Diagnosis vs difference

I read a recent editorial on LinkedIn about the way that the diagnostic criteria for neurodiversity require “impairment” in functioning for a person to reach the diagnostic threshold. It was an interesting topic for a paper, and raised a set of broader interlinked questions in my mind about whether diagnosis is a recognition of difference-from-the-norm in the way some people’s brain or body functions, or whether it is about recognising something that is harmful (like a disease), or whether it causes distress or impairment / difficulties in functioning (like a disability or mental health condition). In particular it is interesting to think about how neurodiversity fits into that framework, compared to mental health conditions or physical health conditions. It opens questions about the purpose of diagnosis and whether that is about recognition of difference and understanding ourselves, or for gatekeeping access to certain types of support. It also raises questions about terminology – whether we acknowledge that many patterns of need or difference fall on a spectrum, and what we call a disorder or condition.

As it stands, in the current diagnostic rules (DSM 5 or ICD 11) each diagnosis has a minimum set of symptoms described. For example, in the DSM for a diagnosis of autism the individual must have “persistent deficits in social communication and social interaction across multiple contexts” and two or more areas in which they show “restricted, repetitive patterns of behavior, interests, or activities”. These difficulties must have emerged early in development, and not be “better explained by intellectual disability or global developmental delay”. However, to be diagnosed, the person doesn’t just need to have the neurotype of autism or ADHD but to struggle significantly with work, life, mental health or relationships because of it. Symptoms must cause “clinically significant impairment in social, occupational, or other important areas of current functioning”.

On first glance it seems a pretty clear description that could be consistently applied, but the more I’ve thought about it the more problems I see. First of all, the impairment criteria mean that people could waver in and out of the diagnostic category according to how well they are doing in their lives at that point, how well their environment and network support their needs, or their developmental stage. For example, a person could be autistic as a child, but then find a lifestyle, job, community or other niche in which they are happy and successful, and therefore fall below the diagnostic threshold – until a change or stressful life event means that they become distressed, when they would be diagnosable once again. Or they could have very subtle challenges that would not meet the criteria in primary school, but increasingly struggle during secondary school and meet the criteria for diagnosis, but then escape the sensory overload and/or social demands of that setting and no longer meet the criteria again.

That doesn’t make much sense given that autism, ADHD and other forms of neurodiversity are currently conceptualised as lifelong, inate differences in how people process information and interact with the world, rather than conditions that come and go. Neurodiversity isn’t a disease that temporarily disrupts a person’s normal functioning and can be treated to return them to normal. Neurodiversity is normal for that person; it is intrinsic to the way they experience and interact with the world for the whole of their lifespan. A neurodiverse brain is set up with a much wider focus of attention, or more attention to detail, or more propensity for sensory overload than a neurotypical one. A person doesn’t stop being autistic or having ADHD or a learning disability even if they learn strategies to fit in better with other people’s expectations or cope better cope at school or in the workplace any more than a person who is colourblind stops being colourblind if someone provides glasses that increase the red-green contrast.

For that reason, neurodiversity doesn’t fit into the medical model of diagnosis in the same way as mental health problems that may come and go, where a diagnosis may be helpful during the period when a person is experiencing depression or anxiety or psychosis, but may cease to be relevant at a later point – as for many people the symptoms will entirely resolve (spontaneously or with treatment) and no longer impact them. In the case of a mental health condition it wouldn’t be relevant to continue to use the diagnostic label after their symptoms resolve, as the individual may return to population-normative ways of experiencing the world. If we retained the diagnosis it would lose all meaning, as about half the population would end up with it, but most of those would have no symptoms that differentiate them from those without the diagnosis.

I also wondered how the idea of impairment fits with masking. In some cases a diagnosis could be withheld from a person who subjectively feels like they are struggling enormously if they were able to mask their difficulties enough for them to not impair their ability to function in their workplace or relationships during the assessment period. Or could it be considered a signficant impairment that it is exhausting to mask difficulties? Or that the effort of masking or coping with sensory overload all day at school or work means the person then struggles to function at home, withdrawing or becoming dysregulated in a way that might on first inspection suggest the difficulty is located within the home.

However, despite all the reservations I have raised, it is possible to think about diagnosis as only being meaningful when it applies to functioning, and a label for a degree of symptoms that is outside of the normative range. Many conditions are not binary variables that are either present or absent. Illness is quite often a matter of degree rather than the presence or absence of a condition. For example, a person’s glucose metabolism can indicate that they are becoming insulin resistant, but it is only above a certain threshold that the diagnostic label of diabetes would be applied, and certain treatments would be considered. Likewise our blood pressure or weight can be in the healthy range, or below or above that, but a diagnosis is only given if it is sufficiently high to cause significant health risks. There are numerous variables where we can be tested to see whether we fall into the typical range, or whether further investigation or treatment would be benficial – from our levels of white and red blood cells, iron, vitamin D, cholesterol, hormones, to the functioning of our liver and kidneys, markers of inflammation, infection or tumours. The threshold at which doctors diagnose conditions is typically the point at which symptoms start interfering with functioning and/or the pattern identified is known to cause harm, risk or distress to the individual.

