politics

Words Matter: Prejudice, progress and professional terminology

How we talk about things influences how we think about things. Whether you believe the people arriving in small boats after perilous journeys are “illegal immigrants” (who have come here to exploit the system and harm us) or “asylum seekers” (desperate people who are seeking better/safer lives for themselves and their families) frames how you treat them. If you believe people who have complex offshore tax arrangements are “legitimate successful business people” or “tax dodgers” frames how you treat them. If you believe that trans people are “men in a dress (who present a threat to women)” or vulnerable people who desire to live in a way that is aligned to their deepest sense of self frames how you treat them. Words matter because they set the Overton window – the range of discourse that is considered acceptable in a society – which frames the prevalent perception and accepted understanding of key issues.

That is why the “culture wars” in politics and social media is so dangerous. People are being swept up into bubbles where if you believe one misleading thing (eg that the difficulties young white men now face are not being recognised because all the focus is on uplifting women and people from the global south, or that immigrants get preference for housing or benefits or are taking away job opportunities from your community) you are suddenly exposed to more and more hideous things – from the incel mindset to vaccine misinformation, transphobia, racism, islamaphobia, antisemitism, sexism, and regressive views about reproductive rights or the value of people who don’t have children – until your understanding of the world can completely detatch from the reality. Once swept into a bubble like that people end up dividing the world into allies (who think like themselves) and enemies (who think differently). To align with the allies who defended you when you faced one area of legitimate criticism is to align with all their beliefs. So otherwise sensible and progressive people can end up defending the indefensible and entrenching into deeper and deeper prejudice and antagonism. Once it becomes about alliances and identity, it seems our ability to apply any critical thinking to evaluate claims is undermined.

Yet progress has made huge strides over the decades before this recent setback. The public are broadly supportive of gay marriage, of women’s rights, of a health service funded from taxes, of a social care safety net, of the need to take better care of the environment and avoid climate change. These have been positive changes over time. There is also less tolerance of prejudice. You can see it when you watch old TV shows, and hear their casual jokes that have a sexist, racist, homophobic or transphobic edge to them, and realise that such content wouldn’t be commissioned now (and rightly so) – although portrayal of people with disabilities by actors without them persists. Problems are most obvious when we look back 50 years or more, where the issue was overt in shows like the Black and White Mistrel Show and sitcoms contained overtly racist content. Disney have had to add content warnings to some of their old films and cartoons. However, shows that were not seen as problematic in my youth have also been reviewed. Episodes of Little Britain, League of Gentlemen and the Mighty Boosh have been withdrawn for blackface. But even relatively recent content can age badly. If you rewatch episodes of Scrubs or Psych (both still highly rated and available to stream) there is content that feels really uncomfortable now. The former has had three episodes pulled for blackface. Psych remains up in full, but has repeated caricatures of people of different nationalities, and lots of casual sexism, racism and transphobia, despite being made from 2006-2014. Times have changed for the better in this regard. The acceptable discourse changing is a sign that progress is being made to reduce inequalities. Frustratingly, as I wrote in my last blog post, the last government and various figures on the right have managed to reverse some of that progress, with inflamatory discourse about immigrants, islam and trans people. Thankfully there are signs that is being addressed by the new government and that the majority of people don’t share such toxic views.

Language also matters when it comes to the terminology people use about their skills and professional status. It might sound boring and pedantic, but it is super-important to use the right words to describe yourself – especially when it comes to the terms that identify your professional status or qualifications. When I go to my GP it matters whether I get seen by a qualified doctor with five or more years of training with signficant breadth and/or depth, or another form of clinician who may only have a year or two of training and a much lower level or narrower area of expertise. If I have stress and worries, it makes a difference if I see a “wellbeing worker” who only has administrative experience or a qualified mental health professional. At the hospital it matters if it is a or “physician’s assistant” or a doctor that examines you – it can be life or death.

So when I read a CV in which someone claims to be a “Chartered member of the BPS” when they only have GBC – the graduate basis that is the first step towards gaining a qualification that could lead to later Chartered Status* – that is a problem. Yet this mistake was made by more than one applicant for one of our recent vacancies. If I read that someone is a “clinical psychologist” but they are not on the HCPC register as a practitioner psychologist, that is misleading and unlawful – yet I’ve seen three examples this month alone (in applications, and on LinkedIn profiles). I suspect that people in the psychological career paths are being impacted by the lack of clarity in the legislation and professional bodies, just as the public are, because there is no clear single source of this information. It is particularly confusing for people entering the UK from countries with different training paths, terminology and regulatory frameworks. Someone who is legitimately a “clinical psychologist” in another country can’t continue to use that title when living or working here unless they gain HCPC registration. Yet it is interesting that it isn’t as obvious as someone not being allowed to practise as a medial doctor or dentist or social worker without the right regulatory status – perhaps because the regulatory framework for psychology is so weak that if they drop the word “clinical” they are free to claim to be a psychologist with impugnity**.

It also bugs me when people self-adopt the term “consultant” because this is not protected by law and they think it will make them sound more impressive, when that title should reflect external validation of the level of responsibility of your role and expertise. I had to earn that title through a process involving a panel interview for a job with national assessors appointed by our professional body. I gained my consultant grading after many years of service gaining specialist skills with a particular client group, only when I gained a post with responsibility for a multidisciplinary team in a multi-agency context, working with highly complex presentations. Whilst the professional bodies haven’t yet resolved the issue of defining use of the consultant grade outside the NHS or large employing organisations, there are some professional recommendations and correspondence. Consultant is a term designed to mirror our medical colleagues in the NHS and is used to designate an individual who has been assessed as having attained a high level of specialist skill, doing a job with a high level of responsibility for leading a service and managing others, as well as having a deep expertise in a particular model of psychology and/or population. It isn’t obtained by time served or by specialist knowledge alone, it is a reflection of holding a post that scores above a particular threshold on the KSF – normally leading a substantial area of service delivery and being accountable for the outcomes and the team that deliver that service. For that reason, it makes me bristle to see self-employed sole practitioners who have claimed the title “consultant” either because they offer consultations or because they think they have earned it through time served or depth of knowledge of a model of therapy. That isn’t how it works. Not only was I judged to be the strongest candidate for the post and to have the required competencies to work at that level, my NHS role was judged to require consultant banding because of its level of responsibility. I have retained the title “consultant clinical psychologist” after leaving the NHS because I have continued to work in complex multi-agency contexts, leading teams and being accountable for their performance. But if individuals within my profession don’t understand and respect this differentiation, how can we expect the public (or the courts, or private service managers, or colleagues in social care or education) to understand what the terms mean, which of them are regulated and how to recognise when people are using them inappropriately and what to do about it?

I still hope that the government will grasp this nettle and regulate the title “psychologist”, require professional indemnity insurance for anyone offering therapy or mental health services to the public, and give the public much clearer information about how to find a suitably qualified practitioner who can meet their needs. I hope that this will then bring clarity for the terminology that people can use, and for public understanding of that terminology. But we are a long way from this happening. For now, I can only try to share clear information on the clinpsy forum, which continues to get millions of page views and to be one of the most accessible sources of information about the career path for clinical psychology in the UK.

*The BPS have lowered all the standards for what it takes to be a member, and how you can become chartered, so this is less and less meaningful, and they have encouraged members (even student and graduate members) to use letters after their name that I believe the public and non-psychologists would find misleading, so they are at least partly to blame.

**The issue of regulation of titles in psychology is something I feel passionately about and consider an important issue of public protection. The UK is the only country in the developed world not to regulate the term “psychologist” so this is a necessary first step. But I believe that absolutely everybody offering any form of wellbeing service to the public requires professional indemnity insurance and to be within the scope of a regulator. Otherwise people will continue to be preyed upon by unscrupulous, abusive and incompetent practitioners when they are at their most vulnerable.

The worst and the best of us

I wanted to write something about recent events. They’ve had a powerful emotional effect on me, and lots of people that I know. People who are muslim, asian or black have been particularly affected, but I think many people will have been a bit more wary of unrest or concerned about what was going on and what it means about us as a nation. I also wanted to express solidarity to those who have felt fearful over recent times, and to think a bit about what we can do going forward.

There will be those who say that commentary on recent events isn’t professional or think it doesn’t relate to psychology, and more generally claim that politics shouldn’t enter professional settings. But, as you’ll have gathered from my past posts on here, I don’t shy away from politics. I think all human behaviour is worth trying to understand, and everything is ultimately influenced by wider political issues and decisions. Mental health does not happen in a vacuum. It is related to physical health, and to our ability to meet our basic needs for safety, shelter, food and relationships. There are also numerous socio-political issues underpinning the wellbeing of individuals and the trauma that many experience, from poverty to employment stress, polarisation (“culture wars”) to waiting lists.

As anyone who has read any of my blog will know, I’m politically progressive. I’d like to think I’ve always been very active in naming the racism/islamophobia on show in person and on social media, supporting my team to think about and deal with the repercussions (and I’ve been a long-time supporter of Hope Not Hate, Stop Funding Hate and various social justice organisations). I’m also have some skin in the game. I’ve previously talked about being a second-generation immigrant myself*, but never experiencing the same prejudices as friends who are black or asian or muslim because I am white, middle class and non-religious (although I was recently rightly reminded of the way white eastern european immigrants were treated around Brexit). I also believe in the golden rule to treat others as we’d hope to be treated. If there was a massive disaster in the UK, we’d hope that another nation would let us take our family to safety there, and give us the opportunity to work and contribute and become part of the community. We can’t resent the people who move here wanting the same thing.

So where do I stand on the recent riots? As I see it, they were the inevitable consequences, not of “reasonable concerns about immigration” or the tragic events in Southport, but of ignorance and hate stoked by the far right boiling over into acts of terrorism, vandalism and aggression. What happened over the weekend was the fruition of a long process of politicians, media and hatemongers shifting the window of acceptable discourse to include racism and islamophobia, with a thin veneer of patriotism to give it cover. It is a story that began before Brexit or the Trump presidency, and is tied into the growth of social media (see my prior blog here). The riots were the symptoms of a sickness that has been intentionally cultivated and allowed to fester for too long. I have watched it grow with revulsion and a sense of powerlessness. I can only hope that the people who instigated the violence face consequences as easily as the saps who enacted it, who have already started appearing in court and await prison sentences.

On the flip-side, as always, where bad things happen, we see good people stepping up. In this case we saw people coming out in force to clear up their neighbourhoods, repair damage and guard mosques. And today we saw thousands of people turn out to face down fascism in every city there was expected to be a far right protest, donating to fundraisers to cover repair costs for vandalised libraries, shops and cars, and expressing abhorence for the rioting. I also got some joy from watching how far right figureheads were throwing each other under the bus to try to seem less personally culpable, further protests failed to materialise and the media that had stoked hate for so many years was suddenly changing its tune. It was a relief to see that the majority of the population believe in a diverse and inclusive society, not in mob rule, and that those promoting or participating in violence will face consequences.

