourishment and legs with rickets. “This one has burns on their hands up to a straight line on their arms, showing they were held in boiling water as a punishment”. No, I don’t want to see, thanks.

The little girl in a religious cult who couldn’t disclose her abuser as she had been taught it was as bad to think or speak badly of others as what they had done, and shown pictures of people rotting in the ground or burning in hell for their sins.

The boy who was conceived through rape, whose mother couldn’t look at him, and whose grandmother thought any challenging behaviour showed he was “living up to his genes”.

A girl asking how she got the zigzag scar on her stomach. The family didn’t want to tell her about how her mother tried to cut her open to let the devil out during a puerperal psychosis. They don’t want to spoil the relationship as she goes to Mum for alternate weekends. When I meet Mum she talks incoherently about spirits and auras, telling me she likes climbing on the roof to be nearer to God. She has no need of adult mental health services, thanks.

The young woman who always claims to be pregnant by her current partner. He is less likely to harm her that way. She is couch surfing at the moment, which is the new name for homeless. Her only possession is a photograph of her son who was removed at birth and adopted. After physical and sexual abuse at home, and attempts to stay with numerous relatives, she grew up in care. She had a sexual relationship with her male carer at 14 which she views as consensual.

Since 2000 I have done expert witness work for the family courts. That means reading bundles of documents about trauma, child abuse, neglect, loss, violence, family breakdowns and mental health problems. It means speaking to parents who have been maltreated in their own lives, lack coping resources and instead of being able to create healthy relationships and flourish have limped from one bad experience to another. It involves speaking to children who have seen too much, had to cope with awful things and missed out on the love and nurture that you’d want every child to take for granted. I read about and sometimes see the state of the home, with rubbish heaped up and rotting, flies circling, dirty nappies on the floor, no clean clothing, nowhere to store possessions and no space that isn’t filled with clutter. I hear about broken bones, bruises, burns, rapes and assaults. Sometimes there are x-rays, photographs or medical records. I see sadness and anger accumulated over many years of getting a raw deal. I measure problems with learning, attention, behaviour, life skills, self-esteem and mental health. I observe who denies the problems, who spills over with them, and who recognises themselves doing as they were done by despite all their best intentions otherwise.

I read, and I listen. I measure and observe. I pull the pieces together to see what fits and what conflicts. It is an active process, trying to understand what happened, how and why. Evaluating insight and future risks. A computer couldn’t be programmed to do this. It takes empathy, curiosity, critical thinking and detective skills. I am the barometer of relationships, of what would feel okay, of what is causing harm. If I felt nothing, I couldn’t do the job. But there is so much pain to feel. So many sad stories.

A little girl with curly dark blond hair who the foster carer told me “shook with excitement to get her own dolly for the first time and promised to keep it pristine so that when mummy gives it to her little sister she will still think it is new”. I nod politely. Take verbatim notes. I have to stop the car on the way home for a cry.

A teenage boy tells me how his father often pinned him up against the wall by his neck or beat him with a belt. He wonders why he dissociates when he perceives threat or criticism now and worries that he is going mad. I try to explain his brain learnt to protect him when nothing else could.

I observe the baby that was rescued from the fire. Her scars are healing slowly, and the medical treatments are painful. She can’t bear to be touched. There is too much pain for someone so young.

A mother tells me how it hurts her watching the foster carer do a better job than she was able to at caring for her children. “I always swore I’d be different to my mum, make better choices of partner than she did, keep my kids safe from harm. I look at where we are now and see it has happened all over again and I can’t bear it”. And neither can I.

A teenage girl tells me she took the overdose because her step-dad broke the door down and overturned the bed to reach where she and her mother were hiding, and hit her mother repeatedly with the broken bed leg. She shrugs and smiles, and says “its just how it is, you know”. I don’t know. But trying to imagine it makes my guts curl and my eyes leak involuntarily.

A mother tells me about the culture she grew up in, and how grateful she is to be here, even though the whole family live in a single room in slum conditions, and it is hard to find work as an illegal immigrant. If her son is hungry, developmentally delayed, and being beaten for misbehaviour at least he is safe. I think that isn’t safe. It is all relative.

A father tells me that his uncle sexually abused him as a young boy, but there was too much stigma to tell anyone and he was afraid to lose this special relationship. He still spends time with his uncle now, and trusts him implicitly with his own children. A few sentences later he says he is baffled why the children are showing sexualised behaviour. I am baffled that other people can’t see how obviously the pieces fit together.

I assess a couple that smell so bad I struggle not to gag. I open the windows but it is not enough. I go out for air every hour. A social worker sprays perfume on my sleeve so I can raise it to my face to mask the smell. I learn the phrase “body odour to an extent causing discomfort to anyone in the proximity”. They don’t own toothbrushes and show me teeth rotting in swollen gums.