Sometimes medics have to determine appropriate treatment without a diagnostic test being available, or where there is not a direct relationship between symptoms and the scores from blood tests or scans. For example, calcific tendonitis can affect the shoulder joint causing pain, reduced movement or even functional paralysis. However, sometimes people with scans that show a lot of calcification don’t report any symptoms, and sometimes people with very little visible in the scans have a lot of functional impairment. Physiotherapy and/or steroid injections seem equally effective at treating symptoms regardless of what shows in the scans. So treatment is typically determined by impairment alone. Likewise, a woman might have lower levels of oestrogen during or after menopause, and this might be associated with certain symptoms like brain fog, anxiety, hot sweats or disrupted sleep. But there is a degree of variation in what level of oestrogen the woman’s body is used to, and the effect she will experience from it dropping that means some women glide though menopause naturally without much ill-effect, whilst others (myself included) would find it entirely disabling without HRT – and this doesn’t map directly onto the level of oestrogen detected in blood tests. For this reason, it is the pattern of symptoms rather than the blood test results that should guide treatment.

Likewise, depression is something that ocurs along a spectrum from very mild to totally disabling symptoms. As is anxiety. There are even levels of the unusual beliefs or sensory experiences that occur in psychosis that would be considered normative – such as thinking you’ve seen a person who has recently died, hearing an internal voice giving you advice, or having strange or intrusive thoughts that you are able to quickly dismiss. In the same way, arguably we are all neurodiverse to some degree – we each have different patterns of cognitive strengths and weaknesses, different ways of processing sensory information, and subjective experiences of the world. But some of us are able to function in the world more successfully than others, with some people constantly feeling discomfort, distress or having to put in huge amounts of effort to do things that others find effortless. It therefore seems logical that it is the level of impairment rather than the neurotype that determines whether a diagnostic label is appropriate – even though this brings both a level of subjectivity to the judgement of whether the label is appropriate and an acknowlegement that the degree of impairment reflects not just the qualities of the individual, but also the qualities of the environment and network that they function within.

It might be that like height or hair colour, sexuality or personality traits, our strengths and weaknesses, there are ways in which we all vary that are not “conditions” that need to be diagnosed but simply differences between individuals. If we conceptualise neurodiversity as this kind of difference, then recognising it can still be a helpful way to understand ourselves, and how we differ from others. It can also help us find our tribe – the people that share our struggles or our interests and talents.

However, all this theoretical debate misses the elephant in the room of how widening the diagnostic range helps people with more subtle impairment recognise their neurotype, at the cost of negating the experience of those with more profound impairment who had historically been able to convey their needs with a label that now gives most people a false impression of much subtler difficulties. What terminology do parents or carers of people with the “autism” described by Kanner (or at the more impaired end of the spectrum described by Wing and Gould) use to describe their pattern of needs? These individuals may be non-verbal, with significant developmental delay, very atypical ways of interacting with others, and obvious stims/stereotypies that instantly mark them out as different to members of the public. This group includes people with autism who are profoundly disabled to the point that they will need signficant financial and practical support across their lifespan – attending special schools, not being able to communicate their needs except through their behaviour, unable to reach independent living, or have the capacity to make decisions about their lives. Having an appropriate diagnostic label functions as a gatekeeper to accessing this kind of financial and practical support.

The problem being that whilst this group have used the label “autism” to describe their needs for eight decades, this is not the same population as now use the word “autism” to describe themselves on social media, to friends or in the workplace. As the diagnostic threshold has lowered to recognise more subtle impairments the label of autism has been claimed by many quite “high functioning” people to self-describe their struggles in a neurotypical world, and – because this group is more articulate and able to speak for themselves – they have come to dominate the discourse about autism, overshadowing the smaller numbers of people with more profound disabilities who had previously been described by this label. The larger number of people who are now included in the same diagnostic category but were previously given the diagnosis of Asperger Syndrome or High Functioning Autism, or seen as having difficulties that were below the diagnostic threshold, typically don’t have the moderate to profound learning disabilities, or need for support in their daily living skills as those who were diagnosed with Autism a few decades earlier. This population group might be independent, articulate, intellectually able, employed, and/or involved in interpersonal relationships including friendships and romantic/intimate relationships. Whilst it is evident that they do find some elements of life harder than neurotypical people, and it is a very helpful and affirming label that lets many people understand why they have felt different to the norm and have struggled with elements of their life, the level of support they require is not equivalent – despite the diagnosis on paper now being the same. A parallel process of widening the diagnosis has happened with ADHD and other elements of neurodiversity, to the point that 10-15% of people now identify with at least one element of neurodiversity, when historically only 1-2% of people were given these diagnostic labels.

This mismatch has therefore become the grain of truth that underlies some very toxic discussions about the growing rate of diagnosis, and the expanding numbers of people claiming disability benefits and adjustments or support within education and the workplace. With larger, more articulate and more powerful groups of voices advocating for the needs of the able end of the spectrum (who often object to any implication of there being a spectrum or such a thing as high vs low functioning or find such labels pejorative), it is hard for the voices of those representing more disabled individuals to be heard. I can understand that we need to respect the voices of lived experience about what terminology they are comfortable with. But some people don’t have voices in this conversation. And it wouldn’t be honest or fair to pretend that the needs of everyone with autism are equal.

The changing use of the diagnostic label doesn’t necessarily relate to the type or degree of support people require, and therefore it may no longer be able to function as a gatekeeper of services. That might still have to rely on an understanding of impairment – the areas in which we are struggling or require more support than the rest of the population. We can’t support everyone equally, that just isn’t viable. We also can’t allow resource rationing to lead the decisions about terminology or diagnosis. But it will have to be consideration of impairment that helps systems to differentiate what levels of support are appropriate – even if that involves subjective judgements, of functional states that are impacted by the environment, and will need to be regularly reviewed over time. Because without us evolving the right language to accurately reflect levels of need, the most disadvantaged will struggle to get their needs met at all – with tragic consequences for them, their caregivers, and the public purse. And, as Mahatma Gandhi is believed to have said, “the true measure of any society can be found in how it treats its most vulnerable members.”