So where do we go from here? I think the government will need to act to prevent the spread of hate and instigation of violence, by considering how they regulate it on social media and in the press. The move towards rapid and visible justice was something we need to see applied to all violent crime, as the current court system isn’t able to keep up with demand**. We need to see changes to the immigration system too – moving people who are entitled to stay rapidly into work and allowing them to integrate in communities, rather than cooping them up in hotels at the tax-payer’s expense. And we need to address poverty, health and quality of life, so people don’t feel they have missed out on progress. It is much easier to whip up hatred against foreigners when people are struggling in their own lives. If we can offer a functional health service, a benefits safety net of minimum income that means people can afford to pay their rent and bills and feed their families. If we can offer hope for the future, educate people to recognise fake news, and show the value of diversity to our society, it will be harder to whip up hatred again.

There is an illustration of three men sitting at a table that I often retweet. One man has a pile of cookies on his plate, one has a single cookie and one has none. Sometimes the man with many cookies is drawn to look like a banker or a press baron or a billionaire, and the man without as an immigrant. The man with plenty of cookies tells the man with one “careful mate, that foreigner wants your cookie”. It is an apt metaphor for how the those with the greatest wealth and power have always targeted resentment towards those with least, so that they can maintain the unfairness of their privilege. It is no coincidence that the peddlers of hate are often selfish and narcissistic millionaires and billionaires, wanting the majority of the population to focus their anger on disadvantaged groups like single mothers, immigrants or people who claim benefits, rather than looking at who is really hoarding a disproportionate share of the world’s wealth and resources***.

*My great grandparents fled religious persecution in the USSR, my parents moved continent again to avoid complicity with a regime that was racist and to take up educational opportunities, and arrived in the UK in 1969. My mum returned 40 years of service in the NHS, my dad over a decade in education/care/justice. And they had me and my brother who haven’t been too bad for the UK either – I’m an award-winning CP and social innovator working in health and care, and he’s a world-leading AI researcher. Accepting a fair proportion of people fleeing persecution is the morally right thing to do. But it also makes economic sense. Without immigration, the UK would miss out on amazing people, and essential health and care staff.

**I also think that the draconian laws about peaceful protest, especially when applied to issues like climate change, need to be reconsidered. I don’t have an issue with prosecuting those who cause disruption or damage, but I think preventing them being able to explain their reasons for doing so in court is a concerning precedent, and some of the sentences have been disproportionate when compared to other crimes.

***The scale of wealth held by the richest few is mindblowing. This illustration starts with a single pixel to represent a dollar. Remember that a billion people in the world live on less than a dollar a day. A tiny square represents the household median income in the USA of £69,000 dollars (this seems higher than UK salaries, but they have to pay for health insurance and various other costs, and get minimal paid leave, and employers don’t have to contribute to employee pension schemes). A small square is a million dollars (a level of wealth that would place you in the top 3% of the world). Elon Musk’s wealth is a block so big it seems endless.

Playing the part: Some comments on political cosplay

Both Liz Truss and the disgraced PM have been pictured in the media cosplaying over recent weeks and months. Johnson dressing up as a fighter pilot, a soldier, a fishmonger, and in numerous hard hats and reflective jackets, and Liz Truss mimicking famous photographs and outfits of Margaret Thatcher have received the most coverage. But they aren’t the only ones. Priti Patel had her police jacket for her publicity shoots about immigration enforcement, and Sunak has been photographed in army camouflage, reflective jacket and hardhat, or white coat and mask during various visits, Sajid Javid likewise.

They are dressing up to play-act different roles, and carefully curating their image more generally (even when they are not overtly dressed up) to engineer public perceptions to create a desired public persona. Just as millionaire Nigel Farage likes to be pictured with a pint, play-acting an everyman whilst ranting about the elites (of which he is actually more representative), these outfits in which they don the trappings of those performing highly skilled, socially valued or manual jobs attempt to show that these posh self-serving elites identify with the working class and those who serve the country in the public sector that they are stripping bare. They want to look like they support the police, health, science, education, construction, armed forces by dressing up like them – but their actions say otherwise.

I suspect it is no coincidence that many actors have made it into positions of power (like Ronald Reagan, Arnold Schwarzenegger, Volodymyr Zelenskyy) and that politicians who wish to rise up the ranks seek out visibility on reality TV and panel shows (Johnson appeared seven times on HIGNFY, four as host). These opportunities don’t show how well they can do the job, or how well they understand key issues, but they try to make the individual likeable and human by showing their charisma and sense of humour. That plays well for those who like to be centre of attention and have learnt to entertain, but it is a poor metric for selecting people into positions of influence, where it could be argued that more serious skills (like getting on and doing a job, rather than doing something performatively or simply arriving to take credit when it is done) should take precedence. For example, Johnson ineptly mopping the floor at my local specsaver for the cameras didn’t mean that he took any helpful actions about flooding or understands the wider consequences of climate change. In fact, it merely illustrated that he is used to other people cleaning up around him, rather than doing so himself.

Over recent years, we’ve seen a move towards comments from the public and funny responses from social media becoming part of the content of news coverage and newspaper websites. The outfits, relationships and trivial events in the daily lives of celebrities are presented as headlines, alongside coverage of the war in Ukraine or the emerging international health risks from monkeypox. Superficial fluff that wouldn’t have been seen as worthy of coverage before is now everywhere, along with clickbait headlines driving traffic to advertising. News has to compete for attention more than ever before. Has reality TV and social media led to this shift away from issues of substance and judging people by what they do, towards celebrity and appearance? Or is it a deliberate tactic to make incompetence and corruption more palatable?

In Johnson’s case it not only seems intentional, but was a tactic he openly discussed in a newspaper column. The formula became wearily predictable: When news coverage about the government is negative, they create a “dead cat” story to change the conversation and focus of attention away from it. Most typically, if stories break that that he doesn’t like, he distracts attention by saying or doing something controversial. For example, when it came to light Johnson had promoted various women he has had affairs with for public funding or employment, demonstrating clear misconduct in public office, suddenly he was visiting Ukraine. Like Donald Trump, he also likes to create so much noise and controversy that he is always in the spotlight, but fact checkers and those who apply any other perspective are always one step behind and swept away in the next headline. Hence the litany of racist, sexist and homophobic quotes. You could even argue that some of the roots of the public vote for Brexit (compounded by Russian misinformation and the outright lies of the £350 million for the NHS paraded on the bus, and the racist posters of queues of refugees, and the fake threat of Turkey joining the EU) were in his made up stories about bendy bananas, condoms or vacuum cleaners being subject to EU red tape. These were amongst more than 500 misleading UK headlines about the EU prior to the Brexit vote.

But it isn’t just the stories that are weaving a fiction in which the public are encouraged to believe something other than the truth, it is the whole persona Johnson has created. Boris isn’t even his real name, or the one he uses with friends and family, but Alexander Boris de Pfeffel Johnson sounds like the posh entitled man that he is, not the the one he wants the public to see. It is well documented that he intentionally messes up his hair before TV appearances or being photographed, and he dons a silly costume for every possible publicity stunt, because he wants to be seen as that funny, harmless oaf and not as the dangerous corrupt risk to national security that appears if anyone pays enough scrutiny. In the case of the outgoing PM, it is hard to know what is beneath the construction of the scruffy buffoon he plays. He seems to have no sincerely held beliefs, to the extent he claims to have written both pro and anti-Brexit articles before deciding which one will serve him better to publish. The only constants that appear through reports about him over his professional life are his lying, his corruption and his infidelity.

So, when I see Liz Truss posing like a pound shop Thatcher, it seems to me to be a symptom of something bigger. Her history too shows weathervane opinions that shift according to what will help her access increased power. From her early Liberal Democrat politics, and her anti-monarchy speech, to her change of heart over Brexit, there is nothing that Truss will not 360 on if she thinks it is in her interest to do so. The latest shift to the far right with increasing racism and populist tax cuts that are likely to lead to both increased inflation and massive reductions in public spending is designed to please the Tory membership and secure her as the next PM. It shows she is cut from the same cloth as Johnson, and bodes badly for the country.

In some ways, the fact she is so unlikeable and insincere, coupled with the far right nature of her policies, might be helpful in the long term. The public are starting to see through the false promises of Brexit, and to see the harm that having such a self-serving government is doing to our NHS, the handling of the pandemic, our international relationships and standing in the world, and the cost of living. I hope that they will want future governments who care about standards of public life in the UK and recognise that self-interest by those with the most wealth and power harms all the rest of us, and the current incarnation of the Conservative party will never be electable again. Hopefully we are simply counting down until a general election, though I fear how much harm can be done in the interrim.

I’m also worried (after Trump and Brexit and the Johnson majority) that the public are too easily fooled by the characters that are being performed by those in and seeking power, and the biased coverage of the major newspapers. There is unprecedented lack of trust in politicians – which research suggests is not entirely unfounded. I’ve heard too many people say “but they are all as bad as each other” as if this government represents all politicians in the UK. The desperate headlines claiming Kier Starmer has millions of pounds of development land (rather than a field in which his mother keeps rescued donkeys) or that he also partied during the lockdown (rather than had a beer and takeaway where they had been working during election campaigning whilst restaurants and hotel catering were closed) seem to have made people think that nobody in politics is honest or genuinely cares about the issues affecting the population any more. I’ve even heard people equate Starmer having been honoured with a knighthood for his work as Director of Public Prosecutions to him being part of the crony establishment, like Lebedev and Johnson’s numerous other patrons who have joined the peerage.

I desperately want to believe that the next government will bring in immediate reforms to correct the course we are on. Some obvious changes would be to bring in electoral reform, to move away from the two party system in which most votes do not matter, towards a more representative system. They also need to make an independent committee to judge standards in public life, with the power to suspend and strike off any politician or public figure for gross misconduct. This could include sexual, criminal, professional or financial misconduct, serious or repeated lying, or making practical or financial gain for themselves, connected persons or donors. This should lead to prohibitions on second jobs consulting to businesses or working for them in the three years after leaving office, or on holding shares or interests in businesses that could be advantaged by their position or policy influence. I want to see immediate reforms to the House of Lords, striking out all recent appointments, hereditary peers, religious representatives and any member who has not participated sufficiently in the work of that office, and instigating transition to a second elected house which contains a wide range of subject experts. I also want to see stronger rules against misinformation, and support for the independence of the media (including the BBC and Channel 4). Social media companies should be made financially liable for harm caused through their platforms, as this is the only way they will act to prevent it.

But most of all, I want to see people I can trust in positions of power (as, it seems, do 97% of the population). I want individuals who have empathy and expertise, rather than just those with expensive educations. People who are motivated to do the right thing for others, rather than self-enrichment, and who have enough integrity to stand down if they are seen to have acted with impropriety. I want politicians who spend less time curating their image, and more time attending to the best interests of the population. Where you see the real person, not a persona they have created, and where being willing to work hard is not a costume they are putting on for the day.

