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 (and I’ve recognised my shamefully judgemental feelings of rage and disgust when interacting with people using image filters, especially those that put puppy ears and noses onto reshaped faces with features made to conform with patriarchal standards of beauty). 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).

Spreading too thin

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

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

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

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

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

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

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

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

How do we know what we need: differentiating evidence based treatments for the public

I am interested in making a website to help direct people at the right kind of sources of support when they are hitting a block or feeling unhappy with their lives. So I started to look at what was out there. I found lots of small silos full of professional jargon that would help people to identify a counsellor, psychotherapist or psychologist if they knew that was what they needed. But I also found lots of sites that point people at all kinds of snake oil that has no evidence of efficacy at all. For example, Findatherapy.org lists the following categories as “therapies”:

Abdominal-Sacral Massage
Acupressure
Acupuncture
Alexander Technique
Allergy Therapy
Aromatherapy
Arts Therapy
Autogenic Training
Ayurveda
Biofeedback
Bioresonance Therapy
Body Stress Release
Bowen Technique
Chiropody
Chiropractic Treatment
Clinical Pilates
Cognitive Behavioural Therapy
Colon Hydrotherapy
Colour Therapy
Counselling
Craniosacral Therapy
Crystal Therapy
EMDR
Emmett Technique
Emotional Freedom Technique
Energy Medicine
Flower Essences Therapy
Foot Health
Havening Techniques
Healing
Herbal Medicine
Homeopathy
Homotoxicology
Hydrotherapy
Hydrotherm Massage
Hypnotherapy
Indian Head Massage
Kinesiology
Life Coaching
Manual Lymphatic Drainage
Massage Therapy
Matrix Reimprinting
Maya Abdominal Therapy
Meditation
Microsuction
Mindfulness
Myofascial Release
Naturopathy
NLP
Nutritional Therapy
Osteopathy
Physiotherapy
Pilates
Psych-K
Psychotherapy
Reflexology
Regression Therapy
Reiki
Relationship Therapy
Rolfing
Sex Therapy
Shiatsu
Speech Therapy
Sports Therapy
Structural Integration
Tension and Trauma Releasing
Thai Massage
Thought Field Therapy
Yoga Therapy
Zero Balancing

That’s a list of 70 “therapies” of which at least 40 are obvious quackery, and very few could be said to have any form of persuasive evidence base for efficacy*. But the practitioners of each are persuasive, and the websites use pseudoscientific rationales that might fool those who are not as cynical or conversant with the scientific method as we are. So how do the public know what kind of help to seek out? How does someone who is feeling miserable, has a job they hate, financial difficulties and problems in their relationship know whether to get financial advice, careers advice, life coaching or therapy? And if they pick “therapy” how do they know whether to get CBT, psychoanalysis, art-therapy or non-directive counselling? And how do they know whether to get it from a therapist or a psychologist or a counsellor or a mental health specialist or any of a hundred other job titles? And within psychology, how do they know when to seek a clinical psychologist, a health psychologist, a counselling psychologist or any of the job titles that the HCPC don’t register?

I think apart from word of mouth and google, they don’t. Most people ask their GP or their friends for recommendations, and then go with something available locally within their price range. They don’t read the NICE guidance or understand the various professional bodies or regulatory systems. They trust that they’ll get a gut feeling as to whether it is going to help or not from the first session, and most of that “gut feel” is probably based on personality and charisma, and whether or not they feel listened to. The decision then rests on whether the therapist wants to work with them and has the capacity to take them on, and the price they ask for (assuming the service is in the private domain rather than the NHS).

Even the NHS itself isn’t very consistent about evidence based practise. For example, the NHS still funds some homeopathy – possibly wasting up to £5million per year on this placebo treatment that is entirely without evidence or credible rationale. Likewise I’ve seen NHS therapists who have done training in models of therapy that are implausible and without evidence (eg ‘energy therapies’ like EFT). Perhaps this is why the majority of clients doubt the efficacy of talking therapies. Yet, despite this scepticism, most would prefer to try therapy than medication yet the use of psychotropic medications has risen much more rapidly than the use of psychological therapies.

So where do we draw the line? If we only deliver fully evaluated treatments and those where we understand exactly how they work, then the amount the NHS can do when it comes to therapy will be much more limited. Lots of therapeutic interventions in practise are derived from other models or by combining aspects of various models. This allows individualisation of care. Similarly, there are many therapies which are being developed that have promising methodologies and are tightly rooted in scientific knowledge, but have not themselves been subjected to RCTs that prove efficacy yet (eg DDP). And many RCTs seem far removed from actual clinical practise where clients have a variety of overlapping conditions and clinicians deviate substantially from the treatment manuals.

The other confounding factor is that when it comes to talk therapy, it turns out that the modality or adherence to the manual matters very little compared to the relationship between the therapist and client. It seems the key ingredients are listening to the client, genuinely caring about them, giving them hope that things could be different, and giving them the confidence to try doing things slightly differently. Whether we have years of training and follow the manual diligently or whether we are newly qualified and muddling through seems to make much less difference than we think. In fact, therapist variables are much more powerful in influencing outcomes than modality, and even than the difference between treatment and placebo. That is no surprise to me as I’ve personally benefited from physiotherapy that included acupuncture – despite having read studies that show it to be no more effective than ‘sham acupuncture’ where random locations are pricked with a cocktail stick!

In the paper I’ve linked above, Scott Miller argues persuasively that we don’t need to focus on understanding how therapy works, or in using the medical model to work out what works for whom with endless RCTs. He shows evidence that experts are defined by having deep domain-specific knowledge, earned by a process of gathering feedback and focusing on improvement. So he argues that in the same way, expert therapists are those who collect and learn from client feedback. So his answer to the issue of evidence-based practise is for us each to collect our own outcome data to show whether our work is effective according to our clients (and by comparison to other options), and to see if we can improve this by using simple ratings within each session that check we are working on the right stuff and that the client feels we understand them, and that the working relationship is good.

So what does this mean for the proliferation of made up therapies? Does it mean that we should leave the public to buy a placebo treatment if they so wish? Or does it mean we need to focus on the modality and evidence base after all? The ideal would obviously be better regulation of anyone purporting to provide therapy of any form, but given the HCPC remit doesn’t even include counselling and psychotherapy, I think we are far from this being the case. To my mind it throws down a gauntlet to those of us providing what we believe are effective and evidence based treatments to collect the outcome measures that demonstrate this is the case. If we are sure that what we offer is better than someone having an imaginary conversation with an imaginary ‘inner physician’ by feeling imaginary differences in the imaginary rhythm of an imaginary fluid on our scalps then surely we ought to be able to prove that?

And what does that mean for my idea of making a website to point people at helpful places to start a self-improvement journey? To me, it shows there is a clear need for simple and accessible ways to identify what might be useful and to allow the public to differentiate between sources of support that have evidence of efficacy, professional regulation, a credible rationale for what they do, reputable professional bodies and/or personal recommendations. Maybe such a website can be one contribution to the conversation, although I’ll need both allies and funding to get it to happen.

 

 

*I’d say EMDR, physiotherapy, speech therapy, CBT and some types of psychotherapy and counselling probably reach that bar. Mindfulness is probably getting there. Art therapy probably suits some people with some issues. Yoga, sports massage, pilates, osteopathy, meditation, life coaching and (controversially) even acupuncture probably have their place even though the evidence for them as therapy modalities is limited. Most of the rest are quackery.

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

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

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

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

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

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

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

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

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

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

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

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.