Give and Take

I’ve run the clinpsy forum for 18 years, and before that I spent a couple of years as a moderator on a precursor forum. I’ve compiled and/or written about 200 wiki posts that have been viewed millions of times between them. Some individual posts have had over 100,000 page views – the most popular being a giant list of interview questions I compiled, a post about transference and counter transference, and one about keeping a reflective journal and one I wrote on clinical vignettes, followed by my post about formulation, and one about clinical interviews. There are also popular posts such as one about what to do with a low degree mark, a more general post on reflective practice, one on supervision and posts about preparing for assistant psychologist and IAPT interviews. The site peaked at about a million page views per month, but has slowed a little as technology has moved away from forums towards WhatsApp groups, and various people have tried to cultivate this audience via social media (often selling products and/or services).

I’ve never really seen running the forum as potential source of income. In fact, it has been a huge drain on my resources – I spent an hour a day for a decade building the content and community, and I’ve paid the server fees, programming, design and other costs out of my own pocket (subsidised at times by a trickle of advertising income). Even now I have to check and activate the new members, respond to emails and PMs at least 2-3 times per week. On the other hand, I have saved a little bit of money on advertising, I’ve been able to promote my own book without cost (and various courses and jobs offered by people that I know). It has given me reach that I might not have had otherwise (I’ve got about 10,000 followers on Twitter, over 5,000 on LinkedIn and this blog has had over 100,000 reads). And I’ve saved a little time in accessing information or publications. So whilst it has cost me about two years of full-time work, and about £5000 overall (plus the cost of the clinpsy URLs and the time spent on social media, but those aren’t constrained to this purpose or audience), I don’t feel like the time has been wasted.

Maybe that is because I don’t do it for the money. I’ve mainly seen it as a way to undermine the added value of nepotistic networks, where information was kept amongst a privileged few who had access to CPs. I wanted to democratise the profession, by puting that information into the public domain, and allowing equal access to sources of support for people from all different demographics. I quite intentionally undercut those who marketed to this group, by offering forum membership and access to various activities for free, and by asking only for a charitable donation for the various webinars, training days, professional development workshops and reviews of applications that I offered (with the level of donation being recommended, but the option being available to pay less or even nothing for people of low means or groups who have been traditionally excluded from the profession). That has also led me to raise thousands of pounds for charities like UNHCR, Magic Breakfasts, food banks, refugee support, and various other causes from replacing the broken electronic whiteboards at a local primary school to dementia care, to educating girls in Africa.

I also get the intangible reward of the people who thank me for the impact that the forum and/or my input has had on their lives. Their notes that say that my feedback made all the difference to them gaining a job or a place on training. Or that my workshop helped them convey their competencies more confidently at interview, or find the next step in their career. It means I am quite widely known in the profession, which builds trust and reputation. And, perhaps most importantly, there are people who have met me through the forum have later become friends, employees and colleagues.

At a few points, people have expressed interest in buying the forum off me. Sometimes that has been an easy no – like when the offer came from the owner of the profit-making travel agency that masqueraded as a charity giving people psychology experience in Sri Lanka and other developing nations. But there have been more benign offers, and now I am so preoccupied with my business, and the other moderators who helped me run the site have mainly fallen away, I do feel like the time and resources I have available to pour into it is limited, and there might be advantages in bringing new energy to the community. So I am torn between a plan to reinvigorate the community, and the idea of handing it over to a new owner.

I also wonder about the balance of give and take, and whether passing on ownership would relieve me of an undue sense of responsibility. After all, there is only one of me, and over 9000 members* and I’m also spinning quite a lot of other plates – I’m Mum of teenagers doing their GCSEs, we are in the midst of building work, and I run my own business which could use my time five times over. There is also something strange about running a forum that feels like the service I provide is taken for granted, assumed to be financed by a professional body, or is treated like public property. Sometimes people have quite unrealistic expectations – demanding immediate responses to messages, sending grumpy emails if their account is not activated right away, breaking the minimal simple rules, or complaining about moderation. People post adverts or self-promoting content without permission or payment (even though our charges are minimal and support the costs of providing the forum). It is as if they believe it is their right to post on the forum to get free promotion for their blog/website/book/course or whatever.

It sometimes feels like a lot of people put very little in but expect to take out as much as they want – asking questions but never contributing to any other discussions, or signing up to request a form review or to apply for a place on a low-cost event without ever contributing to the forum or being part of the community. I like to raise money for the charities and to give people access to information, but each form review takes me 30-40 minutes, and I currently have a queue of 47 requests – which will take about a week’s working time out of my weekends and evenings over the next month. I’d be much better off financially if I donated £1000 to the charities myself and spent the time on income generating work!

But the alternative is to give those selling services to aspiring psychologists an open market to exploit, or for me to have a paid tier of forum membership or to sell products and services, which doesn’t sit right with me, as it reinforces the privilege filter that has always biased our profession towards middle class, able-bodied, white women. Given I don’t want a website and forum full of intrusive advertising, and I haven’t got money to throw at it, the alternative is running the forum on a shoestring – which is fine when we have lots of volunteers contributing to keep the discussion lively and assist with the admin, but more difficult the more of the work I need to shoulder alone.

