Pushing upwards

When I was an undergraduate psychology student, I found parts of the course curriculum kind of boring. I was interested in human behaviour and experiences, because I wanted to understand how to alleviate distress and increase wellbeing. Unfortunately I was not so interested in the neurochemistry or neuroanatomy that is the underlying mechanics for those emotions and behaviours. I was interested in behavioural ecology, like the evolutionary/survival value of altruism to vampire bats, and its parallels in human behaviour (eg why we have developed a system of rules and punishments to enforce the social contract). But I wasn’t so interested in animal perception and cognition. I found some of the early psychological experiments on both animals and humans to be really cruel and distressing, though I was aware that they helped to progress our understanding of brain and behaviour, and helped us to recognise the need for the ethical considerations we apply to experiments now.

Because I didn’t love the whole course, during the second year of the course I began to wonder whether I had selected the subject on autopilot, because my Mum is also a clinical psychologist (now retired).  A few other life events compounded this lost feeling by lowering my mood generally* and I developed an increasing existential doubt about whether I was making the right choices in my life.  I also wanted to test out my values and the options available to me, so my focus drifted to my social relationships and activities outside of psychology. I became less motivated and didn’t attend all of my lectures, and (despite having previously been quite successful in educational assessments) I got a 2:2 for one module that I hadn’t enjoyed. It was a mark that fairly reflected my effort/interest level, and in any other context it wouldn’t have been a big deal. However, I was gutted because I felt like the whole course would be pointless if I didn’t excel academically, as I was aware of how competitive the path into clinical psychology was. I considered changing course or dropping out, but I couldn’t think of anything I would rather do.

One of the images that helped pull me through that time, was from the I Ching – an ancient Chinese book of wisdom, also known as the book of changes. The basic gist is that you throw coins to point you to one of 64 readings, which can be generated with various variations and additional comments, and (like a horoscope or cold reading or fortune cookie, but perhaps with a bit more zen wisdom) the resulting text is ambiguous and non-specific enough for you to draw relevance to your life situation. The page that I was sent to was called “pushing upwards” and the hexagram was of wood below the earth. The image it described was of a seed below the surface, using all of its stores of energy to push a shoot upwards in the hope that it would reach the light and conditions in which it could grow and thrive. The text explained that to do this is an effortful process, in which you are gambling that this investment of energy will be worthwhile in reaching a goal that might still be out of sight. It describes the heaping up of small efforts to create the conditions in which future success is possible. The seed takes time to unfold into the tree: Although the results are not immediately visible and gratifying, “that which pushes upwards does not come back”. The reading tells you to put in a sustained effort if you want to achieve great things. It reassures you that if you are driven by a deeper sense of purpose (rather than wealth or glory) and willing to learn from wise people around you, you should not fear the path ahead. It implies that in time favourable conditions will help you along. In this way, it says, a person can rise from obscurity and lowliness to power and influence, provided that you make your efforts in a humble, flexible and authentic way.

This was a good metaphor for needing to put in more effort to achieve my goals, and it also reminded me of my core values and my drive to in some way make the world a better place, by improving the experience of other humans who had been dealt a tougher hand in life. Thankfully, as I entered my third year I got together with my husband (who has continued to be a supportive and stabilising influence for more than two decades since) and entered a much happier phase in my life. I also found the modules in the final year of undergraduate much more relevant to my interests, because they were much more closely tied in to the theory and practice of clinical psychology. As a result I started to put in more effort and get higher marks. I also started to gather work experience, and to seek out advice from qualified CPs. Gradually, those efforts paid dividends – I secured an AP post on a research project straight after graduating** and then worked incredibly hard to do that job, write up papers for publication and complete a masters degree by research at the same time, before gaining wider experience in a more clinical role with a different client group and then securing my place on clinical training.

From the moment I entered that third year with that mindset, I enjoyed the rest of my journey into clinical psychology. No matter what the client group or type of work, I felt like I was doing something worthwhile and I was also constantly learning and being challenged. I had some inspiring supervisors, both as an AP and as a trainee. I didn’t love every placement (they were all good learning experiences, but my enjoyment varied depending on my interest in the client group, the style and context of the work, and the amount of travel involved to get there). Likewise I didn’t click with every supervisor equally, but I did learn a lot from each of them. In my first AP role my supervisor was a role model of the true scientist practitioner, who secured grant funding to push forward the evidence base of the clinical work, and constantly published papers and disseminated findings. She pushed me to participate in that world, and with her support I co-wrote six peer reviewed journal articles during those two years! She is still my role model of embodying the link between research and practice in psychology, and I would love to emulate Esme’s energy and influence in my own field of work. I then worked in a project that trained student social workers, and assisted with expert reports on parenting – something I continue to have an interest in to this day. It gave me a much more practical grounding, and an awareness of social care systems that I have subsequently built on.

