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.

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.

 

 

I am not a therapist

I’ve always been someone that likes to keep busy, and has a lot of ideas about places where psychological thinking can make a positive impact. The aspect of my character that I now identify as entrepreneurial and put to good use in my business has always led me to want to try new things and create innovative solutions to problems. I like a lot of things about being a clinical psychologist, and particularly our ability to turn our hand to multiple types and levels of work. However, unlike many other clinical psychologists, I don’t really see myself as a therapist. In fact, I haven’t seen more than a handful of clients for individual therapy over the last decade, and even before that it was a pretty small proportion of my qualified jobs. I’ve always had more of a focus on the other facets of being a clinical psychologist. I think the picture of a clinical psychologist as a therapist is so strong that a lot of people will now be wondering how I fill my time!

So I will answer that question: I have done loads of highly specialist assessments (of neurodevelopmental concerns, attachment, parenting capacity, mental health, life skills, self-esteem, wellbeing etc) and lots of formulating and report-writing – some in collaboration with psychiatric or medical colleagues or within a wider MDT, but more as an external expert or second opinion. I have advised the family courts as an expert in care proceedings and complex custody disputes, and completed numerous pre-court assessments for local authorities to help inform their care planning. I’ve managed teams and services, and supervised from 2-20 other staff at a time, along with sitting in various organisational/management structures. I have designed and delivered training to parents, carers and professionals, and I have done lots of consultancy to various organisations and professionals (mainly those providing health and social care services, or involved in the family courts), and help placement providers to improve their services. I design and deliver group programs (eg Managing behaviour with attachment in mind), but then rapidly cascade train other staff to continue to deliver them. I wrote a book about attachment/developmental trauma, and lots of papers and policy documents about Looked After children, and acting as an expert witness to the family court. I sat on a BPS committee and I contributed to NICE and SCIE guidelines. I’ve designed, managed and evaluated therapy services (but employed others at lower bands to deliver the therapy). I’ve been an expert advisor to the HCPC in a fitness to practice case and to the team investigating a death in public care. I’ve done loads of practice-led research about each client group I’ve worked with, from looking at the psychological and health economic impacts of offering brief therapy to hospital users with diabetes, to commissioned evaluations of other services. So I have plenty to fill my days despite not having a therapy caseload!

I have reflected on why it is that I don’t feel drawn to therapy, and reached the conclusion that, whilst I see it as a very worthwhile endeavour, I don’t really have the patience for resolving difficulties one person at a time over sessions spanning many months. I’m always more interested in grappling with the bigger questions of why people are in distress, and what we can do to most effectively prevent or ameliorate those difficulties. When I’ve solved the riddle (or at least, reached a plan that improves upon existing solutions) I like to evaluate its efficacy, modify it if necessary and then disseminate the learning and/or train others to replicate the solution. I try to step outwards from the individual issue to the broader themes and ways that we can intervene on a wider scale. To use a visual metaphor, if dealing with mental health problems is like bailing out a ship, then rather than scooping out water one cup at a time, I am trying to work out how to plug the leaks, and to design boats that won’t have the same vulnerabilities to leakage in the future. It also helps me to avoid feeling hopeless about factors outside my control and demand exceeding supply, or burned out by an accumulation of traumatic stories.

Jenny Taylor, a past chair of the Division of Clinical Psychology, once described our profession as the structural engineers of the therapy world. Unlike a therapist trained in a single modality of therapy, we can survey the landscape and assess the need, then design the intervention that best meets that need – even if we are not always best placed to deliver it. We can base that recommendation on our knowledge of the current evidence base, which can change as new information comes to light.  If we consider the challenges people face as a river they need to cross, a therapist trained in a single model of therapy might be a bridge-maker. A psychodynamic therapist might be a mason who can build traditional stone bridges and claims that this design best stands the test of time. A CBT therapist might be a carpenter with a set of designs for wooden arched bridges that he claims are cheaper and quicker to erect. Each sees their own skill as either suitable to solve the challenge or not, but also has some incentive to sustain their own livelihood by continuing their tradition. A clinical psychologist can survey the land either side of the river, the span length required to cross it, and the materials available in the locality. They can then advise on the various options, including the relative costs and the evidence of how they fare in different conditions. They may or may not feel that bridge required is within their own skill-set to erect, but have a reasonable overview of other bridgebuilders in the area to recommend. If new designs of metal suspension bridges are developed, this is not threatening to the structural engineer, who can adjust their recommendations to incorporate the emerging evidence base.

I really like this metaphor and strongly identify with the role of structural engineer rather than bridgebuilder. I had always thought that this was instilled in me by my first graduate job, where I was an assistant psychologist on a research project about improving quality of life in residential care homes for older people, and I could see how the research and clinical work were closely tied together and built on each other reciprocally. But now I think my love of data and the scientific method runs deeper than that and I can see it infused throughout my whole approach to life since childhood. When it comes to my work I am a scientist practitioner down to my bones, as I always collect data as I go along. Where I don’t feel like I understand the situation well enough, I first look to the literature and then to gathering data and doing my own analysis to try to gain insight. When I develop something new to try, wherever possible I try to evaluate what we are doing, and refine it through an iterative process until we can prove maximum efficacy. I see that process as being part of the USP of a clinical psychologist – that we think like scientists and gather data to inform our interventions.

But I’m not sure that we communicate this mindset well enough, or that it is universal amongst the profession. It certainly isn’t what draws people into the profession in my experience. Too many clinical course application forms I review could be paraphrased as “I want to learn to be a good therapist” with an afterthought of “and do/use research” because they think that is what selectors want to hear – but in my view therapy can be done by lots of cheaper professionals, who might do an equally if not better job of it. I believe that clinical psychologists should be more than well paid therapists. We should know the evidence base and be able to take on the most complex assessments and formulations (even if others then deliver part or all of the treatment) but also to be able to develop, refine and evaluate novel therapeutic interventions, supervise other staff, improve services, consult, train and manage – things that extend beyond the skillset of most therapists. I’m sure it is clear by now that this is where my own interests lie. And I think it shows through in everything I do.