There are echoes of the same theme in decisions I need to make about my business. As we scale I need to decide whether we continue to bootstrap our growth, or we borrow or seek investment to grow faster (making more impact for more children, but with the cost of being pulled towards earning enough to repay a loan, or delivering a financial return for investors). I need to weigh up the value of locking in the mission to the company structure, versus optimising the business for investment. My gut instinct is to lock in our values with a pledge to prioritise impact, and to donate a percentage of profit above a certain threshold to a charitable foundation that can offer access to the tools to those that can’t otherwise afford them. But it might be that keeping a traditional company structure and taking on investment allows us to reach more children and make more impact to a wider population than we would by being too rigid and narrowing the pool of investors that would be interested.

So I need to think more about how I value and prioritise my time. I’m not sure I owe anything more to aspiring clinical psychologists than any other member of the profession does. So I wonder why I felt obligated to take up this mantle, and continue to stubbornly carry it? And why am I willing to sacrifice my leisure time, or the time I get to spend with my family or on my business, to do things with minimal personal benefit? Whilst I love that I live my values – and the way they permeate almost everything that I do – they do have costs, and I think I probably need to prioritise myself and my family a bit more. I’m not sure I’ll look back on my deathbed and think “I wish I sank more time into that website”, or “if only I had offered more professional development support to aspiring psychologists”, or “I should have achieved more with my business” rather than “I should have spent more time with the people I loved, given more focus to my health and wellbeing, and seen more of the beauty of the world”.

*I haven’t pruned off the dormant accounts for a while, so once I do this may well return to the approx 8000 figure where it has stabilised for the last decade.

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.

Hindsight and reflection

When I watched The Usual Suspects, the twist at the end made me immediately re-watch the whole film. The extra bit of knowledge meant the same information from the earlier plot had entirely different meaning. The same thing happens when you realise someone has lied to you, or manipulated you for some secondary gain – you suddenly need to reappraise all the prior interactions you have had in light of this new insight. It is inevitable as we go through life that we learn additional information that helps us understand things in more sophisticated ways. Just as we learn that our parents are flawed human beings, rather than always right and almost omnipotent, a lot of relationships transpire to be less perfect when the first thrill of connection wears off. It can be quite a challenging process to understand why you were fooled, what you should have noticed, and how you could have avoided the bad feelings that come with realising all was not as it seemed.

In one chapter of my book I talk about the poem “Holes, An Autobiography in five short chapters” by Portia Nelson. It is a nice summary of the patterns we can all fall into, and how it is only reflection and insight that lets us climb out, and eventually learn to avoid falling into similar holes in the future. I found it really helpful realising that there were certain “holes” that I recurrently fall into. In particular, I was susceptible to one when others seem to need my help and support, but keep on taking without recognition of the value of that help or any cost it has for me, until I feel exploited. An early example was a student who volunteered when I was an AP, who I supported to apply for similar posts and to get onto clinical training, before becoming aware she had presented some of my work as her own, and named me as a reference for a job she had been fired from (when I wasn’t her supervisor and didn’t work there, in the expectation I’d say only positive things).

Related to this, perhaps, is my sense of myself never living up to the high expectations I set myself. It means I often assume I’ve done something wrong, until I find out that the other person is getting me muddled up with someone else, or has put the wrong time for the meeting in their diary. I feel acutely guilty if I take too long to write up the notes from a consultation, even if I’ve had time off sick or other crises to deal with. And I always first reflect on my part if there has been a misunderstanding (eg if the builder is asking for much more money than the written quote, and implies that we agreed additional costs for changes to the design – even though I know I would have kept track of that). It also made for very difficult dynamics with an AP who appeared really hard working and humble until I wrote them a reference for training, then started being increasingly critical and undermining, blaming me for their lack of progress in any of the tasks they were employed to do until I felt quite upset. It was only when I shared my feelings with trusted advisors and peers that I was able to recognise that the problem wasn’t with me. I then started to recognise I’d been gaslighted, and that if someone else makes me feel bad, I have no obligation to kept bending around them until they are satisfied.

Sometimes it isn’t new information about what happened or the other person’s motivation, but a new perspective or frame of reference that shows past experiences in a new light. I’ve reflected in past blogs about how what seemed like normal teenage boy behaviours, that were a socially acceptable way for them to show their interest in me (and portrayed in my peer group as something I should be flattered by) were actually quite inappropriate – unwanted, overly persistent and at times clearly non-consensual. Likewise, I learnt the term “stealthing” meant the guy at university who knew my consent was contingent on condom use, and made a show of using one but transpired not have to used it after the fact, was not just a selfish scumbag (as I thought at the time), but had committed a form of rape. The new insight gave a different perspective on past experiences that helped to bolster my trust in my own feelings and ethical judgements. And helped make me even more determined that I wouldn’t be complicit with these patterns again even if it means I sometimes have to risk looking emotional or being seen as a “difficult woman” when I assert my position.

From these relatively small examples in my own life, I also gained a new respect for the task of reprocessing past experiences for those who have lived through abuse and trauma. If a tiny piece of new information, or a new way of looking at things can throw my certainty about my past experiences into doubt and demand a high emotional load to process, how much more demanding it must be for those whose lives were impacted by much more serious or sustained experiences such as childhood sexual abuse, grooming, or coercive control in a relationship. It will take time and effort to reprocess their own story when they are no longer in the sway of the person who is normalising the abuse. But often we are also fighting against social norms (eg many women are socialised into accepting “grey rape” as being not the real thing, if they didn’t say a clear “no”, or were intoxicated, or went back to his place/invited him home/consented to kissing or prior sexual activity). The meaning of experience is very much in the eye of the beholder, and shaped by cultural narratives. And there are forms of cultural oppression that change our whole sense of self, such as messages from family or religious/cultural groups that lead to people not feeling able to show their authentic sexuality or gender identity (the latter issue somehow being co-opted by both TERFS and right-wing figures who see trans people as an easy target for their “culture wars”). Finding a safe place and social network in which to be your authentic self is so critical for our happiness. Even feeling okay about your body and appearance is a challenge for many people, and finding body positive role models and reaching acceptance of ourselves that isn’t conditional on weight-loss or conforming to popular beauty standards can be life-changing.