As a trainee I gained a basic grounding in brief CBT-based interventions in an adult service, and learnt more about the structure of mental health services and working as part of a multidisciplinary team. I also worked in services for people with intellectual disability, where I learnt about the value of indirect work, and gave more explicit consideration to issues of capacity and consent. I loved my core child and family placement, and the warmth, pragmatism and commitment of my supervisor, Patricia, set the tone for the kind of psychologist I wanted to become. I returned to her for a specialist placement to pick up the cases that were more complex, transgenerational or involved child protection issues that I had avoided the first time around. I was lucky enough during that second specialist placement to also have the opportunity to work one session a week into an NCH Action for Children project for child and young adult survivors of sexual abuse. There I was reminded of the value of human connections over any academic knowledge, as well as having the opportunity to use Cognitive Analytic Therapy for the first time. I also did a specialist placement in a child development service, with some work into a sexual abuse team – including working with children who had survived abuse and co-facilitating a group for mothers whose partners had sexually abused their children. I learnt more about complexity and systems, and some healthy cynicism about organisational change. I still remember the chart for the new tiered model of services pinned up on my supervisor’s wall, with ovals that widened at lower tiers, entitled “the shape of future services” to which he had added a handwritten subtitle “is pear-shaped”.

When I qualified I was torn between a post with the favourite supervisor I had spent two placements with and one that several people warned me was “burnout waiting to happen” working in child protection. After a long discussion with a good friend I concluded I wanted to continue to challenge myself, and also to put myself where I was most needed. I therefore took the latter post, and worked in a split post across CAMHS and child protection. I learnt from a fantastic supervisor how to work in complex systems and services. David also taught me how to be an expert witness for the family court. The balance between being down-to-earth, approachable and yet grounded in knowledge and theory, as well as the clear communication under pressure gave me another role model of the type of psychologist I wanted to become. He taught me to ask the uncomfortable questions, and to balance holding empathy for parents with speaking up for the best interests of the child. Then in my longest standing post, I learnt from another fantastic head of service to think about process in supervision, how to bring fun and creativity into my work, and also to pick my battles! I also did a lot more collaborative work, and got involved in service development and audit, as well as gradually stepping up to greater supervisory and management responsibility. In that post I had the benefit of working with an inspiring social work team manager who had been doing really innovative work to increase access to permanent placements for older and more complex children. I also went out to America for a couple of weeks to train with Dan Hughes, where I learnt about the power of being present in the intersubjective space, and became more willing to show my own vulnerability and emotional reactions.

I have also learnt from less positive experiences – the times where I got it completely wrong, or unintentionally triggered negative responses in others. For example, I remember an AP I supervised feeding back disliking that I had introduced her to colleagues as “my AP”, intending that to be as supportive as I had perceived it being when I had been an AP myself, rather than as indicative of any claim of ownership. I remember crying when criticised in a multi-agency meeting about the autism pathway, and realising too late that it had been a bad decision to come into work that day whilst my house was flooded and I didn’t have enough emotional resources for work. I still cringe looking back on one time I tried to be supportive to a junior colleague who had to give evidence in court, but ended up making myself look stupid and inhibiting her ability to impart her observations in a useful way. I recall the challenges of having to raise concerns about how a colleague’s homophobia might have a negative impact on service users, and how they justified this being part of their cultural and religious identity. I remember the camaraderie, but also the pressure of working within a big system, feeling responsible for protecting more junior colleagues from organisational changes, worrying about waiting lists, and defensively managing referrals.

Most of all, when I think about negative experiences, I remember how gutted I was when my wonderful employing organisation lost the competitive tender for our service, and how horrible the initial meeting with the new service directors and managers at our new employing trust was. It started with a gloating talk from the new clinical director, and him taking digs at our senior staff about how some people in the room might think they know how to run CAMH services, but clearly he new better as they had won the tender. The jokes about how nobody need worry about their job security, except the consultant grade psychologists, as “you are quite expensive and we haven’t figured out what to do with you yet”. And the patronising response of the service director to my questions about whether the plan for my service section in their tender specification was fixed: “If you think you can do better, cheaper, love, knock yourself out”. I remember the pressure to rewrite the service specification and job plans for my team whilst my kids were in neonatal intensive care, and to take on various tasks to compensate for the fact they hadn’t appointed a locum to cover my absence. I remember my team being left out of the accommodation plan entirely whilst I was on maternity leave, and after protesting, returning to an undecorated, unfurnished office without internet or telephone points (or mobile reception) that could only be accessed by swiping out the fire exit across two flights of stairs, then swiping into another wing of the building and going down to the furthest end of the corridor. I remember being told to income generate or face temporary staff on my team being made redundant, and then being told that I was allowed to neither quote nor invoice as I wasn’t a budget holder. I remember being promised time off in lieu for all that I did during my maternity leave, but then being denied this on my return as “we can’t pay you full-time pay for part time work, no matter what you did in the previous financial year”.

I remember the day I walked out of a meeting with an operational manager, out of the building, out of the car park and down the road, and felt like I could keep walking forever and never go back. In the end I walked across town to my previous base and talked to the directorate manager there, who made it feel less personal. Over the following weeks I sought out some personal therapy through Occupational Health, and picked apart what was me and what was the toxic system around me. Then I decided to take a career break and spoke to HR to confirm that I would be able to continue my self-employed activities during a career break without this being considered “taking up alternative employment” and blocking my right to return. I also wanted confirmation that I would return on the same grade to the same client group. I always joke that the HR lady I spoke to should never play poker, because as I told her my reasons for leaving her face gave away too much. I watched her non-verbally say something along the lines of “oh shit, we’re in trouble here, pretend we’re not, pretend we’re not” before casually raising the option of redundancy and a gagging contract***.