Difference as a strength

I read an article recently entitled “There are no black people in Africa“. The idea seems like one of those obvious-once-you-think-about-it things that needs to be said more: People don’t inherently identify by skin colour, we identify by our culture, language, geography, function within a community etc and it is only when colonialism and migration put people in a context where they are seen as “foreign” or “different” that the labels of others (often those with power) group them with everyone else in the world with their skin colour as if this is a simple homogenous group. So in America or Europe there is a notion of “black” (or BME/BAME or BIPOC) being defined by being anything other than the majority “white” skintone, whilst in Africa or the Caribbean (or Asia) people are not defined by that (majority) characteristic, but by things that are more meaningful to them.

I agree with the author of the article that lazy stereotypes then follow from this overly simplistic labelling of others, which allow people to make assumptions about whole races or continents (eg the fictitious belief that all of “sub-Saharan Africa” comprises impoverished tribal communities reliant on western aid, whose lives bear little in common with those in industrialised nations, because all many Europeans know of these nations is the charity appeals during times of war/famine). It also ties into the white saviour thing, where people without relevant knowledge and experience arrogantly believe they can go and solve the “simpler” problems of more “primitive” countries, where their unremarkable skills will bring remarkable insights by comparison to local knowledge.

Even the language exaggerates and simplifies a multitude of difference into two categories; using white and black as polar opposite colour terms for what are actually countless shades and variants of colour from pink to deep brown. Whilst the language then links together people with wildly disparate geography and culture, simply on the basis that similar coloured paint would be used to capture a portrait – which seems a rather weird and arbitrary thing to see as a primary defining characteristic. It reminds me of arranging to meet someone at a conference that I had never met last year, where I described myself as “short, overweight, with long dark hair and a colourful dress” and the person I was meeting said exactly the same description could apply to her. We successfully recognised each other from the description, and we realised we had very similar professional interests also. However, we also realised the one thing neither of us had named was our skin colour – she was black and I was white.

I don’t think the author of the article that triggered this blog has the clearest writing style to convey his point – and he is almost certainly not the first person to name this exact thing. Nor do I think that his insights in the other articles I glanced at are unique or always right (eg other sources don’t support the 7 phrases he says we should stop using because of racist connotations) but I’m glad to have read the article, because it did really clarify some stuff I hadn’t put together myself. The fact I had not, is in the end a mark of privilege; the fact I’m not personally impacted and therefore haven’t had to do the work that so many others have to do day in and day out when thinking about race. I’m lucky to have never experienced racism, despite being a second generation immigrant (nor have I been on the receiving end of antisemitism, despite the fact my Jewish heritage carries its own burden of discrimination). I attribute that to being white and secular in appearance (I’m an atheist by belief).

As an aside: Identifying my own privileged position does make it feel awkward to write about race – there are so many things that I could get wrong, and so many people who are rightly feeling angry or depleted, or who might rather have minority voices amplified than another middle-class white woman add her two pence. All of that is true. But sometimes hearing things from a different perspective also has value, or gives the easily digested intro in familiar language that helps people to access voices with more lived experience. So I hope that if I’ve written anything that rubs anyone the wrong way, you’ll let me know so I can fix it up for others and keep learning.

Recent world events really have higlighted the extent of the problem, and how easy it is to foment division during stressful times – with Trump undermining democracy with his increasingly desperate attempts to cling to power, social media and much of the press amplifying divisive rhetoric and expressing the propaganda of their billionnaire owners, Johnson appealing to the worst elements of nationalism and the pandemic highlighting growing inequality, whilst the national act of self-harm of Brexit is reaching it’s final act. So it is no surprise that racial tensions have bubbled to the surface too, with the again so-obvious-it-shouldn’t-need-to-be-said Black Lives Matter protests gaining traction all over the world. Here in the UK the unequal death toll of covid-19, and the inequality enhancing manouvres of our xenophobic current government have really highlighted how prevalent and dangerous this unspoken level of latent racism in systems and the population really is. It is another stark reminder that what appears like a meritocracy in which everyone has equal opportunity only feels like that to those who are not weighed down by the adversities inherent in the system.

Thinking about the uneven playing field also ties into a phrase I read recently: Talent is evenly distributed, but opportunity is not. As I mentioned in a previous blog, when it comes to investment in business ideas in the UK:

  • only 1% of investment went to all-female teams, whereas 89p of every £1 invested went to all-male teams, and 10p to mixed gender teams
  • black entrepreneurs receive only 1% of funds invested in the UK
  • black female founders received only 0.0006% of the funding invested in the decade from 2009-2019, with only one black female founder in the UK reaching series A investment in that period (compared to 194 white women, and over 4000 going to all male/majority white teams)
  • female and black founders who do gain external investment, secure lower sums of money than their white male counterparts
  • 72% of investment goes to companies based in London
  • 43% of funding goes to founding teams with at least one member who attended Oxford, Cambridge, Harvard or Stanford
  • investors are 91% male, and 93% white, and only 3% of VCs in the UK are black
  • you are 13 times more likely to receive investment with a “warm introduction” from someone in your own network, which reinforces social exclusion
  • 88% of black entrepreneurs self-fund their business without external investment

Yet there are so many challenges that benefit from personal insight that might only come from certain subgroups of the community. I recently read about the founders of CapWay struggling to get investment because the venture capitalists didn’t understand that there are currently people who don’t have a bank account in the USA, for example. Imagine if the founders of Air B&B had never been broke enough to want to stay over on (or rent out) an airbed in a spare room. It gives a glimpse of what might solve a problem those who have had an easier life might never encounter. I’ve met social entrepreneurs who have explained to me the need for a mobile phone in order to identify sources of food or accommodation if you are homeless, or how much female offenders value employment and how this makes them highly dedicated employees. There are also traits that come from surviving adversity that are really helpful in an entrepreneur – being resilient, persistent, being able to juggle multiple demands at once, being grounded in the reality of customers or service users. There are also strong signs that more diverse founders lead to better returns on investment – women founders return more than men, and diverse founding teams more than all white teams. So this is very much an area that is rightly getting more attention.

In my recent business networking with other social entrepreneurs there has been a wide range of people represented in terms of gender, race, country of origin and socioeconomic class. I’ve spoken to people using their links to other countries and cultures in their business, working spanning boundaries, timezones and continents, and bringing ideas to their business from all kinds of prior experiences both personal and professional. I love speaking to people who see things from a different angle, and I am convinced that it so much more helpful to throw ideas around than simply speaking to others who have had similar life experiences to my own. It is one of the reasons I love Impact Hub, as is one of the organisations where all of us in the early stages of developing businesses with a social purpose can find equal support and a culture in which there is value in different perspectives. I’ve used them as my London base for many years, because their co-working space is so convenient for Kings Cross/St Pancras, but they have been brilliant at making an online only membership to adjust to lockdown. And living through a pandemic, I have never been more grateful for my virtual networks to keep me inspired about what I am trying to achieve.

Learn more about the inequalities in business investment here and more about Impact Hub here.

Coping in a time of coronavirus

Are you finding it hard to adjust to the impact of Coronavirus policies on daily life? If so, you are not alone.

If you aren’t too saturated with top tips for wellbeing type posts, I thought I should share a little bit of basic advice compiled from my knowledge as a clinical psychologist and what I have read on science twitter, in case others are also struggling with the impact of social distancing and experiencing changes to their daily life that are causing high levels of anxiety.

Note: This blog is mainly targeted at those people who are staying at home and trying to comply with social distancing, rather than those of you who are doing the kind of essential work that has to continue to involve direct contact with others. If you are in that group, I’m incredibly grateful to you, but I don’t feel skilled enough to provide specific advice. If you have greater knowledge than me and would like to improve this blog (particularly in terms of the physical elements, which I appreciate will change as the situation and our knowledge base evolves) please let me know and I can fix things.

So, with that said, on with the blog.

It is a worrying time for many people, and there is a real threat that we have very little control over, and a lot of misinformation on social media. However, there are things that we can do, and you are not alone – we are all facing this together. So this is my very simple advice of where to start to ground yourself and remain as psychologically healthy as possible in these challenging times.

First the physical health stuff:

1) Do everything you can to remain safe and protect those around you. First and foremost: Get your vaccination when it is offered. Don’t be put off by scare stories about side effects, as a day or two of aches in your arm or a few hours of flu-like symptoms are a small price to pay to reduce the risks of a deadly disease. Staying safe also means following the latest guidance about lockdowns, masks and social distancing. This applies even after you have had your jab! It is still possible to get covid after you have been immunised, and whilst it is much more likely to be symptomless or very mild, you can still be part of the chain of transmission to others, especially with more contagious variants like the delta strain.

So what do we need to do? The government have put a focus on hand washing with soap for 20 seconds (make sure to wash between fingers, around thumbs and wrists and under fingernails if you have had any contact with someone who may be contagious), and remind us to cough or sneeze into a tissue or your elbow rather than onto your hands. There has also been a focus on cleaning surfaces – however the evidence of fomite transmission (droplets on surfaces) has been minimal, whilst the evidence for aerosols (tiny particles exhaled by an infected person that are airborne for several hours and accumulate in enclosed spaces) has become overwhelming. Thus the key prevention strategies are to wear a mask when entering shops or public indoor spaces, and to follow the rules about physical distancing. This means not greeting people with handshakes, hugs or kisses and standing or sitting further away from them than we would previously have done. Minimise your face-to-face social interactions with people outside your household bubble, and try to ensure you only interact with larger groups of people in a safe way – ideally outdoors or in a well-ventilated space. Unless you work in an essential role this means avoiding crowded events and places, not meeting up in large groups, and trying to remain 6 feet away from others, especially anyone outside of your minimum necessary network. Wear a well-fitted mask in any enclosed space apart from your home – try not to put it on and take it off more than you have to, and avoid touching the mask except by the strings.

2) Be aware that Covid-19 is potentially dangerous, so it is really worth preventing contagion if possible. Even if you are not concerned about the impact of covid on yourself, each of us interacts with people who are older or clinically vulnerable – whether that is elderly parents or grandparents, people with chronic or acute medical conditions (eg cancer, heart disease, diabetes, immune disorders, physical or learning disability, obesity, asthma) whether we are aware of them or not. People we know might also be carers for individuals with these clinical vulnerabilities. In fact 3.7 million people in the UK are regarded as clinically extremely vulnerable, and many of them remain very anxious about the risk of catching covid, even if immunised, despite the fact that the official advice to shield has been lifted.