A similar shift of needing to reappraise the story by which I understand my experiences happened to me recently in terms of my own body and health. After some quite unpleasant side effects to coming off HRT, including excessive bleeding to the extent I ended up in A&E, I had an ultrasound that suggested I have adenomyosis – a thickening of the endometrium, where lining tissue is mixed in with the muscle wall. Reading up about adenomyosis I discovered that this could explain the nature and extent of the period pains I have experienced since adolescence. It might also explain my negative reaction to the Mirena/Jaydess coil (despite this being a recommended treatment for excess bleeding due to adenomyosis) and the problems I’ve had with menopause. It may also explain why I’ve been prone to gain weight, as excess oestrogen can increase fatty tissue and fatty tissue can increase oestrogen production. But the most striking new info for me was the fact it is associated with premature delivery – as I’ve carried a lot of guilt about not having managed to sustain the pregnancy with my twin daughters to full term, and I’ve never had an explanation for why this happened. So I’ve started to reevaluate what I thought were the truths of my own life and how my body operates. I’ll learn more as I follow up with the consultant gynaecologist next week, but it seems bizarre to have lived with something that has potentially had significant impact on me throughout my adult life without being aware of what it was. But women’s health has always been an area in which medicine has lagged, and for the most part when it comes to menstrual or menopausal issues we suffer quietly. I’ve blogged before about how we need to assert our needs, and yet here I am realising I haven’t done so, as I didn’t realise my experience wasn’t the norm until the symptoms became too intrusive to work around.

Health symptoms also remind us of our own mortality, and the privilege of being healthy and able bodied. Having to reappraise our plans in light of health challenges or functional limitations can be another trigger for reflective hindsight. As can the illness or death of a loved one – or a public figure like the queen. Health is not a meritocracy, and lifespan does not reflect the value of a person. We are not guaranteed to live the average lifespan. We may get more time, we may get less. If we knew today that our time was limited, would we look back and wish we had done things differently? If so, maybe it is worth reflecting on our priorities now, because time is always limited – even if I live another 50 years. I feel incredibly lucky to have spent over a quarter of a century feeling loved by someone I love, to have had the benefit of a supportive family, and to have wonderful children who I get to spend time with every day. So the big building blocks of my life are firmly in the right place. However, I’m sure that there are small changes that could help me to spend less time on work and trying to make the future opportunities we have better, and to focus on the joy available within each day. Reading back over this blog, which I started eight years ago, I can see progress in some areas (I’m much clearer about my values, and what I want to do professionally, and have a tighter focus in how I want to make impact in the world). But I also see themes where I identified the need to make positive change that are still pertinent in my life today. So I need to think why I haven’t been able to prioritise self-care more, or to get rid of the physical or metaphorical clutter in my life, and how I can make space to be creative, spend more time in nature and connect with like-minded others. Maybe I should get some more coaching or personal therapy to reflect on this.

Gaining insight about ourselves is a particular kind of opportunity to grow and learn. Whilst it can be challenging, that reprocessing of experience over time and with greater information is a core part of personal growth (and a key foundation of the scientific method – that as we understand the facts better, we look again at our working hypotheses and adjust them to fit the new information). Understanding ourselves better can help us reach greater happiness and self-actualisation, and also helps us to understand our place in relationships with others, and in the wider world. It is a key part of the journey towards both happiness and wisdom, and lets us hang onto our values, despite the storms of political decay, inequality and climate change raging around us, which could so easily lead to feelings of despair and helplessness. Maybe the key to happiness in challenging times like this is to reflect on the things that you can change, and find a way to not dwell too much on what you can’t.

I sometimes find it heartening to think about how each honey bee makes less than 1/12th teaspoon of honey in their lifetime, yet pooled together it is enough to ensure the future of the colony. It helps me to remember that to make the world better, you don’t need to solve the big stuff, just focus on doing your 1/12th teaspoon to help others. A bee won’t directly benefit from the honey she makes; instead, it will allow future generations to thrive after she is gone. This too is how we can change the world — by each doing the small things we can, and inspiring others to do likewise.

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.

Accountability

On 31st March, a week or so after the coronavirus pandemic lockdown began, I was contacted by the HCPC.

“I am writing to inform you that we have received a concern about your fitness to practise” the letter began. “We will now carry out an initial investigation into the potential fitness to practise issues identified in the concern. This may involve gathering relevant information from a number of sources.

In order to assist with our enquiries, I would be grateful if you would provide the following information:

– Confirmation that you are the owner and/or moderator of the site ClinPsy.org.uk.
– Confirmation of whether you, or any of the other owners/moderator of the site have received any concerns/complaints about the content of the forum, particularly regarding [celebrity psychologists]
– If yes, please provide a copy of the complaint/s and the site’ s response.
– If not provided above, you are welcome to provide a brief response to concerns raised.
– Confirmation of your current employment arrangement.
– If applicable, please provide the name and email address of your line manager and HR director.

I replied the same evening:

I own www.clinpsy.org.uk I can confirm that I have never had any complaints in any form about any comment on [celebrity psychologists] on the forum – in fact I have never even heard of [the complainant], and can find no reference to him on the forum. I’m afraid you will need to let me know what comment is being complained about to enable me to respond to it.
As to my employment, I am self employed and run my own small business, so there is no line manager or HR involved – but I have to ask why you would think that relevant when a person is complaining about an unspecified comment on social media?