So I had to uproot and push upwards into new an unfamiliar soil. Initially I applied for other NHS jobs, but ended up withdrawing before interview for one and declining a job offer for another, because I wasn’t prepared to work in another toxic culture. In the end I used my expert witness work as my parachute, and figured I would work it out as I went along. I changed from being a sole trader to a limited company so that I could employ an AP. I felt like I had been gradually dehydrated by the conditions I had worked in until I was just a husk of myself, and as I started doing my own thing I found some rain I started to find my own shape again. At first I used my own business to try to achieve what I had hoped to in my NHS career independently. As I have said in previous blogs, I helped set up a parenting charity, but felt the political agenda of the founder wasn’t consistent with the clinical goals. I secured funding for, designed, managed and evaluated a service to support people with diabetes, but ultimately it wasn’t commissioned. I set up a psychology service within a social care provider, and trained staff all across the country, but whilst I enjoyed the work I didn’t enjoy spending so much time away from my home and kids.

The challenges have continued, as I have had to foster my entrepreneurial side and learn the skills to run a business, hold a budget and manage staff. I’ve found new ways to disseminate knowledge – through being on committees, doing policy work, and writing for different audiences in my book, practice journals and on social media and this blog. I’ve developed ways to use technology to improve services, and I’ve returned to doing research. I’ve had to be flexible enough to try new things until I’ve been able to find a way to work that feels authentic. This blog documents much of that journey.

Through it all I have never been bored or complacent about my work. I’ve always enjoyed finding new challenges, and new ways to apply psychological knowledge. I have always found that my work provides moments of flow – that sense of deep and satisfying immersion in the present moment to the exclusion of everything else, that you get when you have sufficient agency and skills to meet a challenge, and feel a sense of reward from doing something well or contributing to something worthwhile. By comparison with so many people who do repetitive, boring or physically challenging work, I feel a great deal of gratitude that I earn my living doing something that is so varied, with so much autonomy and opportunity for enjoyment. Thankfully I have always been able to find sufficient challenge and novelty in how I work, along with sufficient freedom to satisfy me. And there have always been new human puzzles that intrigue me, and the varied settings and ways of working that I have experienced each involve looking at what I have to offer afresh and customising what I do for the new context.

 

So here I am, running my small business and trying to establish the use of structured needs assessments and outcome measurements in children’s social care. Once again, those themes of pushing upwards are back, as I have been putting in a big investment of time and effort to nurture this project over many years in the hope that it grows into something productive. Now that I am more established and have a mortgage to pay, plus rent on my office and employee salaries it feels like a bigger gamble than early on in my career where I had little to lose. But I have that same feeling of clarity about where I want to make my impact in the world that I did when I decided clinical psychology was for me after wavering as an undergraduate. I also have the same faith that my cumulative efforts will eventually be repaid with positive outcomes and a move into easier progress. If I go back to the image of the seed growing underground, I’d like to think that the journey through the earth has been completed and the new shoots are now reaching up into the sunlight where they can be replenished by energy from the external elements. I know as a gardener that with good planning and regular nurture the slow growth of seeds sown over winter can quickly turn into the rapid growth of spring and summer. I can only hope that I’ve done enough to establish my new plants and all this effort comes to fruition soon!

*My landlady decided to sell the house I was renting (despite having agreed I could stay on there in my third year), so I had to find an alternative place to live. My Dad was tested for prostate cancer. And I experienced the second incident in this past blog about rape culture in which I felt at risk of rape.
** Before you say “it must have been easier back then” I would note that I got that post against 110 other applicants. So even in 1995 things were pretty competitive, and probably more effortful as we had to find job adverts in the BPS appointments memorandum booklet that was posted out with the Psychologist magazine, phone up for an application pack, and then post in a hand written application, as NHS jobs didn’t exist and internet based application systems had not been invented yet. Which makes me feel very old.
*** A legal “compromise agreement” that included terms saying I would not tell people why I was leaving or speak negatively about the trust from which I departed, and could not take legal action against them – terms I understand are pretty common in that situation, but the government has subsequently outlawed after bad publicity, as they can be seen as an attempt to silence whistle-blowers.

Sticking plasters

I realise that this title won’t mean much to Americans or people outside the UK, so let me share a small anecdote by way of explanation before I get into the topic I want to discuss. I was on an American airlines flight back from New York in 2003, having done a lot of walking around the city over the preceding week. When I removed my shoes and straightened my socks it transpired that a burst blister had adhered to my sock, and it started to bleed surprisingly profusely. I asked a member of cabin crew for a sticking plaster, and got entirely blank looks in response. When I explained the situation, a steward showed a sudden look of recognition and sighed “oh, a Band Aid! I keep one of those in my wallet for my kids” and provided what I needed. So yes, a sticking plaster is a Band Aid – an adherent protective dressing for a small wound.