Covid is worth avoiding as even if you are not in a vulnerable group you can pass it on to others, plus – even within the group that are considered to have had only mild symptoms – it makes some people feel like a very bad flu with aches and serious chest pain/breathing problems, and can lead to weeks or even months of tiredness or recurrent symptoms in some people known as “long covid”. However, for many/most people it may not be obvious that you are ill at all, let alone with a serious condition.

If you test positive, or if you have a dry cough or fever, or if you lose your sense of smell or taste, or if you feel suddenly exhausted/weak, you need to get rested and to self-isolate to prevent spread of the virus. You must also minimise risk of transmission until you have been tested if you have had contact with someone else who has subsequently tested positive for covid, to break the chain of transmission. If you have school aged children you will be asked to complete lateral flow tests twice a week, but be aware these are not as reliable as other tests and can lead to both false positives and false negatives.

3) Take extra care over social distancing if you have an existing health condition or are elderly, or if this applies to anyone else in your household or if you are interacting with or providing services to someone vulnerable (as well as older age this could include more serious medical conditions like cancer, but also ones that are not normally seen as a big impairment to daily life like asthma, heart disease or obesity, particularly in combination). Ensure you have enough medication, and keep taking preventers if you are asthmatic. If you are in a high risk category and there is a high level of prevalence in your area, then where possible have deliveries dropped off without interpersonal contact. If you need to interact with others or use shared facilities, wash your hands and surfaces that others touch frequently (eg door handles, railings, keypads, taps, etc) with soap or sanitiser regularly and wash your hands after using them.

4) Remember that viral load may be important in how severely people experience the virus, and ensure that you take precautions when caring for a dependent with possible coronavirus, or if you think you have it, even if the symptoms are mild. A mask is particularly important in this situation, along with good ventilation, careful handwashing and ensuring you avoid physical contact, which can be challenging with a loved one or small child. Anyone ill or who knows they have been exposed to someone who definitely had Covid-19 should stay separate from the rest of the family as much as possible. This needs to be for at least 7 days after testing positive if you have had no symptoms, or for 7 days after you stop having symptoms. Where someone is ill but needs care use PPE such as a well fitted mask and disposable gloves, use as much ventilation as possible, and keep washing your hands.

5) Although the government are telling us to act as if covid is no longer a problem, we don’t know if there will be additional waves of new variants of covid, or whether future variants will break through the protection offered by immunisations. Covid is also still causing preventable deaths and lasting health impacts for large numbers of people, as well as causing large numbers of people (including health and care staff) to self-isolate. Combined with the impact of Brexit and chronic underfunding the NHS is creaking at the seams. We need to ensure that the NHS can catch up with the level of need for other conditions, and is ready to cope with an increase in demand if required.

Politicians and NHS managers need to act to grow the capacity of the NHS by addressing the funding and recruitment issues. However, each of us can play our part by reducing our risk of spreading the virus or adding to NHS demands in other ways. This means we should aim to slow the spread of coronavirus (by getting immunised and using sensible precautions) so that the rate of people requiring hospital treatment doesn’t exceed NHS resources, and lower the baseline demand for NHS services. We can do this by avoiding preventable reasons for requiring hospital care. This means taking care of your physical health and existing health conditions (eg taking preventative medication/inhalers, following dietary advice for diabetes or high blood pressure), being mindful to reduce risk of accidents (eg drive slowly in built up areas, be extra cautious to avoid falls and injuries) and improving your respiratory and cardiovascular health (eg give up smoking, increase exercise, eat healthily, and attempt to lose weight if you are obese).

But importantly you need to care for your psychological health too.

6) Connect with loved ones (physically if you are in the same household and nobody has symptoms, but virtually or with social distancing precautions otherwise) so that you do not feel alone. Hug your kids or your partner if you are together, or speak to them as frequently as possible if you are apart, and listen to how they are feeling. Check in with people who might be isolated and with those who have been bereaved or have had serious ill-health, traumatic experiences, or have lasting symptoms from covid. Keep in touch with your relatives and usual network via phone, social media, email or video chat. Make the effort to speak to your colleagues even if you are all working from home, keep in contact with your friends even if you can’t gather in person. Confide in the people that you trust.

7) Acknowledge that what we are going through is tough, even if you feel lucky not to be having to deal with it face on like those working in health and social care or doing supply chain or deliveries. Trust your own gut about what level of potential exposure to the virus you feel comfortable with, and don’t let anyone make you feel bad if you don’t want to go back to face-to-face work or social events. Change is challenging, the perceived threat is intangible and unknown, so it is hard to reason with the anxiety it provokes, and uncertainty is stressful. The changes imposed on us to manage the outbreak take away some of our comforting routines and our expectations of the immediate future, and it is normal to worry about the impact on ourselves and loved ones. It is absolutely normal to feel shock, denial, anger, fear, grief, or a mixture of feelings and for these feelings to ebb and flow or change unpredictably (think about the Kubler-Ross stages of grief). You might find yourself literally shaking and/or crying at the idea of having to do something you don’t feel ready for, or you might feel nothing at all. Be kind to yourself, and give yourself time to adjust.

8) Manage your own anxiety. First and foremost, breathe (there are some good little graphics and apps about). Then make sure that you take care of yourself by doing all the basic things that we need; eat, sleep, exercise. Try to avoid increased use of alcohol or drugs, including smoking. Give yourself a routine. Confide your feelings in those you trust, or seek out support if you need it. Join in online mindfulness or therapy groups, or – if the anxiety is becoming a problem for you – seek out personal therapy from a suitably qualified professional. If you have a garden or safe outside space, get out there and appreciate the elements. If you don’t, try to sit near a window and let some fresh air in as often as possible, and leave the window open when the weather isn’t too cold. Exercise and relaxation are both important. The former can burn off negative neurochemicals and produce more positive ones, and the latter can help you to soothe yourself (so indulge in a long bath, or listen to a relaxation video). Likewise sex (or masturbation) is good for our neurochemistry, can maintain intimacy in a relationship through a stressful period and/or help you to sleep.

9) Limit news consumption and stick to reliable sources. If you are feeling anxious you might want to learn everything about Covid-19, but whilst this can bring some temporary relief, too much focus on the potential threat can be counterproductive and increase your anxiety. So try to limit how much time you spend on news sites or social media, and ensure that you check the sources of what you do read as there are many seemingly plausible articles and posts that are not true doing the rounds. The BBC, World Health Organisation, official government sources or a trusted newspaper (for me that means the Guardian or the Independent) are probably more trustworthy than celebrities, social media influencers or some politicians. Don’t get your information about the outbreak from social media unless you have personal connections with medical/epidemiology experts and are very skilled at evaluating the quality of the sources and understanding the limitations to individual studies. If covid content makes you anxious but you like connecting over social media, you might wish to use your preferences to tune out posts using terms like “pandemic”, “coronavirus” and “covid”, so that you can focus on more positive content.

10) Keep busy. Give yourself small goals and structure your time into small chunks, rewarding yourself for small achievements. Be mindful about what you are doing, and give it your full attention. Don’t let yourself ruminate, or slouch about in your pajamas all day. If possible, make sure that you sleep when it is dark and are awake for natural daylight. Stick to routines of mealtimes and maintain as many of your normal activities as possible. If you are unable to work or have less work to do, see this as an opportunity to do things you wouldn’t otherwise have time for. Try to find enjoyable activities or those that keep your mind occupied, whether that is arts/crafts, reading, gaming, sorting/tidying, decorating, programming, writing, making or listening to music, watching films/telly or learning something new (there are loads of fab free courses online).

11) Turn your focus towards the practical things you can do. For me that means trying to increase my cardiovascular fitness and lose some weight, because my pre-existing conditions mean I’m at greater risk, and my lack of fitness compounds this – so I’ve been trying to run up and down the stairs first and last thing each day, and each time I feel particularly anxious. This gives me a sense of doing something positive and it can be rewarding to see yourself making progress. You can choose an activity that suits your starting level of fitness, get out and walk or cycle or there are fantastic exercise videos of all sorts on youtube, so why not try some zumba or yoga or calisthenics. Or improve your living environment, or create or improve a garden or vegetable bed. These kinds of things will give you a tangible feeling of achievement and improve your quality of life.

12) Be kind to others. Manage your anxieties before you speak to children, answer any questions they might have and help them to feel safe and loved. Try to be kind and patient if children are off school, and don’t put too much pressure on them to do academic work until they are in a calm enough emotional state to do so. Listen to loved ones and empathise with their experiences, even if they feel differently or are responding in a different way to you. If there is a spate of panic-buying (whether of toilet rolls, fuel or fresh produce) try not to buy more than you need, so that others can get some of key items too. Thank delivery workers, supermarket staff, carers and other essential workers, and don’t pass on frustrations about lack of stock or delayed/cancelled deliveries to them as they are doing their best. Reach out and make connections to those who might be lonely. If you are young and healthy try to be particularly considerate towards those who are not – keeping in touch with older relatives and friends or those with disabilities and/or health conditions whilst keeping them away from contagions. Join neighbourhood networks or the NHS volunteers list. Leave a note with contact details for vulnerable neighbours in case they need help with shopping or collecting prescriptions, or someone they can speak to on the phone or through the window if they feel isolated. Donate to food banks and local charities if you can afford to do so. Shop with smaller companies and local traders where possible.

13) Take time to be grateful for what we have. If you have people who love and care about you, appreciate them. If you have pets that share your life, pamper them. If you can access nature, take time to enjoy that. If you have had the opportunity of education and can continue to learn, value that. Remember that we live lives of relative plenty. Most of us have relatively secure places to live in locations with relatively good health services to fall back on if we need them. Many of us have meaningful work to be involved in, and live in developed nations with some form of social security to fall back on and/or within networks that would support us in a crisis. So although there are greater challenges in our daily lives due to the pandemic (or Brexit and an inept/corrupt government), we still have a lot to feel grateful for. Focusing on the positives helps you put the challenges into perspective.

14) Know that we’ll solve this in time. So many brilliant people are working together to address this new disease. Health care professionals are doing brilliant work all around the world. Scientists are hard at work exploring faster and more effective tests and treatments. New drugs are being developed at a faster pace than ever before, and well-established medicines have been found with positive effects on disease severity/duration. Uptake for immunisations has been good enough to massively reduce mortality. We have tests to show who is contagious. Immunised people (and those who have had covid) are less likely to be a vector for transmission, so rates of infection are likely to fall over time. Air filtration devices are being tailored to removing the aerosols that increase risk of transmission in indoor spaces. Advances are being made all the time.