For example, when I was asked to lead the CAMHS service providing neurodevelopmental assessments I started with a literature review and current policy and best practice guidance. I then conducted an audit of the existing pathways, then tried to make things better. We set up a new clinic system with more rapid throughput and more thorough assessments, and then re-audited showing a reduction from an average of 18 months of input to five, with increased clinician confidence in the service and higher client satisfaction. I also wrote a booklet to help provide the information to parents whose child received a diagnosis of an Autistic Spectrum Condition. Although it required dedicated clinician time for the multi-disciplinary clinic and for the psychometric assessments generated, overall the new pathway freed up capacity because less cases were being held open by other clinicians whilst waiting for assessment, or kept open for prolonged periods afterwards to help the family understand the diagnosis and connect up to local sources of support.  I also sat on a multiagency strategy group to look at establishing best practice standards for the county.

I had the same approach when I was asked to support the adoption and permanence service. I initially set up a consultancy clinic, where social workers could bring cases to discuss or book in families to see jointly. I found that I was explaining similar information about attachment, trauma and neuroscience to multiple professionals, parents and carers in the consultations. So I designed a group to share this content. I called it “Managing Behaviour with Attachment in Mind”, and developed some “doodles” I would draw on flipchart paper to explain the concepts more accessibly. I evaluated the impact and showed it to be an effective format for supporting parents in this situation. The groups were popular and over-subscribed, so I trained others to deliver the group to keep up with demand, first in my service and then more widely. Many people in the groups liked to photograph the doodles to remind them of the topic, so I decided to write a book to share them and Attachment: In Common Sense and Doodles was born.

But I also wanted to know about how we could achieve permanence for more children. I started by looking at the literature about what makes effective adoptive matches. Very little information was available, so I systematically audited the paperwork from 116 adoptive matches and followed them up over 7 years to see what factors influenced the placement outcomes. I was able to look at whether the innovative adoption project to place children with more complex needs had better or worse outcomes, and was able to explore the impact of different motivations for adopting. Whilst to me this was just a natural process of answering the question as an evidence based practitioner, it transpired that these studies of adoption risk and resilience factors were amongst the largest ever done, and I have discovered unique findings that I really should publish*.

You could argue that I was using a sledgehammer to crack a nut by doing all this research and trying to change process when organisations are notoriously slow to change, and that I could have spent my time more productively working with more individual adoptive families. But that’s not how I’d see it. The research I did helped me to understand what the key variables are when considering whether a child can achieve permanence, what kind of family we need to look for to place them successfully, and what kinds of support might ensure that the placement succeeds. I hope that I have fed that knowledge back through my court work, and into various organisational and policy work over the last decade. I have also disseminated it at conferences. However, I would still like to spread it further, because it is my belief that such knowledge can have positive impact at multiple levels – it can help to inform individual placement decisions, service-wide strategies for helping optimal numbers of children to access permanence, and national policy about adoption.

That work led naturally on to developing our services for Looked After Children when I left the NHS and set up my own company, LifePsychol Ltd. We provide training and consulting to foster carers and residential care staff, the social care organisations that support them, and the wider professional networks surrounding them, including education and health staff, police, lawyers, magistrates and judges. As I started to get more immersed in working with children in and on the edge of Care, it led me to recognise that there was a lack of validated and reliable tools to identify the needs in these populations, no outcome measurement tools that could reliably measure change over time in a way that was sensitive to the context and type of life events these young people experience, and a dearth of clinical governance in terms of the efficacy of both placements and interventions for this group of children. That seemed shocking to me, given their highly complex needs, and massively elevated incidence of mental health problems, challenging behaviour, risk to self and others, and prevalence of intellectual or neurodevelopmental difficulties.

As well as the human cost of not being able to identify the best choices for people, it seemed unacceptable that huge amounts of money were being spent on placements and specialist services for this group without any evidence of them changing their wellbeing or life course for the better. Placements seemed to struggle to identify what to work on and how, and there was little objective indication of what defined a successful placement, beyond annual visits from Ofsted (who were predominantly focused on process and procedure). The high level of need and the lack of clinical governance in the sector has allowed various specialist therapists and services to spring up that are virtually unregulated, and many placements have adopted terms like “therapeutic” without these having a consistent definition or meaning. So I wanted to see whether I could make any headway in changing that.

Meanwhile there is pressure from the government to improve outcomes for children in public Care, because they are seen to fare badly compared to the general population of children the same age. The difficulty is that this isn’t comparing like for like – children in care have many more adversities to face, both organic and in terms of their life experiences, that mean they often deviate from the norm. For example, I found that there was a 20 point skew downwards in IQ distribution in children in residential care compared to population norms, meaning that 20-25% of children in this setting had a learning disability, compared to 2% in the general population. Likewise the incidence of Autistic Spectrum Conditions and other neurodevelopmental difficulties amongst children in Care is more than triple that in the wider population. The same is true of young offenders. If we don’t acknowledge that, then the sector is being asked to seek impossible goals and will inevitably be seen as failing, even if placements and services are performing optimally and adding a lot of value to the lives of the children they work with.

To state the obvious, children in care are not just randomly drawn from the population – by definition their needs have not been met, and this can mean both the presence of additional challenges and exposure to harm or deficits in care. I believe that to look at the needs of this population and the degree to which these are met by placements or interventions, we need to either compare them to carefully matched controls or ensure that outcomes are always considered relative to baseline. The latter seems more pragmatic. Scores for young people also need to be considered in the context of what is going on in their lives – as changes in placement, daily routine, contact arrangements, or the arrival or departure of other children from the home can make big impacts on the child’s functioning.