I found it quite an insight into American marketing, as I had also tried to buy antihistamine cream in a drug store to utterly blank looks, until someone realised I wanted “Benadryl”. I had also seen the TV advertising persuading people they had adult ADHD (with a symptom list that seemed to encourage false positives, and a link to a small quiz online that seemed to classify almost anyone as having ADHD), or that they needed Viagra (with the almost comical warnings that “erections lasting more than two hours can be dangerous and require medical attention”). Disease mongering is a pretty interesting phenomenon, and well worth reading about – Did you know that the vast majority of viagra prescriptions are “off label” and written for groups in which there is no evidence of efficacy (including women, when there is not a single study showing evidence of efficacy in this population)? And that the pharmaceutical companies are trying to medicalise “Female Sexual Dysfunction” to create mass markets to address lack of desire or lack of pleasure, with minimal consideration of the context or wider issues, because of the success of such marketing with men? Or that “restless legs” has been marketed to the public as a common condition requiring medication? It made me quite glad for our generics, and lack of medication marketing targeting the public.

But the reason I wanted to talk about sticking plasters is that they are a response after the event. A means of short-term management, and covering up of an injury, rather than preventing it. Like my blisters adhering to my sock, there were many stages at which that bleeding could have been prevented – by covering the blister earlier, or better still byby taking the subway more and/or wearing more sensible shoes to explore New York. The problem is that if we become overwhelmed by demand for the reactive response, we lose the capacity to look at what underlies the demand. And if we spend too much time reacting to distress in health services, it can mean that we fail to do the preventative work that would reduce the need for such services. With austerity politics ensuring that the health and social care sector are too underfunded to be proactive, I think that is where the NHS is heading, along with most of the public sector.

Every single day I seem to read about travesties of social justice, and the lack of thought about the people that bear the brunt of them. Time and time again the most vulnerable members of society are being abused and neglected at a national and global scale. Whether it is the man who has paid UK taxes for 40 years who is being denied essential cancer treatment because he doesn’t have a British passport (due to a paperwork oversight when he arrived as a child with his parents from the Caribbean 44 years ago), or the deportation of a humanitarian/academic couple who are being told to leave because they went abroad for too many days – to complete a government study. Or how about the person that tweeted about having waited for over a year for support after a sexual assault, with rape crisis waiting lists closed for most of London for more than a year due to the scale at which demand exceeds supply?

Perhaps we should look at the rapid rise in mortality in the UK so far this year, falling life expectancy (especially in lower socioeconomic groups) or the rise in deaths amongst mental health patients – despite the falls in smoking and improved outcomes in many health treatments. A man/woman in an impoverished estate in the north of England can now expect to enjoy 32/35 fewer years of life in good health, compared with a counterpart in a wealthy suburb in London or the Home Counties. Or perhaps we can look at the impact of cuts to NHS funding (albeit masked by fake claims of record wage rises) record waits for A&E, the cancellations of operations, and the burnout of NHS staff.

Or look at the increase in homelessness over the last few years (it went up 16% in 2016 alone, with almost 50 000 families living in bed and breakfast accommodation and many more “hidden homeless” living on floors and sofas of friends and acquaintances) with the knowledge that being homeless can worse than halve your remaining life expectancy (homeless women die on average at 43 and homeless men at 47, compared with 77 for the rest of us). As the author of the BMJ article puts it “Homelessness is not an episodic event, but something systemic. It is a neon sign that something is fundamentally wrong with policy across health and housing”. This lack of provision doesn’t even save money as the cost to the NHS of society’s failure to deal with homelessness and other examples of inequality has been estimated at £4.8bn (€5.4bn; $6.7bn) annually.

These same austerity policies have a wider impact on mental health. Psychologists for Social Change have identified five ways austerity policies impact on mental health: 1. Humiliation and shame 2. Fear and distrust 3. Instability and insecurity 4. Isolation and loneliness 5. Being trapped and powerless. They remind us that “These experiences have been shown to increase mental health problems. Prolonged humiliation following a severe loss trebles the chance of being diagnosed with clinical depression. Job insecurity is as damaging for mental health as unemployment. Feeling trapped over the long term nearly trebles the chances of being diagnosed with anxiety and depression. Low levels of trust increase the chance of being diagnosed with depression by nearly 50 per cent”.

So we can’t see mental health in isolation. Whether it is the individual context (for example in the power threat meaning framework I discussed in a prior blog) or in the wider sociopolitical context, we are not brains in a jar, but socially connected beings with experiences that impact on our wellbeing. When we talk about the shortfall in mental health services, too often we are saying that in the context of demand for services exceeding supply, and feeling strongly pulled as psychologists to provide more of the same. That makes sense in at the coal face, where it is hard to have the energy, time or resilience to look at the wider picture beyond the demands hammering on our own door. However, it means that we are discussing the lack of sufficient reactive responses to a problem that could have been dealt with more effectively further up the timeline with proper proactive and early intervention work, and in a lot of cases could have even been prevented with better social policy and provision for vulnerable population groups.

Of course, doing preventative or early intervention work also takes resources, and we can’t take them away from the people currently in need/distress now. But instead of us constantly asking for a little bit more of the same to deaf ears who reply with excuses about finite pots and efficiency savings (and sarcasm about magic money trees), maybe we need to think more creatively about intervening at different levels and in different ways to the set up of existing services. I’d rather be providing sign-posts to avoid hazards than doling out sticking plasters when people trip over them – and best of all I’d rather be fixing the hazards, and helping vulnerable people identify routes that are less risky.