15) We all know the death rates and current numbers of people infected. The negative stories are spread far and wide, but some good things will come out of this too. Pollution has been reduced by the decreased travel and factory activity, saving lives of vulnerable people, especially in the developing world, as well as helping the environment. Reduced car journeys might mean reductions in accidents. Political recognition of changing public perceptions should lead to greater investment in health and social care, as well as increased funding for medical research and response-readiness for the future. The pandemic has also shown that all nations face the same threats, and all people are the same, so (with the exception of some racist idiots) it has increased international cooperation and the knowledge that we are all interconnected. This has the potential to allow greater collaboration on international issues in future. Mass working from home has shown that it is possible for more people to work remotely, meaning there are likely to be reductions in travel and more adjustments for people who need it available in the future. It has also highlighted the value of essential workers in supply chains and delivery as well as in health and social care, raising their status and priority in public perception. The economic impacts have shown the value of universal health coverage, social safety nets, and minimum income guarantees. It has reduced the mindless consumerism of recent years, and made us conserve resources and reduce food waste. So hopefully we will come out the other side having learnt some important lessons and can genuinely build back better (and not just use this as a vacuous slogan to cover for government inaction).

Pessimism, propaganda and politics

I can’t be on the only one being crushed into learned helplessness and pessimism by the triumphalism of the far right taking over British politics, and the impending Festival of Brexit. Unlike the Brexit referendum result, the election of Trump and the results of past elections in the UK, this time I knew it was coming. But that hasn’t made it easier to accept. So how did we get here? And what should we do now? I figured I’d split some content out from a diversion on a previous blog and then share some thoughts about the leadership of the labour party.

It seems evident we are now in a time of propaganda and fear-mongering, where the truth has been lost amongst distortions and misinformation. Adam Curtis captured this prophetically in Charlie Brooker’s 2014 end of the year show (shown in two tweets from the marvellous Carole Cadwalladr here). Misinformation and bias is now pervasive in the way we receive our news, which is mostly delivered via social media and decided by algorithms based on past viewing choices in a way that reinforces our narrow bubbles. The news we read is skewed by the need to to keep us coming back to see the advertising content that funds it. And that means it is full of carefully curated fear, uncertainty and doubt, in between the filler of social media anecdotes and celebrity gossip. No wonder it feels like there are so many layers of bad news in the world at the moment.

Even when we take the time to read a newspaper cover to cover, we hear about so many hideous individual crimes not just in our locality but nationally and internationally because the world is so connected now – the latter often only identifying their location way down the article, meaning the headlines make us feel these are all risks that affect us personally. It makes it feel like the world is getting more dangerous even though the reverse is actually the case. There seem to be so many horrendous incidents of stabbings and shootings, and the ongoing human cost of the various war/conflicts going on in the world. And we start to feel as powerless as we do about the terrible weather events of different types that are being reported all around the world, from forest fires to floods and loss of ice fields. You’d think we know enough already to stop the global warming that is fueling the volatile weather, address the causes of conflicts and mediate solutions, and have effective police and criminal justice systems around the world. But no. It seems as developed nations, we prefer to make superficial changes to actually implementing real change when it comes to the environment.

Sadly, that is no surprise given the disproportionate influence wealthy individuals and multinational corporations have over policy. We seem to have increasingly allowed the super-rich and corporations to covertly buy influence through donations and lobbying. This lets them promote the kind of politicians who will increase the wealth gap further still, remove consumer protections and “red tape” and allow creeping privatisation of public services. The same forces let the far right foment prejudice and anger through internet and tabloid propaganda, so the focus of blame is always downwards toward vulnerable groups and not upwards to those with wealth and power. To compound and consolidate this, in the UK we have chosen to immobilise our entire system of government, civil service and public and private sector management for three years whilst deciding how many feet to shoot ourselves in under the banner of Brexit. This has never been more obvious than in the last week, where we are now poised to undermine all the checks and balances, and scupper the next few years of economic growth to entrench this new post-truth hard right populist culture for future generations.

And whilst the Labour party try to elect a new leader with the credibility and passion to challenge this, the left is fragmenting rather than regrouping. I’ve seen so many posts about Corbyn and Corbynism, trying to make out that idealogical purism is still the way forward, that we lost the election but won the argument and should do more of the same. Another Angry Voice posted as if it was irrational fear of renationalising transport and utilities that was the problem, concluding “If you’re afraid of Jeremy Corbyn’s economic policies, I’m afraid you’re pretty much the dictionary definition of a narrow-minded little Englander aren’t you?” I couldn’t disagree more. Frankly, I doubt many progressives disliked Corbyn’s policies, especially individually. However, together his policies will have seemed very disruptive and expensive not just to conservatives but to a lot of the middle ground and left-of-centre voters that are so vital in gaining a majority in UK politics – meaning he didn’t have mass appeal. Yes, he was undoubtedly a good guy – warm, kind, genuine and thoughtful, and held in high regard by everyone who knows him personally. So was this also an example of a tendency to make snap judgements by first impressions, another consequence of unhelpful stereotypes of what a good leader is like, proof of a corrupt media or some combination of all of these things? I’m not sure.

Even to the diehard lefties (and I’d consider myself left of Blair, and someone who had great hopes for Corbyn in the beginning) Corbyn wasn’t the right fit for the job of heading up the opposition or being elected prime minister. Many of us worried about his leadership ability, his ability to be decisive and persuasive, to convey ideas in simple soundbites, and his failure to crack down on antisemitism within the party – giving the biased millionaire-owned media a stick to beat him with. But most of all, we worried about his choice not to articulate that Brexit was a tax evasion ploy by the super-rich that would harm the most vulnerable most, but also cause child poverty, cuts in public services, the break-up of the union, weaker negotiating positions that allow US pharmaceutical companies to charge more to the NHS and infringement of our right and liberties. Instead he believed/pretended that labour could offer a “good Brexit” of some kind, and lost half his supporters. He then failed to form any kind of progressive alliance, and instead allowed attacks on progressive peers in other parties, which was the nail in the coffin for the election.

So where do we go from here? Is it just about getting a new leader who gives a better first impression? It seems to me that politics has polarised the historic broad and diverse parties on either side of the house into narrow camps at either extreme of the political spectrum, leaving a lot of us disenfranchised by the first past the post voting system and the recurrent gerrymandering of constituency boundaries. We can see it in the hard-right Brexiteers that now dominate the Conservative party, but we can also see it in the way that a dominant and vocal minority supporting Corbyn and accepting no deviation towards incorporating a broader range of voices or considering what policies might be popular or electable has taken over the Labour party. Perpetuating this narrow view of purist socialism in which everyone else is “narrow minded” or a “red tory” is a very significant part of the problem – to win elections you need mass appeal, not to attack and alienate anyone even one degree outside of your bubble. I think Tim Minchin is right that its a massive problem with social media culture that the Overton window for each tribe is now tiny and any deviation leads to people being shamed and out-grouped (“I am afraid to write anything that might upset my own tribe”).

As this twitter thread articulates, I’d much rather have a centre-left prime minister doing many cumulative good things that are slightly less rapid or radical, than for all my beliefs to remain represented by an increasingly narrow, segmented and ineffective opposition. An amazing amount can be done within a party and set of policies that have broad appeal. For all his flaws, the centre-left Blair government made a huge amount of impact in numerous areas:

They lifted 600,000 children and 1 million pensioners out of poverty, provided winter fuel payments, free bus travel for over 60s, free TV licenses for over 75s, and improved a million social homes. It doubled school funding for every pupil, added 36,000 extra teachers and 274,000 teaching assistants, transforming education, leading to record literacy and numeracy. They opened 2,200 Sure Start centres and provided free nursery places, giving a better future for millions. They raised child benefit by 26%, introduced child tax credit and 3 million child trust funds. They invested in the NHS, employing 85,000 more nurses, cutting NHS waiting times by 82% and got in-patient waiting lists down half a million. Heart disease deaths fell by 150,000 and cancer deaths by 50,000. They implemented the smoking ban that has contributed to a 30% decline in the number of smokers in the UK, with massive impact on numerous health morbidity statistics. They created NHS Direct. They also improved employment rates and conditions: they introduced minimum wage, created 1.8 million new jobs, cut long term unemployment by 75%, doubled the number of apprenticeships, and introduced the right to 24 days holiday and 2 weeks paternity leave. They employed 14,000 extra police, cut crime by 35% and increased criminal justice (court) spending by 21%. They negotiated peace in Northern Ireland, brought in the Human Rights Act, doubled overseas aid, wrote off debts for the poorest nations and created GiftAid. They scrapped Section 28 and introduced Civil Partnerships. They banned fox hunting, and gave free entry to museums and art galleries. They also managed to couple this with the longest period of low inflation growth since 1960, and created less debt than the governments before or since them, despite bailing out the banks. I’d say that’s pretty remarkable, and something to aim for achieving again.

However, at the last election, perhaps because of Brexit and this ideological purism – we (on the progressive left) didn’t manage to instill hope for positive change in the people of Great Britain, or to challenge the vacuous headline of “get Brexit done”. The election results were depressing but felt somewhat inevitable. As frustrating as it is that we have a government the majority of the population didn’t vote for, giving us a hard brexit that the majority of people don’t want, whilst we watch the world polarise and allow neo-fascist populists to rise, there are some tiny silver linings: The Tories have to work out how to do Brexit and will be responsible for the consequences and, hopefully, the Brexit party are gone.

I think this time around we need to pick someone who stands for all the right values, but has been able to articulate them in a way that has made real traction and can engage a much wider range of people. As much as I’d like that to be a woman, ideally from the north of England, supported by someone with a differing ethnic or cultural background, from the line-up on offer, I think Keir Starmer is the right person for the job. He’s spent his whole career knowing, following and effectively challenging the rules and processes of the legal system for the benefit of ordinary people, including challenging corporations and government policies and holding them to account. And he has done so without seeking personal glory, or making a reputation as a troublemaker. Whilst I really like Jess Phillips, I think she is too marmite to gain mass support and bring the country back together. Emily Thornberry seems nice, but very much a part of the north London bubble, and I don’t think the other candidates have the public profile or despatch box clout of Starmer, and we will at least get Angela Rayner as deputy leader.

Picking yet another white man from London for a political leadership role feels frustrating, as it plays into all the stereotypes of what a leader looks like. But I’m prepared to make compromise to get greater influence for progressive policies that will make the biggest impact on diversity in the long term. Plus we can only choose the most credible candidate standing. And for me that’s Keir Starmer. Hopefully he can bring the party together, tackle the scourge of antisemitism, and speak out in a way that appeals to a much wider demographic and geographic population than his predecessor.

I sincerely believe that if we all work together to encourage compromise and collaboration hopefully a more effective opposition can rise from the ashes that is more willing to be welcoming to a broad range of voters and more able to articulate how the current government continues to benefit the richest few at the cost of the rest of us, and particularly the most vulnerable in society. We need to show that the choices that Johnson and his remarkably homogeneous new pack of white male cronies are making are directly responsible for harming the welfare of large numbers of Brits. Current Conservative MPs being only 24% women and 6% BME is pathetic, and the greater diversity of candidates on the left should bring us a plurality of ideas and allow us to appeal to a wider demographic and opinion range amongst voters, if we get out of the silo mentality.