A woman tells me she has put on 9 stone as she needs to have fat deeper than the knife blade is long, since she was stabbed by her ex-partner. She wheezes for a long time after climbing the stairs at the contact centre, and she struggles to get down on the floor to play with the baby. I worry when she is slower than expected to return from the toilet, do I need to check if she is okay?

The child was born with HIV. His mother died of it. He lives with his grandmother. She doubts the diagnosis. “He doesn’t look ill, the English doctors don’t know about us”, she says when I ask why his prescriptions have not been collected.

A lady tells me that she must have had post natal depression. If she wasn’t ill she would keep the house clean, but when she is ill she can hardly get out of bed, and gets ideas that the world is very unsafe. That is why she kept the children in her bed with her, rather than sending them to school, until they were no longer able to walk. She’s on antidepressants now, and saw a counsellor for six sessions, so everything will be fine. The social workers are making a fuss about nothing.

A man tells me he has exercised to pass the time whilst in prison. He is proud that he is bigger and tougher than his father now. He says the robbery was the fault of the friends who bought him the beer and suggested the idea, and much exaggerated by the victim. I am glad I brought with a student to observe, as the room is quite isolated and his body language makes me tense.

This couple have managed to sustain the acrimony of their separation for five years. She says he was controlling, violent and obsessive about having every last penny accounted for. She tolerated his promiscuity for far too long. He says she was moody and manipulative, and it is probably her mental health that’s the problem, and her jealousy that he moved onto another relationship. It makes me cross that both of them seem to have forgotten the kids in the middle of their conflict.

A little boy tells me what it felt like to be buggered. I try not to think about it that night in bed. I play tetris on my phone until I fall asleep at 4am.

A woman tells me that all of her relationships have been with men who present a sexual risk with children. They are all so different, she says, that whenever she learns what to avoid the next one is nothing like it. And why wouldn’t you move in with someone you’ve just met? How else do you get somewhere to live after the last relationship has turned sour?

The story stems of a girl of eight show the family repeatedly pushing the girl off a cliff and laughing at her. For variation they poison her and laugh as she vomits. She repeats the loop for 90 minutes, then returns to lying foetal under the table as I leave, just as she was when I arrived.

“I had a cold, mum caught it, and it made her sick so she fell down the stairs” says the boy with autism. “That is why she had to go to hospital”. It wasn’t the head injuries her partner caused, it was his fault. But later in the conversation “Daddy gets out of prison soon. When he finds us he will kill us this time”. It is deadpan. An emotionless fact of life.

The girl in the children’s ward tells me “I didn’t want to go home. I jumped off the bridge because it would be better to be dead. They say I will need to be in hospital at least six weeks whilst my leg heals”. She smiles showing me the metal cage and all the pins reassembling her bones, and counts the pieces in the x-ray. She won’t say what is wrong at home.

“He spat right in my face and pushed me over. I was so angry then. I hit him with the lamp until it broke, then I whipped him with the cable. I could see the shape of the switch in the bruises when I was done. They might have seen it, but that’s not the same. I’d never hurt the children.”

A boy tells me what is different in foster care. “It was the best day ever. We went to the garden centre. I got to look at the fish, and we had a drink and a slice of cake at the cafe. We eat at the table with the grown ups here. I got my own coat too, nobody wore it before me! And my skin is better”. The carers tell me that they had to wash the grime off the bath after he arrived, replace all his clothes and do twice daily treatments of his infected eczema. They had to get a court order to shave off his matted hair as his parents would not give consent.

A five year old girl tells me about the day she came into care. “I could hear they had fish and chips in the front room. I could smell it. I tried to walk there, but my legs weren’t working and I kept falling over”. The medical records show that a visitor called an ambulance when they saw her unconscious and malnourished. Her blood test results are marked with blue biro. Haemoglobin is captioned “how is she alive?”. She dances when she shows me the foster carers have a rabbit run in the garden.

In each family I hear many of these stories from each individual, and I see several families each month for assessment. I’ve been doing this for over a decade now. I have banked hundreds of such narratives, maybe a thousand. All involve a child or children being harmed. The stories are each unique, but the themes recur. James blurs into Joshua and Jared and Jacob. Samira merges with Samantha and Saskia and Sasha. Depression and anxiety, broken bones and bruises, filth and mayhem, conflict and violence, cancer, obesity and sensory impairment, neglect and abuse heap up in my repertoire of human experience and leak out into my life. I see those stories lurking at the edge of my vision, in the arguments partially overheard in the shops, or behind the headlines in the news. I see their echoes amongst people that I know; my neighbours and colleagues and friends.

I set myself impossible standards. I worry if my child has messy hair when she gets back from school, or I notice mud under her fingernails. Will people think we aren’t taking proper care of them? Are we not taking proper care of them? We go to A&E after my daughter burns her hand. I ask her to tell the story before I speak and she says “it was your fault mummy, it was your drink that tipped over”. I feel like a failure and a hypocrite. My cat has a jaw infection and needs teeth removed and antibiotics. I should have known. He smells like the couple I assessed at the social work centre last year.