I’ll give Psychologists for Social Change the last word: “Mental health isn’t just an individual issue. To create resilience and promote wellbeing, we need to look at the entirety of the social and economic conditions in which people live”.

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 strip away 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.

Nature versus nurture revisited

This week I have been reading the Power Threat Meaning Framework published by Lucy Johnstone and colleagues. This document is an attempt to challenge the dominant medical model in adult mental health with a more functional framework for formulation, based on the person’s experiences and circumstances. It is an interesting and challenging read, because it tries to cover the political and philosophical context of challenging the medical model, and input from service recipients about the benefits and challenges of different ways of conceptualising their difficulties. But at the core it rests on a pretty simple and (I’d like to think by now) well-established concept – that the adverse childhood experiences a person has prime them to use survival strategies that make them vulnerable to difficulties later in their life. Those early templates for dysfunctional relationships and the sense of self created by inconsistency and maltreatment also mean that people are more likely than others without those experiences to go on to have other relationships and experiences that are traumatic/harmful as they grow older, which compound the strategies and narratives with which they navigate adult life. The survival strategies which made perfect sense in response to their experiences at the time, have a lasting impact on the brain, body and behaviour. They change the way the person perceives themselves, understands the world and relates to others, and go on to have detrimental effects long after the initial trigger is gone.

As I have mentioned in previous blogs, a person exposed to high levels of trauma or adversity, especially if lacking protective relationships, will become more vigilant to signs of threat, less able to focus on the tasks that help us attain educationally and in the workplace. Where their early relationships have been dysfunctional, they are likely to struggle with forming healthy later relationships, and are more likely to express needs indirectly and in ways that cannot be ignored – including in ways that lead to negative societal responses, such as rejection and/or pejorative judgements by others, involvement with mental health services (and being given diagnostic labels), involvement of criminal justice systems. This leads to an increased risk of socioeconomic adversity, lower social connectedness and a greater chance of a range of adverse outcomes.

In short, thinking about adversity in both the person’s childhood experiences and current context, not only gives us insight into the biggest variable in personality disorder, attachment disorder and other specific conditions. It also explains a lot of the risk factors for wider issues with physical and mental health, challenging behaviour, addiction, violence, crime, homelessness, harmful relationship patterns and helps determine our sense of self and our ability to make healthy social connections. Adverse childhood experiences increase the risk of a very wide range of  physical and mental health problems, for a range of reasons including lower self-care and poor lifestyle choices, a lack of self-monitoring and seeking of appropriate care in the early stages of problems, and what seems to be increased propensity for ill-health mediated by the stress messengers in the body.

I’d go so far as to say that getting child protection and parenting right is the biggest task facing humanity, and the area where I believe we can make most difference for the future – hence dedicating my career to working with the kids who have experienced the most adversity and trying to improve their outcomes. But as I have explained above, it doesn’t just stop there, because the ripples of that early adversity continue to spread out into the lifespan for many people, forming a barrier to the protective factors of education and employment, establishing social networks, and the means to access pleasurable activities. This can then be compounded by financial hardship, hostile systems (such as benefits sanctions and fitness for work tests) and lack of access to resources (including finding it hard to identify and navigate access to social care and health services, to know and assert their rights, or appeal against decisions made by organisations). So the same people who experienced chronic developmental trauma and have unresolved psychological consequences from that are often struggling with their personal relationships, as well as practical issues like debt, homelessness and crime. In that context, dysfunctional coping strategies like substance abuse or presenting with challenging behaviour or mental health symptoms make more sense as attempts to obtain escape or safety.

There are also vulnerability factors such as being in a disempowered/minority population group, that also bring compounding adversity such as sexism, racism/xenophobia, homophobia, transphobia, ableism, ageism, religious intolerance, etc. These can impact at all life stages. For example, a child with physical or intellectual disabilities is more likely to be the victim of abuse, to experience bullying, and (perhaps increasingly as they grow up) to struggle to access community resources, financial independence or a supportive social network. For people from cultures outside of the majority in the country where they live, there can be language and cultural barriers, prejudice and political/economic challenges, as well as exposure to poverty, war, terrorism and other threats to survival that are outside the experience of the majority of lifetime residents of developed nations. Certain population groups such as asylum seekers find things particularly challenging in terms of finding safety, housing, financial security, after already experiencing multiple traumas in the country they have left and during their journey to find safety. Each individual is unique and their story, current situation and past experiences are a huge influence on the way that they experience and interact with the world.

As Johann Hari rightly points out in his recent article to promote his new book, everybody knows that our experiences, relationships and living conditions impact on our state of mind. If a loved one such as a partner or child dies, you are likely to be sad (and perhaps angry, or relieved if they were suffering, or many other complex feelings). Likewise, if you are given a warning of impending missile attack most people would feel anxious, and become hypervigilant for signs of threat. Therefore, most people would not think of grief after a bereavement or loss, or anxiety when in an acutely threatening situation as pathological. Which makes it somewhat curious that the medical model has been applied to mental health in the way that it has. Why has it become that depression or anxiety or even addiction is seen as a disease, a neurochemical imbalance that needs to be treated with medication?