But more than that, we need to take on the issues. We need to campaign for environmental action nationally and internationally, strengthening of the legal system, an end to racism, xenophobia, antisemitism, islamophobia and discrimination, and the important task of electoral reform, so that we don’t end up with scumbags in power or people who lose elections being given cabinet roles via the House of Lords. And we need to grasp the nettle with proper regulation of social media as a publisher. But they will only take action if enough of us insist on it. As I said earlier, the million dollar question is whether we want things to change enough to take action, and to find common ground. I’ll end with the wise words of Jo Cox, “we are far more united and have far more in common than that which divides us”. So let’s act like it!

16/2/2020: Lisa Nandy just made a really good speech about anti semitism that has really raised my opinion of her, so maybe there is a woman from the north that can do the job after all!

The rise of the bad guy

Trigger warning: first two paragraphs mention paedophiles, middle section is about racism and sexism, later content is political

The first time I met a paedophile I had no idea. He didn’t wear white towelling socks that showed below his slightly-too-short trousers, he didn’t wear a dirty trench coat, and he wasn’t a socially awkward man with greasy hair, unflattering glasses and a slight squint. Quite the contrary. He was a well-groomed, educated, articulate, middle-class man. He attended appointments to express concern about his grandchildren, and appeared supportive to his children in trying to sort out their problems. He was polite to professionals, and always thanked us for our time and expertise. I later found out that he had sexually and physically abused several members of the family. Looking back, our only clue (beyond the fact the children referred to us were evidently troubled and failing to thrive) was that the receptionist in one clinic said that she didn’t like the way he spoke to his wife in the waiting room, saying “I wouldn’t talk to a dog that way”. But we didn’t know how you could appropriately record that in the notes, given only the children were open to the service. So we didn’t record it.

The next time I met a paedophile he didn’t fit my stereotype of a creep or bad guy either. In fact, he tried to be my friend and find areas of common ground. If I hadn’t met him in my professional capacity and known of his conviction in advance, but instead had met him socially under different circumstances, I suspect we would have found some. Perhaps we would have had a pleasant conversation about politics, video games or running internet forums, and I’d have left thinking he seemed like a nice person. He was young, outgoing and wore a colourful T-shirt referencing a slightly crude meme. He was charismatic, informal and irreverent, and he flirted with the admin staff. However, I might have picked up on something when I found out his partner’s IQ was more than 60 points lower than his, that she had a serious trauma history, and they had met on a dating app for single parents where his profile bragged of how much he loved children. But I doubt his attraction to vulnerable single mothers is something apparent to most people that meet him, at least until they know him well.

The opposite face of this coin, where people assume they can judge a person’s character accurately from superficial appearances, almost certainly contributes to a lot of prejudice and discrimination. So many people from specific population groups are assumed to be aggressive, untrustworthy, or unacceptably different because of their culture or religion – but whether people experience these prejudices or not doesn’t reflect their behaviour or beliefs (or even whether they actually belong to the assumed demographic). Think of the prejudice about gypsies and travellers, or Muslims, or young black men, for example. Likewise the stereotypes about gender, or age. As I mentioned in another blog post, women in the public eye get judged for how well they conform to societal expectations of women – to look decorative at all times, to not be perceived as “aggressive” and to look after others. Any emotional expression is seen as a weakness compared to the perceived standard of cold logic that is perceived as more masculine and therefore preferable. There is a whole lexicon of words used to put women down when they step up to the plate.

Again, most of us are blind to our prejudices and we are also blind to our privilege. We assume an equal playing field when we congratulate ourselves for our achievements, and we don’t see the constant attrition that marks facing prejudice that contextualises individual incidents. This forum conversation (from post by mr0860 near the bottom of page 2 onwards), this twitter thread and this twitter thread show exactly what happens when the recipient flags sexism or racism, but those in the audience who have not experienced it do not pick up the same cues. You end up with a split between those who think it is legitimate behaviour/debate and those who are fed up with it (the recipients of the behaviour). The former group are disproportionately white men who have never been on the receiving end of the issue they cast doubt on. In fact they often haven’t even witnessed the issue first hand, giving them the false impression that it is rare, due to the false belief we all hold to some extent that our own experience is universal. The latter group are then branded as over-sensitive snowflakes stifling debate (though ironically it is those bandying those terms about who cry the loudest if they feel they are being criticised or their voice isn’t being given enough credit, see Stephen Yaxley Lennon or Milo Yiannopoulos).

Meghan Markle has been a particular victim of this pattern, as a mixed race woman that has used her platform to speak up for feminism and against racism and inequality, so it is no surprise that the vested interests of the British tabloid press dislike her and want to put her in her place. Yet there are still those who claim it isn’t racism, or that she brought the problems on herself in some way. In this brilliant clip Dr Shola Mos-Shogbamimu calls it out perfectly. The emotional labour of explaining or performing inequality is exhausting, and falls disproportionately on those who are subject to the prejudice in the first place, who already have additional burdens to carry.

My point is that we all make assumptions about other people, and often we aren’t as good as we think we are at picking out people’s true character from their appearance or what we get to see of them before we know them well. In fact sometimes we can know people very well and still miss huge facets of them, as is often evident in the terrible guilt and grief post-mortem when someone dies by suicide. The same thing might also contribute to why people enter relationships with partners who later become abusive toward them. Yet we are often blind to what we don’t know – I had someone on twitter recently claim to be certain that nobody in her extended network of over 100 friends and family members has ever experienced mental health problems. Statistically that’s as probable as a lottery win on a day you get struck by lightning, unless her family deviates very far from the rest of the world population in some way.

That isn’t to say there aren’t horrible people who are outwardly and obviously bad. There are. And I’ve met plenty of them, both personally and professionally. But I don’t think we can always pick them out from a line-up. And even when we can, it doesn’t seem to always hold them back. After all, we’ve had some very popular and powerful men come to light after many years of sexually abusing people on a massive scale (eg Weinstein, Epstein, Savile). There are also more than a few repugnant men in prominent political positions at the moment. Somehow being a division-stoking, lying, philanderer who will take whatever political position is expedient to him or his far-right paymasters, or a hate-mongering, tax-dodging, cheating, sex-pest who has asked foreign powers to interfere in his country’s elections hasn’t blocked two rich, overweight, blond men from some of the most powerful offices of power in the world. Far from it. Instead of their moral character being a barrier to office it is a selling point. Rather than denying or attempting to mask their true nature, they have started to double down in the knowledge that it isn’t reducing their popularity. Perhaps their carefully constructed persona of being harmlessly dim keeps them filed under ‘amusing oaf’ rather than ‘dangerous autocrat’. It is clear that their simplistic slogans have appealed to populations fed up of being ignored or talked down to, and made them seem more down to earth, whilst their decisions (no matter how hypocritical or founded on lies) make them seem like men of action.

I can’t be the only person that finds this incredibly frustrating. Surely we need to value truth and honour and block bad people from power? We need to stop it being amusing or acceptable to lie, express prejudice, exploit others, or to foment hatred of vulnerable people, and that means challenging the way that this is reported. Critical in this is the regulation of social media, and the support of journalism that is ethical and independent, rather than being reliant on social media, misleading narratives from biased sources and badly checked hearsay that spreads more rapidly and widely than the corrections that follow. I’m with Carole Cadwalladr that this is key to helping the public understand the truth about key issues and allowing democracy to function. If everyone who wanted progressive values to stand a chance in the world boycotted Facebook and lobbied for better regulation, their advertising revenue would fall and their business model would have to change. The million dollar question is whether we want things to change enough to take action, even if this means we have to find alternate ways to journal and share our lives with our networks*. Otherwise the bad people might tighten their hold on power and lead us in increasingly worrying directions.

 

*If that feels too much of a step, then I’d recommend you take three simple areas:
  1. Increase your privacy. On Facebook change your name and set your privacy settings higher so little or no information is public. Be wary of services with poor privacy and data protection.
  2. Be more data savvy. Watch The Big Hack. Be aware of what data you are giving way. Be mindful of what data your mobile phone and/or internet browser is collecting and what “personalisation” of advertising you are allowing, read what you are consenting to in the user agreement for apps and software
  3. Install apps that block advertising and show who is funding the adverts you do see. I use FB Purity and Who Targets Me?

The elephant in the room: Mental health and children’s social care services

I heard a few months ago that the Housing, Communities and Local Government Select Committee were undertaking an inquiry to look at the funding of local authorities’ children’s services, and thought that sounded like an interesting topic that might relate to my areas of interest. I therefore met with a local MP about the topic, contributed to the BPS response to the inquiry, and (on the request of the committee) submitted my own response in relation to my innovative work with BERRI. I have subsequently been called to give evidence in person to the enquiry in a few weeks time.

Given I’ve been so immersed in this issue it seemed a good topic for a blog. I’m going to start with the evidence that this sector is in crisis, before thinking more about what a clinical psychologist like myself can contribute to addressing elements of this need. Hopefully I can then write another blog in a few weeks time to talk about my experience of giving evidence, and report back about whether the politicians grasp the issues and appear motivated to do something about it.

It didn’t surprise me that this was an issue that the government wished to give more scrutiny, given the steep increase in need in this area over the last decade, whilst funding for local authorities has been substantially reduced by the government’s austerity agenda. Human distress and unmet need rarely seems to gain political attention unless it is in such a crisis that the public are aware of the issues, or it has financial implications for the public purse, and children’s social care has suddenly hit both of those thresholds in the last year or so. 

A number of factors have combined to increase need in children’s services. This includes growing awareness of child abuse and its impact (particularly emotional abuse which has long lagged behind the more tangible forms of abuse), along with reduced stigma in disclosing having been abused (due, for example, to the publicity surrounding the Jimmy Saville scandal, the various institutional abuse enquiries, and the #metoo movement) and a reduced tolerance for forms of abuse that had been normalised or ignored in the past (due to cases like Baby P and the Rotherham child sexual exploitation trials, and subsequent prosecutions in many other areas). A lot of teenagers who had been allowed to remain in unsuitable living circumstances because of the belief that they would “vote with their feet” if removed are now appropriately protected and brought into Care, perhaps because of some precedent setting cases in which people have taken successful legal action against local authorities and have been compensated for failures to protect them in childhood. This includes an enormous legal settlement for two Care leavers from Jersey, who have received tens of millions of pounds compensation.

Children in Care are also entitled to stay in their foster placements up to the age of 21 where they want to and it would be beneficial for them, and to have support after leaving Care from a personal advisor until the age of 25. Another pressure is the reduced use of secure units on welfare grounds, and a reduced willingness to incarcerate children in institutions for recurrent minor offending. The increased stress, shame and social hardship of benefit changes and increases to cost of living has led to move children growing up in poverty, and more families developing the risk factors that can cause harm to children, such as drug or alcohol use, mental health problems, domestic violence and family breakdown. This has had a particularly negative impact in families in lower socioeconomic groups.