I then contacted my professional indemnity insurance provider and spoke to Mike Wang, chair of the ACP (he was my MSc supervisor and then my clinical course director, and we have stayed loosely in touch since then) who were both reassuring that this wasn’t a legitimate complaint. Later I got legal advice through my membership of the FSB, to check I had fully understood my legal obligations as a forum owner. All of us wondered why the HCPC would launch an investigation at all, given that I had never made a comment myself about any of the individuals named in the complaint, and the forum had been very proactive in ensuring no defamatory content was permitted. The forum does have a thread about “celebrity psychologists”, where legitimate concerns are raised about individuals who appear on television or in the newspapers making comment as “psychologists” who are outside of the scope of HCPC registration. But I could see nothing defamatory in it. In fact the moderating team had carefully checked the content and I had even posted a reply to remind people about our defamation policy and how to raise a concern. So I started to draft a full reply to the HCPC.

Just to be sure, I spent many hours obsessionally trawling through content on the forum and my social media and could find no interaction with the individual concerned, or any defamatory content about any celebrity psychologist on my forum. That isn’t to say members of the forum haven’t criticised such individuals, or that I don’t share similar concerns. Quite the opposite, I’ve been raising concerns about the limited scope of regulation for psychologists and therapy professionals for more than a decade and see this as another example of where the legislation fails to protect the public. However, I have never expressed this as a personal attack on an individual, or said anything unprofessional or defamatory.

At this juncture it might be helpful for me to note what defamation is, what a complainant can do about online defamation, and what the legal rights are both of the individual who believes they have been defamed, and the established defences against claims of defamation, as they will set this complaint in context.

Defamation is the action of damaging the good reputation of a person through the oral or written communication of a false statement about them that unjustly harms their reputation. The important part of that definition is that the statement must be false, and it must cause them harm (which must be demonstrable within 12 months of publication). Being rude about someone or insulting towards them would not normally be defamatory, though it might be unprofessional. As a website owner I am technically the publisher of the content shown on the site, and whilst I cannot be held legally accountable for other users being rude or insulting (though we have worked hard to create a professional culture and to have policies that prevent personal attacks or unprofessional behaviour), I would be accountable if something defamatory was published – if I was aware of it and failed to act to remove it when requested to do so by the individual it affected.

The problem here was that the HCPC did not share any details of the complaint with me, and the complaint communicated was entirely vague and did not refer to particular comments or even allege defamation. It was also made by a third party, rather than the individual that the complainant said had been maligned – making it rather extraordinary that the HCPC would give it even a cursory investigation.

But even with the assumption that someone had said something on the forum that an individual had felt was defamatory – which was far from the case – the law requires that individual (not a third party) to inform the publisher and ask them to remove the content, within 12 months from publication. And in this case most of the comments about celebrity psychologists had stood for 7 years, and no complaint had ever been raised with the forum – despite every post having a button to report it to moderators for review, and a prominent defamation policy that was linked by me in the very thread concerned, in a post giving the forum email address to make such a report.

There are also two main complete defences to defamation allegations; truth and honest opinion. If a statement is true it cannot be defamatory. For example, to say that a celebrity psychologist is not a registered practitioner psychologist or does not have a doctorate is not defamatory if these statements are factually correct. The other defence is that someone is expressing an honest opinion or making “fair comment”. This allows discussion of matters of public or professional interest, and means it is not defamatory to express a view that an honest person could have held on the basis of any facts or anything asserted to be a fact by reasonable sources available to them at the time. That is, if I said “Boris Johnson is a liar” this could not be defamatory because numerous sources have asserted this to be the case. Honest opinion can also be a reaction to something else that has been published, and can even defend someone posting something that is incorrect, if it was an honest belief based on the information available at the time (for example, writing “X isn’t registered with the HCPC” wouldn’t be defamatory if a person had their HCPC registration in a different name, or it didn’t show on the website yet, or the name checked was spelt incorrectly because that was the spelling used in the article under discussion).

As far as I could see, all comments that were on the forum about celebrity psychologists, or made or retweeted by me on social media, involved telling the truth or making fair comment about known or published facts.

On the other hand, my investigations showed me that the complainant was someone financially connected to a celebrity psychologist who frequently threatens properly registered mental health professionals who criticise his connection with referral to the HCPC. I also found that the individual concerned had used anonymous IDs to respond aggressively to critics of his favoured celebrity psychologists, and to place more flattering quotes and reviews about them into the public domain (and to post about her on my forum). I also heard from other colleagues who had been harassed for raising similar concerns. One noted:

“This is one of the perversities about the register and use of the title psychologist; as [celebrity psychologists] are not registered they are able to freely mislead the public about their status and not be held accountable and yet they can put in complaints to the HCPC about those of us that are properly qualified. The complaint is vindictively motivated [and yet effective as a deterrent/punishment for critics]“

So on 2nd April I sent the HCPC a robust reply:

I have had a better look into this and I am now in a position to reply more fully.