Perhaps the advances of modern science studying genes and neurochemicals made us think of ourselves as complex biological machines that could be understood at a physical level. Perhaps there is wishful thinking about biological models leading to potential cures. Perhaps the fact that brain injuries, tumours, dementias and neurodevelopmental conditions can make an impact on our feelings and behaviours made it seem that all feelings and behaviours could be attributed to brain changes. Perhaps the idea of massive numbers of people suffering is too distressing to think about and it is a common defence to depersonalise that, and to other the person suffering. Perhaps the narrative of mental illness has sustained the power and income of the medical profession as experts and gatekeepers to such treatments. Perhaps it was clever marketing propaganda by the pharmaceutical companies to sell more of their products. Perhaps it was so persuasive because it fits with the neoconservative narrative to think of individual failure rather than individuals showing the symptoms of societal problems (and therefore our collective responsibility to solve these problems and look after each other, rather than just thinking of ourselves). Or, more likely, it was a combination of these and many other factors.

Of course, we don’t want to throw the baby out with the bath water. There are certainly people for whom psychiatric medication has made a massive positive difference. People who feel more able to concentrate and gain attainments when on stimulant medication, or who feel less hopeless, anxious or angry when on antidepressants, or people whose distress, confusion or aggression is reduced by neuroleptics. But we can’t work backwards from positive impact to considering that proof of a neurochemical deficit or imbalance. After all, the evidence for analgesics is very strong, but I doubt anybody thinks a headache is a symptom of lack of aspirin! We need good unbiased data to understand what is going on, not the cherry-picked examples that currently make it into the public domain. Alltrials is a good step in the right direction in this regard, but there is still bias in what research gets funded and what gets published, with bias towards the sexier topics of new technology, genetics, scans and hard science, and less towards the sociopolitical aspects affecting individual and population wellbeing.

I’m not saying that nature isn’t important. It seems likely that various medical/biological factors do mediate the impact of experience. For example, some conditions like autism, intellectual disability, and dementia do appear to have predominantly biological causes, whilst having impact on thoughts and feelings. Brain injuries and diseases can affect personality, mood and behaviour, and various hormonal and physical conditions can affect brain function and impact on mental health. There seem to be genetic differences (eg to telomeres) that make some individuals more resilient to adverse experiences than others. And some twin studies show genetic factors influence the incidence of conditions like schizophrenia and bipolar disorder, although again the epigenetic factors seem important, it is not clear whether the biological differences are a cause or a symptom of the condition, and the role of biology is not large enough on its own to explain who gets these conditions without also considering experience. Like most of these debates, the answer isn’t going to be one extreme or the other. I am glad that the pendulum has swung back towards considering nurture and experience more, and not exclusively the high tech science of genes, psychopharmacology and brain scans. It seems likely that who we are and how we feel and function in the world is affected by both our biology, our experiences, our circumstances and our relationships both now and in the past.

So, whilst Christine Courtois and Bessel van der Kolk’s efforts in the adult and child spheres respectively to get the impact of complex and multiple traumas and damaged attachment relationships recognised as a better way to understand attachment disorder and personality disorder than a neurobiological disease model (and their challenges to the DSM) have not yet been successful, I am heartened if this way of understanding the impact of experience is gaining more credibility in the field. I think the power-threat-meaning framework might be helpful for some clients, and the questions that they advise asking are certainly good way of starting a clinical assessment.

“What is your story?” Specifically:

1) What has happened to you? (How is Power operating in your life?)

2) How did it affect you? (What kind of Threats does this pose?)

3) What sense did you make of it? (What is the Meaning of these situations and experiences to you?)

4) What did you have to do to survive? (What kinds of Threat Response are you using?) and are you still doing this?

5) What are your strengths? (What access to Power resources do you have?)

It certainly resonates for me, and I wrote about a lot of this stuff in my book, Attachment in Common Sense and Doodles in relation to children who don’t live with their family of origin. I wanted to make information about attachment and the impact of trauma more accessible to carers, legal professionals and social care staff and other profesionals in the child’s network. It isn’t novel content, as it was based on themes that had been researched, written and spoken about by others before me, but I have tried to present it in an accessible and engaging way.

I am heartened that in the last few weeks the idea of experiences and nurture being important in mental health seems to be reaching the public consciousness. It seems to be being promoted more vocally by a lot more clinical psychologists, and to have reached me in various different ways. I’m glad if it is gaining traction and a wider audience, but it might be that’s wishful thinking on my part, and merely a product of my unrepresentative sampling. In light of how horrible a lot of the news is since the Brexit vote, Tory election win and Trump victory, I’m trying to be more selective about what I read and the social media I engage with, so it could be I’m in more of a bubble of like minded thinkers these days, and that is the explanation for hearing more about models that fit my own thinking!

What is wellbeing?

A typical GP appointment is 7-10 minutes long. Therefore it was no surprise to me that when I started talking to my GP about my blood pressure a couple of months ago and diverted to talk about my lack of energy, I was referred to the “wellbeing worker” linked with the practise. There was a five week wait for an appointment. I sat in the waiting room at the designated time wondering if this was a new name for a practise counsellor, or an offshoot of IAPT linked to physical health, or whether it was a specific scheme designed to get people eating better and doing more exercise. When she invited me in the wellbeing worker introduced herself and said her remit was to work with people about “diet, exercise, smoking, drug use or to improve your wellbeing”. She asked me to rate my wellbeing on a likert scale for six variables.