It is therefore unsurprising that over the same period of time the demands for social care services have risen steeply. Over the last decade there has been a 9% increase in referrals to social care and numbers of children considered in need, but there has been a 84% rise in child protection cases, and 26% more children are in Care. This creates a lot of additional workload for children’s services, with a 122% increase in demand for section 47 enquiries, and a 125% increase in Care Proceedings (as less children are now informally Accommodated with parental consent). Yet the budgets have shrunk, so there is no resource available to meet this need.

The financial picture is genuinely shocking, and yet it has hardly made the news (perhaps because looking at the numbers is considered too technical or boring for the lay public, and the political and news agenda has been hijacked by the continuing debacle of Brexit). But reviewing the figures makes sobering reading. The cuts to local authorities since 2010 are unprecedented. The National Audit Office highlighted the extent of the shortfall in their report on the financial sustainability of local authorities published last year. They point out that central government spending on social care has halved. This has been masked by changes in how funding is delivered, and some additional funds from council tax being made available to spend locally, but the cuts are still enormous and amount to a real terms reduction of nearly one third of the entire budget for local authorities, but the burden is again being disproportionately felt in more deprived areas.

Such cuts are unrealistic and unsustainable, as they make the total budget too small to cover anything other than statutory services, which are legally protected. This means that councils have no means to make ends meet without dipping into their savings. The report shows that two thirds of local authorities had drawn from their reserves by 2016-17, so there is an ever decreasing amount left in the pot for contingencies, and the audit office predicted that 11% of authorities will empty that pot by the end of this financial year. Councils are having to sell off properties and come up with increasingly radical plans to try to fulfil their minimum duties. Recently Northamptonshire County Council had to declare themselves bankrupt as they had no means to cover statutory services from the available budget.

This mismatch between demand and resourcing has led to enormous cuts to non-statutory services, with two thirds of the spend on preventative and community children’s services disappearing. This means that, as with mental health, there is a minimal set of brief services delivered for milder or less entrenched difficulties, but that there is then an abyss in which no services are available until they reach the threshold for the crisis-focused specialist services – which are expensive and time-consuming to deliver and can’t keep up with demand. The focus has moved from collaborative work to assessments and interventions that are perceived as the end of the line, despite the absence of the precursor interventions that might have enabled change.

To me, the elephant in the room when it comes to children’s social care is mental health need. I don’t just mean the clean single-condition, diagnosable treatable mental health need that gets through the doors to CAMHS. That’s the need up on the sterile concrete plains of mental health research that Prof Miranda Wolpert describes so well. I mean the real messy need down in what Miranda calls the swampy lowlands where real complex people live in varied circumstances, where numerous issues intersect to create barriers in their lives that are not straightforward to address, and do not fall into the simple diagnosis to treatment pathway that currently gets through the doors to CAMHS. That’s the need that determines the outcomes for these children, and the pathway on which they leave Care and try to negotiate adulthood. It is that need which determines whether they can go on to happiness, employment and family life or whether they become one of the Care leavers who end up facing prison, homelessness, mental health problems, addiction, conflict and/or their own children going into Care.

So what are these broader mental health needs? In my experience, a complex and interwoven picture of trauma, adversity, behaviour problems, attachment difficulties, developmental disorders or delay and mental health needs is typical of children in Care or receiving social care services. As well as the traditional “mental health” needs of anxiety and depression I see a much broader picture that is expressed in a variety of ways. Some children act out with their behaviour, others withdraw and show signs of emotional difficulties (including low mood, poor self-esteem, and a lack of positive identity or perception of belonging). They often struggle to form healthy relationships/attachments to others, and can present a risk to themselves and others. They have an increased prevalence of conditions like Learning Disability, Autism, ADHD, or psychosis that add an additional layer of challenge in standard services effectively meeting their needs. That is why my BERRI assessment system attempts to cover all of these areas.

Seen as a group, children who are Looked After have high levels of mental health difficulties (45% have a diagnosable condition, and over two thirds have significant mental health need), so it would be easy to blame the Care system. However, this extraordinary level of need is predominantly caused prior to them coming into Care. It is well established that Adverse Childhood Experiences lead to multiple layers of vulnerability, and these are very prevalent for Looked After Children (my own research suggests an average of 4 historic ACEs per child, along with 2 current vulnerability factors at the point they come into care, such as involvement in gangs, sexual exploitation, school exclusion or the criminal justice system). Looked After Children are in the vast majority traumatised children, who have experienced abuse and/or neglect. But these problems don’t occur in isolation. They are contextually embedded. Children in Care come disproportionately from families that experience the adversities of poverty, crime, family breakdown, and poor housing. They are more likely to be born to parents who have lower education, higher risks of unemployment, and a higher incidence of mental health problems, substance misuse, domestic violence and a history of abuse or neglect in their own childhoods. As a result, their parents are less able to provide safe and stable care. Patterns of difficulty often carry through many generations of the family, and the problems they face are a symptom of our increasing social inequality. 

However, CAMHS are not really set up to meet these complex and interwoven needs, and cut off at 18 years of age, whilst children can stay in care until they are 21 and receive leaving care services until the age of 25. They also have ongoing needs that will need to be revisited over time as they develop or different themes emerge as they enter different life stages or face different challenges. It might be that a dental care model, in which there is long-term oversight but with responsive services as and when they emerge works better than the time-limited episodic care that is currently on offer. Likewise services need to be embedded so that they collaborate with placements and other support services, rather than stand in isolation.

The wider context of the underlying contextual and vulnerability factors mean that treating symptoms or even specific conditions might be an ineffective model of intervention. We need to think back to Maslow’s hierarchy. These children first and foremost need their basic needs met, and to have reliable food, shelter and warmth. They need safety and security, medical care and an environment that doesn’t contain ongoing risks. They need opportunities for identity and belonging, such as education, employment, hobbies, peer relationships, and family. They need intimacy and trust in their friendships, sexual/romantic relationships and relationships with carers. When that is reliably in place they need opportunities for achievement and being valued, so that they can gain self-esteem, confidence, status, responsibility and individuality. The icing on the cake is then self-actualisation, the chance to explore creativity, set goals, reflect on morals and values, and feel purpose and fulfilment. Mental health needs only fit in mid-way up that pyramid. We cannot expect a child to have a positive outlook and good coping strategies and social skills if they are not in a safe environment, don’t have their basic needs met, or cannot trust those around them. To see the point of going along to a therapist takes enough self-esteem to believe you deserve to feel happier, and you then need the organisation and social skills to get there, and the trust to confide your story, or a carer who will advocate for you and help you to achieve these steps. There are many building blocks that need to be put in place by the caregiver and environment before therapeutic interventions are possible, and it may be that when we get these other elements right, the child is able to recover using their own resources and that of their caregivers, without ever seeing a therapist.

My perspective is that if we can help to identify needs of children as early as possible and skill up the caregivers and the systems around the child, we can make the most impact. That is why I have increasingly moved from working with individual children to working with their caregivers and the systems that surround them, and have developed the BERRI system to identify needs and help carers understand them, as well as developing and delivering training to help carers and professionals understand the needs of the children and young people better. It doesn’t have the depth of working psychologically with a single individual, but it has the scope to make impact on a much wider scale, and it fits better with my personal strengths and interests. As I’ve said before, I’m not the most patient therapist to walk a long journey of recovery or personal development with a client, but I do have strengths with assessment and evidence-based practice.

My aims have always been to address human needs. I believe that Clinical Psychology in its simplest form is an attempt to make people happier and more able to lead fulfilling lives, and that is what drew me to this profession. And within that broader mission, my focus is to work with the most vulnerable members of society at the earliest possible point in the lifecycle, which has brought me to working with Looked After Children and the broader population of children and families receiving (or in need of) social care services. Recognising the mismatch between the level of need and the resources available to meet that need has increasingly led me to focus on systemic and population level interventions. Rather than drowning in the burnout that comes with trying to solve an overwhelming problem, I’ve tried to find a niche where my skills can make an impact. Having looked at this population group from multiple perspectives, and tested out projects in various settings, I have become increasingly persuaded that there is scope to make positive changes through the use of better systems to identify need, and increased clinical governance over the choice of placements and interventions. 

I have tried to develop practical, cost-effective ways to make a difference, and to gather evidence of their efficacy. I have then tried to share my findings, and what is already known from research, with the widest and most influential possible audience. That is why I have given so much of my time over to writing best practice papers and contributing to policy. Through these experiences I have gradually learnt to shape the messages I share to make them relevant and understandable to various audiences. After all, whilst most of psychology seems common sense to those of us working in the profession, once you have learnt about the main findings and the methodologies for gathering knowledge, to lay people (and professionals, commissioners and politicians) it might seem very complex and unfamiliar. Over time I have learnt that being able to articulate the financial benefits of improving people’s lives helps to get decision makers on board. So my goal in responding to the enquiry was to explain both the human and financial case for greater psychological input for children receiving social care services. I don’t know how well I have achieved that, but I’d be interested in your thoughts and feedback.

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

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

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

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

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

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

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

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

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

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

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

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

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

Communicating the value of evidence

I presented at a couple of conferences over the last few weeks about my BERRI system. And I was struck, once again, by how little weight is given to evidence when it comes to services that are commissioned in the social care sector. Various glossy marketing claims and slick consultants were successfully persuading commissioners and service managers that it was equivalent to use their systems and “metrics” (in which people gave entirely subjective ratings on various arbitrarily chosen variables) to using validated outcome measures. By validated outcome measures, I mean questionnaires or metrics that have been developed through a methodical process and validated with scientific rigour that explores whether they are measuring the right things, whether they are measuring them reliably, whether those measures are sensitive to change, and whether the results are meaningful. A pathway that then leads to an established scientific process of critical appraisal when those studies are presented at conferences, published and made subject to peer review.

But outside of the academic/scientific community it is very hard to prove that having a proper process is worth the time and investment it takes. It means that you are running a much longer race than those who work without evidence. At one event last week, I asked a question of a consultancy firm making hundreds of thousands of pounds out of “improving children’s social care outcomes”, about their basis for what they chose to measure, how they measure it, and how they had validated their claims. The answer was that they were confident that they were measuring the right things, and that having any kind of scientific process or validation would slow down their ability to make impact (aka profit). My answer was that without it there was no evidence they were making any impact.

They couldn’t see that their process of skipping to the doing bit was equivalent to thinking that architects, structural drawings, planning permission and buildings regulation control slow down building houses, and selling houses they’d built without all that burdensome process. Thinking anyone can build a house (or a psychometric measure to track outcomes) feels like an example of the Dunning-Kruger effect, the idea that those with the least knowledge overestimate their knowledge the most. But the worst thing was that those commissioning couldn’t see the difference either. They find the language of evidence to be in the domain of academics and clinicians, and don’t understand it, or its importance. We are in an age where expertise is dismissed in favour of messages that resonate with a populist agenda, and it seems that this even applies when commissioning services that affect the outcomes of vulnerable population groups. I don’t know how we change this, but we need to.