For reference, the forum has run for 13 years and contains 152,000 posts on over 15,000 topics. We have never had a formal complaint about our content, and we have a team of moderators who are all HCPC registered clinical psychologists who help to ensure we maintain a professional tone in all content. Every user has to agree a statement about the rules of the site to sign up (which can be read here: https://www.clinpsy.org.uk/forum/viewtopic.php?f=2&t=16012) and we have written guidance for users that spells out our rules (which can be read here:https://www.clinpsy.org.uk/forum/viewtopic.php?f=2&t=10). The guidance is sent to each user in a welcome message as they sign in for the first time and cautions against personal abuse or defamation. Rules 9 and 11 specifically talk about being respectful of others even when disagreeing, avoiding defamation and ensuring posts do not risk bringing the profession into disrepute. It also explains how any post can be reported to moderators by clicking the small triangle button and stating your concerns. We have a pinned post giving specific guidance about defamation (see here: https://www.clinpsy.org.uk/forum/viewtopic.php?f=2&t=9&p=10) that is linked prominently from that guidance, and note it includes the means to contact us to report any content that is potentially defamatory at the bottom of the page: “If you believe a post has been defamatory about you, or an organisation you represent, please email us at clinpsyforum@gmail.com and we will respond as quickly as possible”.

We have a proper process for responding to a complaint, and a team of qualified CPs who act as moderators that I consult with. However, our complaints process has only been activated once (when an approach to purchase the website turned into correspondence disputing our negative review of a travel agency offering work experience placements to psychology students, but they did not register a formal complaint and we did not find any content that was not factually supported when we investigated) and I can confirm that we have never had any complaint from any of the individuals mentioned in your email. We respond frequently to reports on individual posts, which mainly notify us of spam but can also highlight inappropriate content such as potential breaches of confidentiality. These are dealt with within 3 working days. We have never had a report in relation to defamation or to any content relevant to this complaint.

We do have one thread where [celebrity psychologists] are mentioned – you can read it here: https://www.clinpsy.org.uk/forum/viewtopic.php?f=12&t=13708. It was started in 2012 where forum members raised concerns about “celebrity psychologists” who do not have HCPC registration but appear to be giving the public the impression they are regulated professionals. The thread stood for 8 years and the majority of content was posted two or more years before I contributed to it at all. I did review the entire thread at that point and found nothing defamatory. Nonetheless my response includes the following:

“The issue of psychological therapists who practise outside the scope of professional regulation is one that is important to many of our members who work hard to gain practitioner status with the HCPC, because we believe in the principle being important to protect the public (regardless of the individuals involved).

As with any other thread on the forum, if any of the content of this thread is considered defamatory the the individual involved is welcome to email the site (clinpsyforum@gmail.com) and point this out and we will remove it.”

The thread was then dormant for nearly six years, before being raised to discuss the way some “celebrity psychologists” were using BPS membership to give the impression of professional qualifications, whilst apparently breaching BPS guidance. I had raised these concerns with the BPS and mentioned doing so on the forum and on twitter. However, as with the content in the thread, the concerns were about the misrepresentation of professional titles and skills, and the role the BPS take in giving credibility to psychologists who are not HCPC registered practitioner psychologists, and their lack of will to intervene or regulatory teeth when concerns are raised about these individuals. Whilst one or two of my posts are critical of specific things that [individual celebrity psychologists have] written or said I cannot see any defamatory content. I have made no direct criticism of [the individuals named in the complaint], and there has never been any mention of [the complainant] on that thread or elsewhere on the forum.

Nobody has raised a complaint about that thread. I have reviewed it today, and whilst there is legitimate concern about misrepresentation of qualifications and the public perception of psychologists, based on things written or said by various unregulated “psychologists” in the media, I cannot see anything defamatory in the content. [Far from being unprofessional, I believe we have gone above and beyond requirements to prevent defamatory or unprofessional content. I posted in that very thread] how to report any concerns about defamation, and have been mindful to allow only appropriate professional concerns about misrepresentation to be raised on the forum, rather than personal attacks or potentially defamatory content.

I do not believe that it can possibly impair my fitness to practice as a clinical psychologist to have hosted or participated in discussion about potential misrepresentation of professional qualifications by “celebrity psychologists”. This has not been defamatory, and I believe it to be legitimate for members of a clinical psychology forum to raise professional regulatory concerns about public figures – especially when these are factually based, shared by many practitioner psychologists and early career stage psychologists, and have been raised appropriately with professional bodies including the BACP and BPS. The posts on the forum that were critical of these individuals were based on the content of their newspaper columns and television appearances, how they are introduced in TV programs, and their stated qualifications and experience on their websites. For example, it is a true fact that Emma Kenny is not a clinical psychologist, despite being introduced in a BBC television series as being one, and this being a breach of the regulations that brought us under the auspices of the HCPC.

I would note that it is entirely lawful for individuals to publish honest opinions on a matter of public interest and based on facts which are true – this is known as “fair comment” or “honest opinion”, and has been tested through the courts by cases such as British Chiropractic Association vs Simon Singh, which led to the Defamation Act, 2013. This introduced a number of protections against allegations of defamation, including truth, honest opinion, public interest, and a defence for website operators hosting user-generated content, provided they comply with a procedure to enable the complainant to resolve disputes directly with the author of the material concerned or otherwise remove it. This ensures that individuals who own or run websites that allow comment are not liable for the content of other user’s comments on it. It requires that the complainant must contact the site owner or administrator to raise a complaint in which they specify the complainant’s name, the statement concerned, where on the website it was posted and explain why it is defamatory, before taking any other action in relation to alleged defamation. These complaints can only be made by the person who has allegedly been defamed or their legal representative.

We have never received any complaint or notification of potential defamation, or any communication from [celebrity psychologists] or their legal representatives, and as previously stated we have never mentioned, heard of or communicated with [the complainant]. Thus a non-specific complaint to the HCPC made by an individual who has never been mentioned on the site seems quite inappropriate as a means to address concerns. I would therefore hope that the complaint can be quickly dismissed.