So I’ve been beavering away exploring these issues and developing systems to measure needs and make the data meaningful for those providing care and services. The impact might not be as obvious as delivering psychological therapy directly, but I’d like to think that over time it can improve services for thousands (or even tens of thousands) of children, and make a greater net change in the world.

 

*Maybe I’ll write more about this in a future blog. But the short version is that I have been trying to secure some funding to complete the statistical analysis and disseminate this information, and would still like to do so, so if you have any ideas or useful connections to assist with this please let me know. Failing that I hope I’ll find enough time to write a book on making better adoptive matches at some point in the future.

Well-being check-ups

Two of my cats are geniuses. They have worked out how to open the cat flap inwards when it is set to only allow them to come in and not to go out. The other cat is either even more of a genius and has been able to hide his skills from me better, or isn’t motivated to go out into the cold at night, or isn’t as smart as his brothers*. I am yet to work it out. But either way a cat should not be able to “hack” an expensive cat flap fancy enough to recognise their microchips, so I phoned the maker, Sure Petcare. They said that it is very unusual for a cat to work this out – so unusual in fact that they hand make an adaptation kit for the few customers that find this an issue, and would send one out, which they duly did. If that doesn’t work they will refund us, and we can buy a design with two point locking instead.

What was interesting was the figures they let slip in the telephone call. According to the member of staff I spoke to, it seems that five percent of cats can open their catflap when it is on the setting that is supposed to allow inward travel only. That is, if you have a smart cat who wants to go out, then it doesn’t work. When looking at their customer experience, one in twenty of their cat flaps doesn’t fulfil the functions they claim for it and has to be returned or replaced. Yet somehow they have decided that it isn’t worth modifying the design, despite this failure rate. So they are reliant on cats not working it out, and/or customers not complaining, and/or the cost of making and sending out the modifications for this smaller number of cat flaps being cheaper than the change to the manufacturing costs involved in solving the problem.

They aren’t alone in that. The Hotpoint/Indesit fridge that caused the Grenfell tower fire was a model known to have problems with blowing fuses, temperature control and noise at night. Other products by the same manufacturer, such as a particular model of tumble dryer, had been known to cause fires. But neither had been subject to a recall until after the tragedy at Grenfell. Likewise many models of cars have been found to have various safety problems, and the manufacturer seems to weigh up the adverse impact of the negative publicity and the cost of the preventative work, replacements or repairs and to compare this to the cost implications of not acting – it has only been since the larger financial impact of customers taking up legal compensation cases after deaths and serious injuries, and increased government fines for not acting on safety issues that the balance has tipped towards preventative action.

My car was recalled by the manufacturer a couple of months ago because of a fault with the ABS, which can overheat and fail in an emergency situation, so I took it in last week to be checked and modified. The modification was completed without event, but the VW dealership also provided a “free service check” of the rest of the vehicle. This identified two “red” repairs they felt were urgent or affected safety, and one “amber” issue with the brakes, and they suggested I should have all three repaired before leaving, at a cost of nearly £700. What they might not have known is that the car had passed its MOT with no recommendations for work less than three weeks previously, so I took it back to my trusted local garage for their opinion on this “urgent” work. The mechanic explained that the items identified were not necessary, let alone urgent (particularly on a nine year old, 100,000-miles-on-the-odometer car destined for the diesel scrappage scheme within the next year or two).

I’m not a car person really, so I mention it only because it seemed to me that VW (or that particular dealership) had decided to offset the cost of the recall to check the ABS, by identifying other potential sources of work they could undertake and presenting minor issues in a way that appeared more serious or urgent than they really were. In that way, garages are pretty shameless about creating work for themselves, and from the start they build in customer expectations of maintenance and additional expenses. We accept the idea that safe operation of vehicles requires periodic checks and repairs, and we need to take them in for regular servicing because certain parts have a limited lifespan, and don’t see that as indicative of the original product being defective.

You would think this is even more true in healthcare, given that so many conditions can be prevented or treated simply if identified very early, saving pain and trauma for the individual whilst also saving cash to the public purse. It isn’t impossible to deliver, as this type of model is used in dentistry – we attend for periodic preventive checks and expect to need maintenance from time to time. Likewise we expect to need regular eye tests and to update our glasses. And we get letters reminding us to come for flu jabs or smear tests from the GP. But it isn’t applied to our general health and wellbeing. In fact my health had deteriorated quite significantly before I was assertive about requesting the tests that showed I was anemic, severely vitamin D deficient, had blood pressure high enough to be risky and an abnormal ECG. And the only context where there are screening and preventative measures for mental health that I can think of are during pregnancy and the occupational health checks when applying for a new job. However, there is a massive incidence of mental health problems and it has huge impact on people’s lives, the lives of those around them, and their ability to engage in education and employment, with knock on effects on physical health, social engagement, work, relationships and parenting.

When thinking about mental health and therapeutic interventions, we could probably learn from the maintenance model of dentists (or the regular intervals of car servicing) that keep an overview of how things are going, give preventive advice and identify the need for more in depth work. It would also take away the stigma of talking about mental health if it was something universally considered at regular intervals. Of course it will never happen, at least not under this government which is trying to strip away essential health and social care services, increase the wealth gap and the vulnerability of socially excluded groups, and blame individuals for the way they respond to experiences outside of their control. But it is nice to think now and again about what things could be like if we no longer worked within the constraints of austerity. And I’d like to have an annual well-being check up where someone with a mental health qualification starts by asking “so how are you feeling at the moment?” and actually cares about the answer.