So I diligently explained that since being rear-ended by a lorry 2 years ago, I have not been able to make a full range of movement with my left shoulder. This meant I had been unable to continue weight lifting. I also had to have 3 teeth removed and then had a very severe ear infection, causing some other health complications I detailed in an earlier blog. I told her that I have had intermittent earache, headaches, and a feeling of being underwater, which are exacerbated by changes in pressure or getting my ears wet so I had stopped swimming. I have also had ripples in my peripheral vision and a general lack of energy and motivation. I explained that the combination has meant that I had stopped my three times a week gym-and-swim habit and reduced to a fairly sedentary lifestyle with occasional longer walks.

I mentioned that been overweight for my whole adult life, and I had drawn some psychological links to the root of this. I explained that I am fairly comfortable with the idea of being overweight but that stress may have contributed to my more recent problems. I was of the opinion that there is clearly a significant physical component to my health issues, as it has transpired I am anaemic and vitamin D deficient as well as having high blood pressure. But I acknowledged that there is also a lifestyle component, as I had reduced activity and gained weight over the preceding months, and I acknowledged a substantial stress component too.

I noticed that the wellbeing worker had not taken any notes beyond “weight” and “exercise”, so I paused and tried to clarify her role. I asked what professional background she came from, expecting to hear she was a nurse, health worker or psychology graduate. “I’m an admin” she said, and explained that she had taken the job during a reorganisation, having been told that it was predominantly administrative. She said she had initially worried about what she would do if told about problems she didn’t know the answer to, but her manager had been reassuring that it wasn’t her job to solve everything and she could report any concerns to the appropriate person.

It turned out that her job was to identify which pathway to put people onto, from a choice of weight management, exercise, smoking cessation, drugs or alcohol and then fill in the paperwork to make it happen. She booked me in for the weight management group, and gave me a referral to the local council run leisure centre for 12 weeks free membership.

Don’t get me wrong, those things are good low-level interventions. The weight management group is friendly and non-shaming, even though it is pitched at a simplistic level, and I completely endorse exercise on prescription schemes for improving physical and psychological wellbeing. But where was the space to actually talk about what was going on my life? The website for the wellbeing service says:

‘Wellbeing’ means feeling happy, healthy and content in life. Our wellbeing can be affected by our physical and mental health, the people around us, the place that we live, the money that we have and how we spend our time. Our Wellbeing Workers can help you to identify and prioritise changes you might want to make to improve your overall health and wellbeing. They offer lots of support to help inform, motivate and empower you [including through] … Support with confidence issues and to improve self esteem

They offer services to reduce social isolation and assistance to address issues such as debt, housing and education (though this branch appears to prioritise people who have an intellectual disability or socio-economic deprivation) but the only mention of mental health or psychology is in relation to the specialist branch of the weight management pathway for people with BMI over 45 and those considering bariatric surgery. There are also leaflets linked from the weight loss section of the website which talk about “finding happiness” (helpful habits) and “mastering your thoughts” (basic CBT intro) and “relaxation and stress relief” (mindfulness, visualisation/anchoring, breathing exercises). But I was never even told these existed, and even when on the website I had to use the search feature to find them, and as far as I could tell there was no connection to the local IAPT service.

Six weeks later the wellbeing worker rang me up again, to see how I was doing. But again, she didn’t really want to know how I was doing psychologically in any meaningful sense. She wanted to know if I had followed the pathways she had offered. She asked me to give the six ratings again. It felt pretty hollow giving more positive scores, as I didn’t feel like the services provided by the wellbeing service were responsible for the changes – I had lost 10lb in weight before I joined the weight management group (and 2lb since), and feel better because I have more iron, more vitamin D, lower blood pressure, more energy and less pain.

So I was left feeling that it was a service that I was glad existed, but it seemed to tackle symptoms in isolation to their causes, and didn’t seem to connect physical and mental health. I’m guessing that is because public health is still local authority commissioned, whilst mental health is within the NHS. Wouldn’t it be nice if there was a single point of entry to this kind of wellbeing service and IAPT? Surely that would reduce stigma and mean that both symptoms and cause could be addressed, and patients would be able to tackle the interwoven issues of mental and physical health together.

 

Falling through the cracks – the current state of NHS mental health services

Recently I spent sixteen hours trying to get an acute mental health assessment for a someone. The details of the case are not what matter here, but I want to talk about what I learnt from the process, and to do that I’ll need to give some context. It is necessarily vague and some information has also been changed to protect confidentiality.

However, as a pen picture it is fair to say that there was a combination of a severe deterioration in mental health with risk to others (the person had bizarre beliefs that led them to want to injure/kill people within particular demographics). The person did not want any mental health input, but I felt that the risk issues were so acute that it was necessary to override the lack of consent and request that an urgent mental health act assessment be undertaken. The other members of the household were keen for this to happen, as were various professionals who were already involved from the health, social care and criminal justice sectors. The person was open to a locality mental health service, but after the initial assessment identified various needs nobody had been allocated to undertake the work, so although it was an open case there had been no service for several months.