Yet the case still wasn’t dismissed, despite the fact I had demonstrated that a) I had not made any defamatory comments about the individuals concerned and b) there was no legal basis to hold me accountable for posts made by others on a forum that I own (even had any been defamatory, when none of them had been).

I was then asked on 6th April to provide proof that no complaints had been made to the website. Aside from the fact that it is not my burden to prove a negative, and almost an impossible task, I spent the next 3 hours responding to this request, searching the email correspondence, administrator and moderator report logs for each name or the word complaint, and submitted screen shots of every search. These were acknowledged on the following day.

Yet the case still wasn’t dismissed.

I then heard nothing for 4 months. So I wrote on 12th August to ask whether the complaint had been dismissed. This email was acknowledged, and I was told I would receive a reply within 5 working days, but received no reply. I therefore emailed again on 20th August, which again had no reply. So on 26th August I raised a complaint.

My complaint was that this “fitness to practise concern” was obviously spurious from the start, and should never have reached the point of even a cursory investigation (given the complaint was from a person I had never interacted with, about comments made by people other than me about people other than him). But even if it did, in error, reach a cursory investigation, surely the information I provided within 3 days was enough to say “sorry, it is now clear this isn’t a legitimate complaint” and not keep me under the stress of a formal fitness to practise investigation? How this can still be hanging over my head five months later is very troubling. Surely there must be a process for checking the prima facie validity of complaints, that should have dismissed this? What if I had been employed, and this had led to me being suspended or fired? How you could do this to a person struggling to sustain their business through a pandemic lockdown over such a trivial and spurious complaint is beyond me.

On 4th September the investigation was officially closed. The HCPC informed me:

I am writing to let you let you know that we have now completed our initial investigation into the concerns we received about your fitness to practise.

During our investigation, we obtained information from the Complainant and yourself. We have now assessed the concern, and all the information we received, against our threshold criteria for fitness to practise investigations.

In doing so, we have considered whether this matter may be a breach of the following HCPC Standards of Conduct, Performance and Ethics:
2. Communicate appropriately and effectively
6. Manage risk

The outcome of our assessment is that the threshold criteria for fitness to practise investigations has not been met in this instance. This means that we do not consider that the concern, or the information we have obtained about it, amounts to an allegation that your fitness to practise may be impaired.

The reasons for our decision are explained in more detail below:

Issue 1 – comments of an offensive, bullying or inappropriate nature on social media

Registrants are not prohibited from expressing their opinions on social media, provided the content or language used is not inappropriate or offensive.

HCPC Guidance on Social Media advises Registrants: ‘ When using social media you should apply the same standards as you would when communicating in other ways. Be polite and respectful, and avoid using language that others might reasonably consider to be inappropriate or offensive. Use your professional judgement in deciding whether to post or share something.’

From the links and screenshots provided, the content of the forum appears to be confined to a discussion of professional concerns and information already in the public domain. Regarding the opinions and concerns expressed in the forum, the HCPC would be out of place to prohibit its Registrants from having a free discussion about their concerns or limit their ability to express their opinions. Of the information provided and the search conducted, I am unable to find any statements which amount to ‘trolling’ or bullying.

As our process is evidence based, we cannot proceed with our investigation without evidence to support the concerns. The Complainant was given multiple opportunities to provide evidence that you contributed to and offensive or inappropriate content, but has failed to provide information which supports the concerns.

Issue 2 – hosting comments by others of an offensive, bullying or inappropriate nature on your site

You have provided evidence that you have put multiple protections in place to ensure the tone, language and content of the forum is not defamatory and does not stray into inappropriate content or language. Where members breach these terms, you have a team of moderators who will respond.

In providing individuals the ability to report specific posts and comments, you have acted in accordance with your professional duty to support and encourage others to report concerns(SCPE 7.2). You have evidenced that you have not received complaints on this thread, and therefore have not been in a position to respond to such concerns.

In the absence of any evidence to suggest you have not complied with the relevant obligations, there is no information to suggest that your fitness to practise may be impaired.

We will therefore not be taking any further action in relation to this matter and have closed our file on this case. However, please continue to be aware of our communication guidance when reviewing your forum/website.

We appreciate that this has been a very stressful time for you and would like to thank you for your co-operation and patience during our investigation.

So, to my relief, they got there in the end and the complaint has been dismissed. However, my question is why the complaint got through the starting gates, and why it took 5 months, 2 emails and a formal complaint to resolve.

But more than this, why do the BPS continue to endorse these “celebrity psychologists” and do nothing to protect or support genuine practitioner psychologists against this kind of attack? Despite numerous complaints about “celebrity psychologist” Jo Hemmings in the context of her article about Meghan Markle being manipulative, the BPS sat her down for a chat and took her at her word that she would be more careful in future. And they’ve not replied to any of my emails in the six months since I suspended my membership, saying I would not continue membership until they responded to the concerns I raised about their endorsements not protecting the public.

And more than this, why does the legislation not distinguish genuinely qualified and accountable professional psychologists within the scope of regulation from anyone who calls themselves a psychologist? In Australia it is an offence with enormous financial penalties to misrepresent someone as a psychologist or claim to be a psychologist if not within the scope of statutory regulation. So the public cannot be misled by the media citing quacks or charlatans who claim qualifications, but actually have to check their registration before using them as experts. Here we haven’t even got that protection for who can be called as an expert witness to inform critical decisions in the courts. The scope of current regulation fails to protect the public, yet nobody – not professional bodies or politicians – seems to care.

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