 

*I’m not judging, I love all three of them equally.

Six degrees of separation

My brother, David Silver, is panning out to be one of the significant players in the world of artificial intelligence. His PhD topic was applying reinforcement learning to the oriental strategy game of Go, and he has gone on to be the lead researcher on AlphaGo at Google DeepMind. That is the program that last year beat the world champion human player and became the best computer player of Go. More recently AlphaZero has taught itself to play Go from scratch (AlphaGo started by learning from thousands of top level human games) and has also taught itself to play chess and shogi, all to unprecedented levels of excellence. It has been very exciting following his progress, and going to the premier of the documentary film about AlphaGo (which is a lovely human drama, even if you don’t know or care much about the technology, so do give it a watch on netflix/prime/google play/itunes if you get the chance).

It is no surprise to me that David has gone on to find a niche that is intellectually impressive, as he has always been a pretty smart guy and done exceptionally well in education (though reassuringly he isn’t all that practical, makes the same silly mistakes as the rest of us, and has remained quite down to earth). I’ve always been glad to be the older sibling, as I think it would have been difficult to follow in his footsteps. As it was, I could be proud of my relative achievements before he came along and beat them all! He has always had a very analytical mind and enjoys solving logical puzzles. I guess I do too in some ways, but I’m much more interested in how people work than complicated mathematical calculations, and how we can reduce suffering and help people recover from trauma, rather than pushing the boundaries of technology. We’ve chosen quite different career directions, but I think we still have quite similar underlying values and ethics.

Although I’m proud of him, I’m not mentioning my brother’s achievements to show off (after all, I can take no credit for them) but because they’ve given me cause for reflection. Firstly, it would be easy to feel inadequate by comparison. After all, he is making headlines and working on the frontiers of technology, whilst I’m just a clinician running a tiny company and have made relatively little impact to date. It would be easy to be jealous of the financial security, publications and plaudits that he has got. He has made the news all around the world, and even has a wikipedia page! But I think I’d find that spotlight uncomfortable, and I suspect I’d find his job pretty stressful, as well as finding all the maths and computing pretty boring and unfulfilling. So whilst there is plenty to admire, I don’t really envy him and wouldn’t want to swap places.

Secondly, and perhaps more interestingly in terms of this blog, it has made me think about what my goals are. Making the best possible AI to play Go is quite a narrow and specific goal, and within that he selected a specific methodology with reinforcement learning, and he has focused on that for the past decade, before looking at what other applications the same system might have. Yet in that same time period I’ve been pulled in many different directions. I’ve been an NHS CAMHS clinician and service manager. I’ve been an at home mum. I’ve helped to found a parenting charity. I’ve set up and evaluated a project to improve outcomes for diabetes patients. I’ve bid for grants. I’ve tried to help recruit psychologists and improve clinical services within a children’s home company. I’ve undertaken specialist assessments of complex cases. I’ve been an expert witness to the family courts. I’ve delivered training. I’ve run a small therapy service. I’ve conducted research. I’ve tried to influence policy, and sat on committees. I’ve written a book about how to care for children affected by poor attachments and trauma. And I’ve developed outcome measures. Most of the time I’ve done several of these things in parallel. It is hard to keep so many plate spinning, and means I have not been able to invest my full energy in the things I most want to do. I’ve also had hesitations about investing in entrepreneurial ideas, because of guilt about saying no to other stuff, or fear that it won’t pay off  that have taken a really long time to shake off.

Greg McKeown says in his brilliant articles for Harvard Business Review about ‘essentialism’, that success can bring on demands that cause you to diversify, and ultimately reduce your focus on your primary goal and cause failure, and that is exactly what I’ve experienced. It reminded me of a reflective exercise I did as a trainee on a workshop about creative methods, where I made an amoeba shape out of clay to represent the pulls I felt in different directions. The amoeba was a resonant image for me as it can’t spread too thin without losing its depth at the centre, and it can’t travel in two directions at once. Finding the right direction of travel and resisting other pulls on my time is something I am still working on 20 years later! It has been a growth curve to learn what to say ‘no’ to so that the company does not become overloaded or incoherent*. There are also other forces that influence what a small business can deliver – we have to do work that we are passionate about, uniquely skilled to deliver and that there is a market for. There is no point offering services that nobody wants to buy, or that other people can provide better, or that you are not enthusiastic about, so we need to stick to things that we can deliver brilliantly and build a positive reputation for. However, with the breadth of clinical psychology there will always be multiple demands and opportunities, and it is necessary to find a focus so that we have a single defined goal** in order to attain the most success.

I’ve taken time to refine my goal from “applying clinical psychology to complicated children and families facing adversity” (which is actually quite a broad remit, and includes a wide range of neurodevelopmental, mental health, physical health and social aspects of adversity, being applied to all sorts of different people) to “applying clinical psychology knowledge to improving services for Looked After and adopted children” to “using outcome measurement tools developed through my knowledge of clinical psychology with placement providers and commissioners to improve outcomes for Looked After and adopted children”. Likewise, it has taken me time to clear space in my head and in my diary, and to be in good enough physical health to give it sufficient time and energy. But I am finally able to dedicate the majority of my working time to making people aware of BERRI, doing the statistical analysis to validate and norm it, and supporting/training those who subscribe to it. I have secured an honorary research fellowship at UCL and some data analyst support, and a trainee from Leicester is making it the subject of her doctoral research, so I very much hope that 2018 will be the year that we publish a validation of the measure and methodology, and can then roll it out more widely. I believe that is my best chance to make a difference in the world – to improve the standards of care for children living outside of their family of origin by encouraging universal psychological screening, regular outcome measurement, and the ability to identify and track needs over time.