So, I rang the local service to ask for a psychiatric assessment. It wasn’t an area where I have worked before or a service that I had any prior experience with so I rang the number on their website. I explained I felt that there was acute risk coupled with obvious decline in mental health, but a lack of consent to treatment, so I enquired what kind of urgent services could be triggered, suggesting that the person involved would be difficult to approach and it would almost certainly be necessary to undertake a mental health act assessment and an admission against the person’s will might be necessary to safeguard others. And that is where I hit a brick wall.

The local service told me they were not commissioned to have a crisis service, and that unless the person involved had self-harmed they did not meet the urgent criteria. No amount of risk to others, or deterioration in mental health would qualify for their service, unless there was self-harm, or the person presented at A&E themselves, or we waited the timescales of their routine service (which had no capacity to allocate a worker). Pointing out the NICE guidance required a same-day response didn’t shift their position. Highlighting the risk to others or the individual likewise seemed to go unheard. The Approved Mental Health Professionals team said that the person met their criteria, but they could not get involved unless there was a psychiatrist from the locality team who had seen the person and would identify the bed if it was necessary to use a section. The psychiatrists said they were not resourced to go out and see people, and that they were not prepared to put themselves at risk by attending a person who presented a risk to others, even though I had arranged for the police to be present. They said the only way they would see the person was if the police used section 136 to bring them to the hospital as a place of safety, where they could then provide an assessment. They suggested that we call 999 to ask for ambulance and police assistance. The ambulance and police said they were not there to provide transport, and if the person was calm and inside the house, they did not present an imminent threat that required removing them using section 136.

Deadlock.

The next day I phoned the local mental health team again and asked to speak to someone senior to raise my concerns about the case. The duty clinician called me back several hours later. I got asked “what do you expect us to do on a Friday afternoon?” and “why is this our problem?” and then got talked over loudly again and again as I tried to explain the issues with risk and mental health. I asked politely four times for the person to stop talking over me, without effect and then asked her name. She refused to tell me and ultimately hung up on me. Her service wouldn’t tell me who I had spoken to, or give me any information about the complaints procedure beyond telling me to write a letter to their postal address. I asked to speak to a service manager. Unavailable. To a psychiatrist. Unavailable. I asked for someone to call me back. at 4.45 I got a return call with the same content as the previous conversations. No crisis service. Doesn’t meet their urgent criteria. A&E, the police bringing in under a 136 or nothing. I wrote a report giving all of my concerns to the whole network in writing.

In supervision I talked about my anxiety about a serious incident, and my fear that nothing would be done, and everyone would pass the buck. I was supported that my concerns were legitimate, and made the decision to try to take it up the chain of command. I called the department again. Then I called the directors of the trust involved, and the complaints department. I made calls all morning with no response, having already had no response for over a fortnight to concerns I felt were so acute they needed a same day response. So I called the CQC.

The CQC were very helpful, and made me feel that it was the right place to raise my concerns. I feel that the systemic issues will eventually be addressed because of the CQC having sufficient power to influence commissioning decisions, but that doesn’t help in the timescale of the individual. Likewise someone near the top of the trust concerned did get back to me the next day, and want to learn from the process (perhaps motivated by awareness of the CQC being involved). Hopefully we’ll look at the pathway, and address the various issues that my experience flagged up. But again, that’s fixing the stable door after the horse has bolted. At the individual level, the outcome was disappointing. The person is moving to a different area within the next few weeks, and the service have decided that means that they don’t have to do anything, whilst the new area will only act if concerns are raised once the person arrives.

So the story doesn’t have an ending yet. There wasn’t a happily ever after, because the service I felt was required within a matter of hours hasn’t been provided, despite several weeks having passed. However, there hasn’t been a serious incident either. I’m keeping my fingers crossed the former happens before the latter.

But it was a pretty weird experience for me. Normally, if I raise a concern people take that pretty seriously. I’m a fairly senior clinician with the titles Dr and Consultant by my signature. I’ve been an expert witness in 200+ court cases. And I’ve had 20 years of experience against which to judge risk and after 16 years in the NHS I also think I have realistic expectations of services. I’ve never made a complaint about an NHS service before, and I hope I never have to again, but I didn’t feel like I had any other option. I was genuinely horrified to see defensive service specifications being used to deny a person with clear acute mental health needs a service. I felt like my concerns were ignored and dismissed because they were inconvenient and didn’t fit within existing pathways.

I’m not sure that my involvement did any good at all for the person in the end, despite spending hours and hours on the phone and writing emails and letters. But it made me wonder, what if I wasn’t there? What if there wasn’t someone with a title and qualifications and NICE guidelines to cite to try and agitate for the services to do the right thing? What if a family member or friend of the individual rather than a professional was trying to express their concerns? Why are the barriers so high when it comes to accessing mental health services? Why have services got specifications that exclude people in serious need? Why are the processes to raise concerns so opaque and so slow? Why don’t services join up better? Why are services always reactive and so rarely proactive? Are age, gender, race or other demographic characteristics a barrier to accessing treatment? Why are we still so far from parity between mental and physical health services? Why does mental health still not have the kind of services there are for acute physical health needs? Most of all, why does common sense and compassion get lost in pointless bureaucracy when it comes to referral pathways and criteria?

I used to be so proud to be part of the NHS. Now I wonder about what it has become. Is this just what is left after decades of cuts and reorganisations, or was I always a roll of the dice away from hitting a dead end?

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.