For those who don’t know, I’ve been working on BERRI for 12 years now, on and off, with the goal of being able to map the needs of complex children and young people, such as those living in public care, in a way that is meaningful, sensitive to change and helps those caring for them to meet those needs better. For as long as I’ve worked with Looked After children, there has been a recognition of the fact that this population does worse in life along a wide range of metrics, and a desire to improve outcomes for them for both altruistic and financial reasons. Since Every Child Matters in 2003, there have been attempts to improve outcomes, defined with aspirations in five areas of functioning:

  • stay safe
  • be healthy
  • enjoy and achieve
  • make a positive contribution
  • achieve economic well-being

A lot of services, the one that I led included, tried to rate children on each of these areas, and make care plans that aimed to help them increase their chances in each area. Each was supposed to be associated with a detailed framework of how various agencies can work together to achieve it. However, whilst the goals are worthy, they are also vague, and it is hard to give any objective score of how much progress a young person is making along each target area. And in my specific area of mental health and psychological wellbeing they had nothing specific to say.

As with so much legislation, Every Child Matters was not followed up by the following government, and with the move of children’s social care and child protection into the remit of the Department for Education, the focus shifted towards educational attainments as a metric of success. But looking primarily at educational attendance and attainments has several problems. Firstly it assumes that children in Care are in all other ways equivalent to the general population with which they are compared (when in fact in many ways they are not, having both disproportionate socioeconomic adversity and disproportionate exposure to trauma and risk factors, as well as much higher incidence of neurodevelopmental disorder and learning disability). Secondly it limits the scope of consideration to the ages in which education is happening (primarily 5-18, but in exceptional circumstances 3-21) rather than the whole life course. Thirdly it doesn’t look at the quality of care that is being received – which has important implications for how we recruit, select and support the workforce of foster carers and residential care staff, and what expectations we have of placement providers (something I think critical, given we are spending a billion pounds a year on residential care placements, and more on secure provision, fostering agencies and therapy services that at the moment don’t have to do very much at all to show they are effective, beyond providing food, accommodation, and ensuring educational attendance). Finally, it masks how important attachment relationships, and support to improve mental health are in this population. I can see that strategically it makes sense for politicians and commissioners not to measure this need – they don’t want to identify mental health needs that services are not resourced to meet – but that is significantly failing the children and young people involved.

In my role as a clinician lead for children in Care and adopted within a CAMH service, I kept finding that children were being referred with behaviour problems, but underlying that were significant difficulties with attachment, and complex trauma histories. I was acutely aware that my service was unable to meet demand, leading us to need some system to prioritise referrals, and that there was a lot of ambiguity about what was in the remit of CAMHS and what was in the remit of social care. I wasn’t alone in that dilemma. There were a lot of defensive boundaries going on in CAMHS around the country, rejecting referrals that did not indicate a treatable mental health condition, even if the child had significant behavioural or emotional difficulties. The justification was that many children were making a normal response to abnormal experiences, and that CAMHS clinicians didn’t want to pathologise this or locate it like an organic condition inside the child, so it should best be dealt with as a social care issue.

On the other hand, I was mindful of the fact that this population have enormous mental health needs, having disproportionately experienced the Adverse Childhood Experiences that are known to lead to adverse mental and physical health outcomes. Research done by many of my peers has shown that two thirds to three quarters of Looked After children and young people score over 17 on the SDQ (the Strengths and Difficulties Questionnaire – the government mandated and CORC recommended measure for screening mental health need in children) meaning they should be eligible for a CAMH service, and various research studies have shown that 45% of LAC have a diagnosable mental health condition, but the resources are not available to meet that need. As The Mental Health Foundation’s 2002 review entitled “Mental Health of Looked After Children” put it:

Research shows that looked-after children generally have greater mental health needs than other young people, including a significant proportion who have more than one condition and/or a serious psychiatric disorder (McCann et al, 1996). But their mental health problems are frequently unnoticed or ignored. There is a need for a system of early mental health assessment and intervention for looked-after children and young people, including those who go on to be adopted.

My initial goal was to develop a new questionnaire to cover the mental health and psychological wellbeing issues that this population were experiencing, as well as considering attachment/trauma history and the child’s ability to trust others and form healthy relationships, and the behaviours that these often expressed through. I was also interested in what issues determined the type of placement given to a child, and the risk of placement breakdown, as well as what opened doors to specialist services such as therapy, and whether those services and interventions really made any difference. I therefore ran two focus groups to explore what concerns carers and professionals had about Looked After children and young people, and asked them about what they saw that might indicate a mental health problem, or any related concerns that led people to want my input, or that caused placements to wobble or break down. One group contained foster carers and the professional networks around them (link workers, children’s social workers, the nurse who did the LAC medicals, service managers) and one contained residential care workers and the professional networks around them (home managers, children’s social workers, the nurse who did the LAC medicals, service managers). I wrote their responses down on flip-charts, and then I sorted them into themes.

I had initially thought that it might cluster as behavioural and emotional, or internalising and externalising, but my items seemed more complex than that. In the end there were five themes that emerged:

  • Behaviour
  • Emotional wellbeing
  • Risk (to self and others)
  • Relationships/attachments
  • Indicators (of psychiatric or neurodevelopmental conditions)

The first letters gave me the name for the scale: BERRI. I then piloted the scale with various carers, and then with a group of clinical psychologists involved with CPLAAC (the national network within the British Psychological Society that contained about 300 Clinical Psychologists working with Looked After and Adopted Children that I was chair of for about six years). I then added a life events checklist to set the issues we were identifying in context.

The working group I chaired in 2007 on the state of outcome measurement for Looked After and adopted children (on the invitation of CORC) came to the conclusion that no suitable metrics were available or widely used. We therefore agreed to further develop and validate the various tools that members of the group had home-brewed, including my BERRI. There was acknowledgement that it takes a lot of work to develop a new psychometric instrument in a valid way, but a consensus that this needed to be done. So I resolved to find a way to follow that proper process to validate and norm BERRI, despite the lack of any funding, ring-fenced time or logistical support to do so. The first challenge was to collect enough data to allow me to analyse the items on the measure, and the five themes I had sorted them into. But I didn’t have the resources to run a research trial and then enter all the data into a database.

My way around this barrier was to get my peers to use the measure and give me their data. To do this I took advantage of some of the technically skilled people in my personal network and developed a website into which people could type anonymous BERRI scores and receive back a report with the scores and some generic advice about how to manage each domain. I tested this out and found my peers were quite enthused about it. We then had a formal pilot phase, where 750 BERRIs were completed by Clinical Psychologists about children and young people they were working with. I then talked about it with some young people and care leavers to check that they felt the areas we were covering were relevant and helpful to know about. Then I started to use the system in a large pilot with residential care providers and developed tools to focus in on particular concerns as goals to work on, and track them day by day or week by week, as well as creating tools to give managers an overview of the progress of the children in their care. We’ve had a lot of feedback about how useful and game-changing the system is, and how it has the potential to revolutionise various aspects of commissioning and decision-making in children’s social care.

But I really wanted the process to be one in which we were truly scientific and based our claims on evidence. I’ve never marketed the BERRI or made claims about what it can do until very recently, when I finally reached a point where we had evidence to substantiate some modest claims*. But to me the process is critical and there is still a long way to go in making the data as useful as it can be. So from day one a process of iterative research was built in to the way we developed BERRI. As soon as it was being used by large numbers of services and we had collected a large data set we were able to look closely at how the items were used, the factor structure, internal consistency and which variables changed over time. We ran a series of validity and reliability analyses including correlations with the SDQ, Conners, and the child’s story – including ACEs, placement information and various vulnerability factors in the child’s current situation. But even then I worried about the bias, so a doctoral student is now running an independent study of inter-rater reliability and convergent/divergent validity across 42 children’s homes.

BERRI will always be developed hand in hand with research, so that there is an ongoing process of refining our outputs in light of the data. The first step in that is getting age and gender norms. But the data can also indicate what we need to do to improve the measure, and the usefulness of the output reports. For example, it seems that it might be meaningful to look at two aspects of “Relationships” being distinct from each other. If the evidence continues to show this, we will change the way we generate the reports from the data to talk about social skills deficits and attachment difficulties separately in our reports. We might also tweak which items fall into which of the five factors. We also want to check that the five factor model is not based on the a priori sorting of the items into the five headings, so we are planning a study in which the item order is randomised on each use to repeat our factor analysis. We also want to explore whether there are threshold scores in any factor or critical items within factors that indicate which types of placements are required or predict placement breakdown. We might also be able to model CSE risk.

The results to date have been really exciting. I have begun to present them at conferences and we are currently preparing some articles to submit for publication. For example, I am currently writing up a paper about the ADHD-like presentation so many traumatised children have, and how we have learnt from our BERRI research that this reflects early life ACEs priming readiness for fight-or-flight rather than proximal events or a randomly distributed organic condition. But the findings depend on all the groundwork of how BERRI was developed, our rigorous validation process and the data we have collected. It is the data that gives us the ability to interpret what is going on, and to give advice at the individual and organisational level.

So you’ll forgive me if I’m somewhat cynical about systems that request a subjective likert rating of five domains from Every Child Matters, or an equally subjective score out of 100 for twelve domains pulled from the personal experience of the consultant when working in children’s social care services, that then claim to be able to map needs and progress without any validation of their methodology, areas to rate, sensitivity to change or the meaning of their scores. Having gone through the process the long way might put me at a commercial disadvantage, rather than going straight to marketing, but I like my houses built on the foundations of good evidence. I can feel confident that the load bearing beams will keep the structure sound for a lifetime when they are placed with precision and underpinned by the calculations and expertise of architects, structural engineers, surveyors and buildings control, rather than cobbled together as quickly as possible, marketed with amorphous claims and sold on rapidly to anyone who will pay for them. After all, I’m not in it to make a quick buck. I know my work is a slow and cumulative thing, and BERRI still has a long way to go before it can create the greatest impact. But my goals are big: I want to improve outcomes for children and young people who have experienced adversity, and I want that impact to influence the whole culture of children’s social care provision in the UK and to continue to be felt through the generations. And to do that, I need to build the thing properly.

* that carers, therapists and managers find it useful and easy to use, that using the BERRI pathway demonstrated an improvement of 14% over 6 months for the first 125 children placed on the system, and that BERRI has a robust factor structure, good reliability between raters, and the basic statistical qualities that suggest sufficient validity for use. We also have some testimonials, including a commissioner who used BERRI to map the needs of 15 high tariff children and found four suitable to move to foster or family placements with support, saving nearly half a million pounds per year from his budget – a finding we would like to replicate with a much larger study, given the opportunity.