Finally, my brother’s achievements have given me pause for thought because him working at Google has made me feel a sense of being somehow distantly connected to silicon valley, and all the technological and entrepreneurial activity that goes on there. Suddenly the people who founded Google, Facebook and Tesla/SpaceX are no longer as abstract as Hollywood actors or international politicians, but are now three steps away in a technology game of six degrees of Kevin Bacon. It makes the world feel a little smaller and making an impact seem more possible, when your kid brother is connected (however peripherally) to the technology giants who are changing the world.

Alongside this, in my ImpactHub coaching peer group several people have gone on to make successful social businesses that have rapidly scaled and made an impact on the world. Proversity for example, have expanded massively into the digital education space. Old Spike Roastery & Change Please have expanded their coffee businesses that employ homeless people, and School Space have scaled up a project they started at the age of 17 to help their school rent out its premises out of hours into a thriving business that has generated £350,000 of income for participating schools. Code Club have partnered with the Raspberry Pi Foundation to teach children in 10,000 clubs in 125 countries all around the world to program computers. And Party for the People have made a competitor for TicketMaster or SeeTickets where the fees go to a good cause, and have set up arts spaces in old factory buildings.

In this context, it seems possible to dream big, to think that an idea could become a reality that has an impact on the world. So whilst my main vocation remains to bring the process of regular outcome measurement to services for Looked After Children (and that is making some really positive steps at the moment), I’ve started to work out how to make my back-burner project a reality. This one is a proper entrepreneurial idea in the digital space and tied in a little to my previous blog topic of the issue of how the public understand the evidence for different kinds of interventions. I’m hoping I can develop a pilot and then seek some investment, so watch this space as I’ll report back how it goes.

In the meanwhile, I still want to make some changes in my personal life. I’m generally feeling quite upbeat about the future at the moment, and I’ve sorted out the issues I mentioned in a prior blog about disappointment. We’ve also pulled in payment for many of the outstanding invoices, and the business is the best organised it has ever been. But after reviewing how I spend my time and who I interact with the most, I have become much more aware of my various different networks, and to what degree I feel able to express myself authentically within them. I am being a bit more thoughtful about my networks, both in real life (where I want to make greater efforts to meet like-minded people locally) and online, where I need to spend less time. I have realised that I haven’t been choosing the company I keep well enough, so I am trying to connect more  with those who are positive influences on my life, and to pull away from people who are a drain on my emotional resources. I am also choosing to engage more with people in the social entrepreneurial space. As Jim Rohn is much cited as saying “you are the average of the five people you most associate with” and hanging out with inspiring people allows us to be more creative and entrepreneurial ourselves.

So hopefully 2018 will be the year where I make a success of BERRI, complete the validation research and get some publications out. I’d also like to get a pilot of my entrepreneurial idea up and running. And in my personal life I’d like to get back to the gym, to get the planning permissions sorted out for my house, and most importantly to make more real life social connections with people who share my values. If I’m only a few degrees of separation from people who have achieved all of these things, then maybe I can too.

 

*I wrote more about developing my business model and setting up a social enterprise in clinical psychology forum number 273 in Sept 2015

**or failing that, a primary goal, secondary goal and fall-back plan, in ranked order of preference (with an awareness than only exceptional polymaths like Elon Musk can achieve in more than one area at the same time).

Trauma and the return of hope

I wanted to write something about the recent traumatic events including the Manchester arena bomb, the London Bridge incident, the Grenfell Tower fire. These are very painful and raw events that have been quite distressing to learn about, and I am aware that we still don’t have the full picture. I also wanted to touch on the reaction to these tragedies including the One Love concert, and to give my reaction to the election results. I hope it doesn’t seem disrespectful to connect the two, but to me they represent both the fear and sadness of recent events, and the compassion and hope that have followed them. I should warn you now that the second half of this blog is less psychological and more political than usual. That probably isn’t surprising when I am writing about the election, but I know that type of content is not for everyone so I’ve marked where you might want to skip to the end.

Barring 9/11 I can’t remember a month in my lifetime with more traumatic events. The Manchester bomb killed predominantly young people and parents, and felt very close to home for me. The idea that innocent young people and families going to a concert could be the target for terrorists was unbelievably horrific, and the ages of the victims made the story identify with people of all life stages around the country who could imagine it being their child, grandchild, sibling, friend or parent who was affected. This wasn’t some far away event in another country, where people speak another language or have different culture or appearance that can let us abstract the horror away from ourselves.

The impact of the explosion was felt in ripples that spread far wider than just those who tragically died or were injured in the blast, to those who lost friends, relatives and loved ones, and wider again to those at the concert who witnessed the horrific scenes and felt scared by the situation, the emergency services and NHS staff who responded to it, and those who were peripherally involved in the aftermath of helping people find ways home or places to stay, or in looking for people who were missing. As well as the terrible loss of life, and lasting physical injuries, psychologically these events will have changed the course of people’s lives in various ways and to various degrees.

The same was true of those involved in the events on London Bridge and Borough Market. These were ordinary Londoners and tourists going about their daily life. On another day, or with another roll of the dice this could be any one of us or people that we know. Again, the ripples spread far and wide.

And now we have another unspeakably awful tragedy, where the Grenfell Tower fire has killed and injured large numbers of people representing the full spectrum of age and cultural diversity. What they had in common was living in a tower block built by the council in the 1970s. Preliminary commentary suggests that the decorative and insulating cladding used in a refurbishment of the block was highly flammable and caused the fire to spread rapidly and the compartmentalisation system to fail. If that is true, and it was cost-cutting and a delay in updating the fire regulations that was to blame, then that is unforgivable and needs to lead to legal consequences for those responsible, as well as learning that prevents similar tragedies occurring in the future. I can understand the level of anger that is being expressed by the local residents whose concerns were ignored, and by those who feel that the balance of power in the current political situation means that the lives of people with below average income are given little value compared to the profits of the rich.