I say we need to leave the restaurant. I can hear a mother saying “ungrateful brat, I should never have had you” to her son. Outside the school a mother pushing a baby in a pram says to her friend “look at him giving me evils, he’s going to be just like his father”. I walk away. The couple outside the pub argue incoherently and their voices get louder and shriller as we walk back to our car after a night out. The child in the park approaches me and asks me to push him on the swings. People on the internet disclose abuse. In the supermarket I hear a slap and the child is crying. The woman walks past on the street with a fading black eye. They are anonymous and legion. The scale of the problem is overwhelming. I can do nothing.

Friends of friends ask for advice as they have heard I am a psychologist. Its important to try to point people in the right direction, but I am depleted. Another 2 lever arch files arrive at work. Its an incest case and mother is terminally ill. Surely there can be no more stories this bad, but there is a queue awaiting my attention. The next one has police transcripts of the interviews of all of Dad’s victims. He might be a paedophile but his daughter wants to see him anyway. The one after that they want me to see Dad whilst he is in prison for abducting the children to a different country. He believes it is his right; fathers own children in his culture. Then back to the bread and butter of court work, another family where neglect and maltreatment has been the norm through many generations. One of the children is the same age and gender as one of mine. Don’t make comparisons. Don’t go there. Change the subject.

A letter from a solicitor tells me that my invoice has been reduced by the Legal Aid Agency on appraisal. I will get £400 less than the total billed, despite not billing for 6 hours work already because of the fee caps. The hours were “not proportionate”. Do I explain again that it takes longer to do assessments via a translator? I don’t have the energy. Another one is querying the hourly rate. I should work for £7 less if I only see the adults as I won’t be a child psychologist. I ask if a psychiatrist gets paid the rate for a psychotherapist if they don’t diagnose or prescribe. The solicitor is sympathetic but says there is nothing they can do. A father doesn’t attend an appointment that is booked to fill a whole day. I have driven 2 hours to get here, and I wait for an hour whilst phone calls are made, then drive 2 hours home, exhausted. I can do nothing else with my day. Legal Aid say a psychologist can fill their time productively with other activities and refuse to pay anything over travel costs, even though the contract says that they will pay for any appointment cancelled with less than 72 hours notice. I can’t bill for materials, venues or typing. The questionnaires cost an average of £5.31 each. I used 6 per child and there were 7 children in the family. Does it add enough to my report to justify £220 of lost income? The LAA ask what ‘capacity’ is and why it took me 4 hours to assess it. Is it not embarrassing to work for the family court system and not to know this or to have the sense to Google? The self-funding father who was supposed to have lodged the cost of the report with his solicitor hasn’t. He now wants to pay in monthly instalments, but my staff get paid next week. I have to turn away two cases a day after reading about the plight of the children, because I am booked up too far ahead. The wealthy mother from abroad hasn’t paid her share of the bill from 4 months ago, but the court wants me to do more work for her case. There are 16 follow-up questions from the report I filed last week. Why do I do this again?

Tomorrow is the appointment to assess the teenage mother in the mother and baby unit. Yesterday her boyfriend told me about how they met online, and gave me their usernames. Google shows me his dating site entries seeking single mothers, Facebook posts about the violence in their relationship and a video of the baby’s “sexy dance”. A solicitor phones. Can I squeeze in one extra case this month? Mother has been evicted. She doesn’t want to see her child and is too anxious to talk to her lawyers. Could I fit the capacity assessment in this week? I get an email to my personal account. My builder’s sister’s son is feeling suicidal. I reply with the phone numbers for the Samaritans and the local crisis service. I watch the news story about the children in the refugee camp and am horrified to find I feel nothing. I have reached compassion fatigue. I turn off my phone and computer and go back to bed.

I am empty. My emotional resources have run out. Is this constant aching tiredness what they call burnout? I run on clockwork. I am a robot Mum and a robot wife. I fall asleep on the sofa. I am exhausted. At night when I finally fall to sleep I dream about children with their eyes sewn shut. I can’t save them all. When I wake I go to work and do it all over again. I’m good at this. It is important. It is needed. It is never ending.

Then I pause and take a few weeks off for a family holiday. Soon after we arrive the bubble of numbness bursts. I cry watching a video on Youtube. It segues into crying for all the children I’ve met, and all the children someone like me never met or didn’t reach in time, including the parents I speak to so often. I cry with frustration at my own limited reach. I cry for the selfishness of politicians, the broken systems and missing safety nets. I despair at how you increasingly need money to buy justice, and how hopeless and disengaged wide tranches of society are becoming. I click to sign petitions. I donate to campaigns. I counsel compassion in online debates. But I am tired. Achingly tired. Tired in my bones and my guts and my heart. I know how much this needs to be done. And I don’t know what else I can do. But I can’t do this any more.