Here too the psychological consequences will ripple out widely beyond the horrendous loss of life and physical injuries to those who were bereaved, traumatised by what they witnessed, those who tried to raise the alarm but couldn’t reach everybody, the emergency services who responded so admirably against insurmountable adversity and those more peripherally involved. There will be complex feelings for those who survived when others perished, and I can’t begin to imagine how it must feel for the person whose flat the fire started in. If it is true that a faulty washing machine started the blaze, they must be wondering whether there were any choices they could have made differently that would have prevented or reduced the terrible outcomes that followed. Likewise those on lower floors or adjacent buildings who escaped early on and had to watch others jumping from windows, throwing out children, or being trapped too high to do either. I can’t begin to imagine how that will impact upon them over time, as it was overwhelming to even watch on the limited TV coverage.

Yet, everywhere there is tragedy, we see good people come out to try to help. From the emergency services and NHS staff, to those running charities and organisations to help those affected to those doing practical things on the ground because they happened to be there and felt compelled to do something. The One Love Manchester concert had the highest viewing figures of the year and the fundraising for Manchester victims and charities has topped £11 million. Likewise the fundraising for victims and organisations that can provide support in relation to the London incidents and the Grenfell fire have been astronomical (last figures I read suggested there had been donations of over £1.5 million in 24 hours to causes related to the fire). Overall, following these tragedies we have seen an outpouring of love and kindness on an unprecedented scale.

So perhaps in that context it is not quite as surprising as the political commentators think that the election results suggest the tide is turning against austerity. Public sector workers with frozen pay are those who have been responding to these crises, killing and arresting the terrorists and identifying their networks, fighting the fires and patching up the injured. That means that the public have remembered what heroes they are, and look in a different light at the cuts to the public sector that are preventing them from doing an effective job and mean we are not rewarding them adequately for the essential work that they do. We have also been roused into action to prevent further victims. We can no longer ignore the fact that the NHS and fire service are warning of their inability to provide sufficient cover to meet the need with budgets cut to the bone. Hospitals are struggling to sustain staffing, let alone recruit, without nursing bursaries and international staff. Children are being harmed and dying because of insufficient social care services, and people with disabilities and health problems are suffering and dying because of cuts to their benefits and support packages.

In short, as events have awakened our empathy it has become clear that the government’s policies are without compassion, and are all about protecting big business and the super-wealthy. They are making the rich richer and the poor poorer, and the vulnerable are dying as a result. Tough talk about immigrants and scroungers has been used to justify a lack of public spending coupled with policies that harm the most vulnerable in society – yet the sudden change away from austerity when their electoral majority was lost confirms that these were idealogical rather than economic choices. The negative focus on blaming disadvantaged groups in society has turned the spotlight away from much bigger abuses of the system by international corporations who manage to pay little or no UK tax, and who exploit staff on zero hours contracts, or even force them to work for their benefits through work fare schemes. The wealthiest in society are able to pay accountants and lawyers to help them avoid tax the most, and to hide income in off-shore schemes for tax avoidance purposes.

So at a time when compassion is so needed, and so evident in response to terrible events, there has been a political shift. It hasn’t happened in isolation – we have seen increasing unpredictability in public voting over the last year. I can only make sense of this in terms of a desire for radical change. Young people and those who have felt disempowered and disenfranchised by a political system that seemed to occupy only the middle-right and work only to sustain the vested interests of those who are already wealthy and powerful have been voting for the option that they think will upset the establishment. Sadly, the only options for rebellion available last year were to vote for Brexit and for Trump, or to not vote at all. But this year, as the government has moved the Overton window further right since the Brexit vote, clear blue water has emerged between the parties. And to the surprise of many, the Labour Party has moved left from their centrist policies and candidates of the last decade. Somehow a genuine socialist candidate has been voted into leadership in the form of Jeremy Corbyn, and despite all the efforts of the press and his own party, he has stuck in there stubbornly, growing support from the ground up, and now he seems to have popular support and the potential to be a future Prime Minister.

[If you aren’t a fan of politics, feel free to skip to the last paragraph now, because the second half of this blog is about the election results and what they might mean].

Corbyn might be an unlikely leader following past templates, as he does not use glib press-friendly soundbites. But he is a man who has stuck to his principles throughout his political career, and has been a voice of reason and negotiation when others have been shouting. From day one he has been an authentic voice in a world of spin. Although he was damned for it at the time, he acknowledged the complexity of the issues and did not ally himself fully with either of the polarised sides of the Brexit debate (though he said on balance he would prefer to remain). He has subsequently been able to make a positive campaign in a time in which the fashion is to blame and ridicule. In the words of Michelle Obama that I like so much “when they go low, we go high“. It doesn’t mean not being outraged or angry. It means choosing to focus on how we can solve problems, rather than on denigrating opponents. Corbyn was not only an underdog that would upset the establishment but an opportunity to say enough to austerity. That message has connected with people whilst Theresa May was curiously defensive and robotic, repeating the same soundbites over and over again and refusing to engage in the debate.

Corbyn’s politics roused a new generation of political campaigners (Momentum) who fought a savvy campaign on social media, where it is said a budget of just £2000 reached more voters than over a million pounds spent by the Conservative party. Over 12 million voters saw a facebook post started by a Momentum member in the week before the election. Partly as a result of this, 622,000 people registered to vote for the first time. This image of Facebook reactions to a live stream of the Prime Minister made me smile:

It is obvious to anyone that knows me or anyone who reads what I write that I identify as being on the left of the political spectrum. I was alienated by Labour’s move to the centre, and have become a lifetime member of the Green Party, despite being pragmatic enough to recognise that whilst we have a first past the post voting system the UK will be a two party political system. So I have been quite interested in the rise of the left within the Labour Party, and a fan of Corbyn as an individual politician for some time (I wrote about Corbyn on this blog a year ago).

So, unsurprisingly, I saw the election outcome as a great result. I was afraid that the Tories would get a landslide victory and use it to push through ever more austerity, and channelling of wealth to the super rich. So to see them lose their majority was a brilliant outcome. I’m delighted, and the more I have thought about it the more I think a hung parliament is about the best possible result.

First off the Tories have lost the mandate for their hard right, hard Brexit plans. And young people have been engaged in politics. Hopefully we can prevent repugnant policies like the dementia tax and fox hunting and cuts to education because the majority is so slender and these policies haven’t played well with the public. But I like that brexit will be a Tory problem to resolve, because when it gets messy they will have nobody else to blame. There is a stronger position to oppose boundary changes and to press for electoral reform. Maybe we can improve the terrible cuts to benefits and the regime of sanctions whilst their focus is on damage limitation and Brexit. And the next election might be one in which change is possible.

I don’t think it is a panacea. After so many cycles of hope and disappointment in recent politics, I’m cynical about whether this is the beginning of a sea change, and worried there is still a lot of conservative thinking about the economy and UKIP influenced blaming of foreigners around. I’d like to believe that things will get better from here, but I don’t think we should expect too much too soon. Some of the optimistic predictions of having a Corbyn government by the end of the year, and reaching a point at which the populace don’t want to go through with Brexit by the two year deadline seem just too good to be true. However, I am optimistic about the long game, because of what the analysis about voting patterns shows. Corbyn’s support is younger and more educated than that of his opponents. That is supported by this chart from the Financial Times:

Screen Shot 2017-06-10 at 01.27.16

You can see that over 65s were 35 points more conservative than the UK average, whilst under 45 year olds are more prone to voting progressively. That split by age is a relatively new thing and it has been much more marked over the last two elections. Then I think about what the five year interval between elections means to the population. With half a million older people dying every year, and half a million younger ones becoming eligible to vote, surely over time that will tip things in a positive direction. The only question is whether the tendency of people to swing right as they get older will continue as the current population ages and/or whether the Tories can start to market successfully to these new voters.

I’ve been trying to understand the reason for these demographic shifts, to judge whether the current middle aged moderates are the retired conservatives of the future. From what I have read I’m not sure that the fade from red to blue is inevitable. I think a lot of us who will be entering the top half of that graph soon age-wise grew up under Thatcher and have much more reticence for those kind of policies than the current over 65s who grew up during and soon after the war. We are also more educated (and education is associated with more progressive values) as well as growing up in a more socially liberal world, with greater exposure to diversity. As this article puts it “When my parents first voted in the 1960s, homosexuality was illegal, abortion was largely illegal, the death penalty was still in force and openly racist attitudes were widely acceptable. Now, the death penalty is a distant memory, abortion rights are firmly entrenched, gay marriage is legal” and (perhaps with the exception of the Brexit effect and islamophobia) racism isn’t socially acceptable. Environmental issues are really embedded in the values of young people, and the scientific consensus for climate change and the need to preserve our limited resources has become overwhelming over the last decade or two. Every school has recycling bins and anti bullying policies, every home has energy efficient light-bulbs and lots of products market their green credentials. There is an increased focus on making healthy choices for ourselves and our planet. Anyone under 40 is also growing up immersed in social media, and with the perspectives of the whole world available to them immediately, rather than just the opinion of the local community and the newspapers. The media barons have less influence, and the circulation of the tabloids is decreasing (and there is increased coverage of celebrity “news” within them, and less coverage of the more serious topics).

So I’m optimistic. Despite all of the things in the world that are upsetting people and setting them against each other, I think the march of time takes us towards an increasing prevalence of progressive values. I hope by the time my children are voters the world will be a nicer place, and the Overton window will have moved back to the left.

 

Sowing seeds

I was late to plant my vegetable seeds this year. Due to Defra restrictions to prevent avian flu, our chickens were living in our polytunnel until the end of March. It then needed digging over and the raised beds building for this year, as well as some plans for irrigation. We don’t have any staging in there yet, and I don’t have a greenhouse here in which to start my seedlings. And so because it seemed complicated and I didn’t have much energy due to ongoing health irritations, we reached the second weekend in April without any seeds planted. I could have conceded, as I did last year, and bought seedlings to plant out, but that seemed like a lazy option and I knew taking a shortcut makes me feel less proud of the results. Plus I have accumulated a stockpile of seeds that needs to be used, and the kids love planting, so that is what we spent the first weekend of the Easter holidays doing. Thankfully most of them have sprouted quickly and just reached the size where I have started planting them out (though some have not grown at all).

It struck me whilst I was planting out the seedlings and topping up the seed trays that sowing seeds is an act of faith that they will sprout and grow to produce plants, flowers, fruit or vegetables given time and nurture. Whilst generally the freshest largest seeds do the best, that isn’t always the case as weather conditions and wildlife can easily disrupt your plans in the garden. Sometimes the most promising looking seeds don’t lead to viable plants, or the most lush looking plants fail to produce fruit, whilst the least promising looking seeds or most straggly plants can sometimes surprise you with an abundant harvest down the line. Some of the outcome depends on skill, some on diligence and some on factors outside of our control. Each time you have to prepare the soil, sow the seed and water it regularly to see what comes out. It is an investment of resources and energy that will hopefully be repaid in the future. That idea was resonant for me for a number of reasons.

Firstly, I am trying to invest effort in improving my physical health. The motivation for that comes from looking forward into the prospective futures available to me, and how my health and fitness will affect me and my family. It has become much clearer that what I eat today, or the exercise I do or don’t do, has an impact on me that I’ll feel in the future. I’m making an effort to be more active, get enough sleep and to eat more vegetables and less processed food (I’m a big fan of spring greens at the moment – they are so cheap to buy, but are deliciously sweet and tasty, as well as being seasonal and grown in the UK). So far I have lost 10lbs but I have bigger goals, and want this to be the beginning of cumulative changes in my life. I want my kids to have an active, happy Mum who does lots of stuff with them, rather than a perpetually tired Mum who is preoccupied with work stress. There is a famous Reddit post that talks about non-zero days and effort being a gift from past you to future you that I would recommend reading if you haven’t stumbled upon it yet.

Investing energy for the future potential also connects to the wider theme of working in mental health – where we and the client invest time and energy in trying to make the future better for them – and also that of trying to make a career in psychology. As application season passes on the forum, we can see the hope and heartache that this involves. Many people become almost obsessional about checking the forum for news of when courses have short-listed, and when the offer letters come out – so much so that it completely changes the traffic pattern to the forum (which normally has an average visit time of over 10 minutes, in which the typical user views many pages, but has two months per year in which repeat checkers raise the number of visits, but bring the average visit time down to 2 minutes, often just viewing a single page over and over again).

The early years of most psychology’ careers are seen as an investment necessary to pass the career bottleneck of being selected for training. Prior to that, many applicants feel they are gambling their time on a potential future that may never happen. There is a sense of trying to tick boxes, but not knowing exactly what the boxes are, or why they are necessary which I think needs to be explored and challenged. For many people, it seems like those early stages feel pointless in and of themselves. They are not seen as a long term career plan, and are therefore easily dismissed as being worthless except to jump hoops to try to gain a clinical training place, but I think they have merit in their own right. Many people gain great satisfaction from doing these “low level” care jobs, and they are invaluable in the daily lives of many people in their times of greatest need. They are also a fantastic way in which you can gain and apply the basic psychological skills of listening, empathy and compassion to client’s lives, and to experience the ways that the system around them can help or hinder their wellbeing. Being a mindful and reflective frontline care worker (or researcher) is the time at which people engage the most in the lives of clients, and ensures that the advice we give later down the line is grounded in reality. It also lets us experience the hard work and competing pressures of the staff we may end up advising from the lofty perch of being a qualified health professional, so it is a shame to see so many people horizon gazing to the detriment of getting the most out of the moment they are in.

The same theme of investing time and energy to create something for the future is true in setting up a small business. All over the country people are ploughing in their own money and time to set up small ventures, despite the time involved being more than full-time hours and the initial return often being much less than minimum wage. I hadn’t realised when I set out that even when the business has been running for a while, you often end up having to repeat this process over and over again. As staff move on, or contracts change, or the balance of work stops being enjoyable, or you hit hurdles along the way you have to regroup and use the available resources to fulfil your commitments, or even to start over in a new direction. That process can be disheartening, but it can also be an opportunity for growth, and is a good reminder for those running a business to take a step back and look again at the short, middle and long-term goals of the business and the methods used to achieve them. It is hard when a business feels so personal to lose a member of staff, or to have to step away from a long-standing contract or area of work, but it can allow you to invest more energy in trying to plan the business you want to create.

The toughest part of running a business rather than being self-employed is wanting to do the right thing for your employees, whilst also achieving the aims of the business and creating an enjoyable role (and some profit) for yourself. It can be particularly hard to make good financial and business decisions as a caring, empathic, progressive person who wants to do the right thing by everybody else involved, so it is extra important to have good business and financial advice if you are not just responsible for yourself, and your own plans for the future. The owner of the business is always the last to get paid, and feels responsible for the well-being of every other member of staff – even though for them it feels more like a job, and less like a personal mission.

In a social business we are also the ones responsible for deciding how we provide our services, and what the focus will be. There is endless demand for my services as a court expert witness, as a trainer and consultant to the residential and foster care sector, but I know if I get too swept up into delivering services personally I don’t leave enough capacity to steer the business. So I have to pick and choose the activities that best align with my long-term goals. I have to plan the future of my company in a way that has the most impact on recipients and creates a financial reward for me and my employees in the future. That “triple bottom line” of caring about people (employees and service recipients) and the planet (systems and wider issues) as well as profit (earning enough to pay employees and yourself) is part of the joy and challenge of running a socially worthwhile business.

The sheer number of choices and possibilities can be quite overwhelming at times, and each decision feels like it needs knowledge that I don’t have to make it in an informed way. For example, I need to decide whether to formalise the social enterprise structure within which we deliver our outcome measurement tools. If we do it will open doors to sources of investment that might allow us to scale more rapidly and would be closed to a traditional company. However investment always comes with strings attached and can easily change the direction of the company, or reduce the autonomy with which it operates. It feels similar to decide on a new office base. Do I rent a serviced office, commit to a 3 year rental of a unit on a local farm, or get a business loan and purchase a small building? What if we need to grow or shrink so that this choice doesn’t fit the company structure in 12 months time?

It is hard to predict the future impact of seemingly small choices in the present. I can see why anxiety can sometimes make these choices overwhelming, as it is easy to end up with endless background research and tables of pros and cons that are immobilising. I’m sometimes tempted to make them with a coin toss* or a counting rhyme as we did on the playground at primary school. Like sowing seeds, we just have to research and plan the best we can within reasonable time constraints and then follow the instructions and see what grows!

 

*I was once told to toss a coin and then check if your reaction was relief or to want to make it “best of three” and to then follow your gut rather than the result. It seems as good a method of decision making as any other.