What to do when you can’t do it all

There was an interesting little discussion on the forum this week about the perceived pressure to do everything, and to do it all right now. That fits with the concept of the insecure overachiever that is actively sought out for certain high demand jobs (and was the topic of a recent radio 4 show) and also the concept of Imposter Syndrome, where you constantly feel like a fraud who might be found out and identified as inadequate for the job. There is a widely perpetuated narrative in modern society that people should be willing to work longer and harder, and there is always a mythical person who is doing more than you. Whether that is more revision before exams, or more prep for their clinical application or assessment day, or more voluntary work, or managing to juggle more things in their working week, it always makes you feel a bit guilty and inadequate no matter how much you are doing or how hard you are trying. The truth is we are in a profession where demand for our services will always exceed supply. The early stages of the clinical psychology career path are competitive, and there are lots of people who claim impossible workloads and huge amounts of experience that can make you feel like you’ll never measure up. So how do we tackle this pressure to do more?

There are probably lots of layers to the answer. Some are political, as this culture springs from job insecurity, underfunding, and the focus on attaining wealth and status – so the ideal is to change the game, rather than trying to win a game that is rigged against us. Another layer is to communicate with others and band together, as this undermines our personal insecurities that see it as our own personal failings, and allows us to normalise our experiences and work together to resolve the systemic issues that underlie them. But even at a personal level, there are things that we can do.

So this blog is about my top ten suggestions to tackle that feeling of having too many plates spinning and not enough time, and the cognitive distortions that maintain the belief that we should do more. I’m not saying I’ve got all the answers, or that that I’ve resolved all these issues in my own life. Far from it! I’ve mentioned many times that I’m not a good role model in this regard. I think I am a bit of a workaholic, and whilst other people say I’ve achieved a lot, I always feel like there is more I could/should be doing. However, the things that have started to help me change my own patterns are:

1) Know when you are taking on too much. Having had a minor car accident, the physical repercussions made me cut down my work to a more manageable level. They remain a good reminder if I’m overdoing things, as I get aches and pains in my ear/jaw and shoulder. Obviously, I’d not recommend having an accident as a self-care strategy to others! The bit worth sharing is to be aware of your own physical and mental state, and to learn to recognise your own signs of stress as early as possible. Then you can be responsive to your own needs, and learn to stay within your own limits. It is also a good reminder to ensure that you build self-care and exercise into your routine.

2) Fit in friends and fun. Giving higher priority to the people and things you enjoy and are recharged by. We all need to have support networks, and family and friends need to be given enough time and priority in our lives to perform that role. I can’t persuade myself to “do less work” or to leave gaps in my diary, but I can put in commitments to the people and activities I value in my life that compete with work. I make it a personal rule that I finish work at 4pm on Mondays to take my kids to their swimming lesson and do my 30 lengths. Every evening the 7.00-8.30pm slot is time I always give to my kids’ bedtime routine, and 8.30-10.30pm is time I always spend with my husband. I’m also trying to cook with the kids twice a week, to fit in a creative activity each month and not to work on weekends. My advice it to start small, commit to something for at least a month and then build on good routines once they are established. Once in a while make time for fun or frivolous things like having a spa day, or sneaking out for a cinema or lunch date with my husband, or booking a holiday.

3) Sleep. No matter what else is going on, make sure to get enough sleep. For me that means eight hours per night. I’m a night owl, so I often work until the task is done, even if that means resuming work after everyone else in my house is asleep and working through until the small hours. Then I often have to get up and fulfil work commitments the following day. If I could stop doing those extra bits of work after everyone else is asleep and get a proper sleep routine where I sleep during the hours of darkness and get out into the sunlight more in the daytime, that would have positive knock-on effects on my energy levels, mood, appetite and attention span. You can see from the fact I’m drafting this post at 2am that I’m not managing that yet, but for now allowing myself to have at least one lie-in on the weekend is a lifesaver.

4) Use your time better. Stack commitments together with similar content, that involve particular colleagues or that you can do in particular locations. Get the right kit to do the job efficiently. Travel less. Use video chat rather than meeting in person. Minimise your commute, or use it for something relaxing like reading a novel or listening to music or audiobooks. See if you can work from home even if it is just a small proportion of your time. Work out what the blocks or bottlenecks are in your process, and how you can solve them, For me having templates of common reports and letters was one helpful step. According to where you are in the power structure, you can also look at how you can draw in support or what you can delegate to others.

5) Diarise the in between stuff. Don’t just fill your calendar with the face to face stuff and expect to fit in the admin and support tasks in the cracks, because they either escape into non-work time or don’t get done.If you have to write a report between appointments, give yourself a diary slot to do it in. Need to read the papers before a meeting? Book the hour beforehand for that task. Want to write up a paper? Diarise three days for it. Then make sure that you keep that time for that sole purpose. Book an admin slot at the beginning or end of each day, or a half day at the beginning or end of the week. Check out how much time you need and when you are most productive. If that is a time that is earlier or later than other people work, make sure that you take the time back somewhere else*.

6) Prioritise, then focus on the key tasks. Isolate yourself if you need to get something important or time critical done. Turn off your phone and your email alerts, ideally unplug from the internet, and prevent distractions. Then give it your full attention. Work out what is interrupting you, and then stop it so you can get work completed in one steady sprint, rather than having to come back to it again and again after dealing with phone calls, emails, other people interrupting, or diverting onto the internet. Deal with the quick stuff straight away. But then make yourself a task list and work down it. Prioritise the important stuff over the seemingly urgent but unimportant. Try to check email and messages at the beginning and end of the day, not every few minutes. When you need to get something done turn off social media, email alerts, etc. Turn your phone onto silent and then put it out of sight.

7) Clarify your goals, and how to reach them. Envisage where you are trying to get to, what the steps you need to take are, and what barriers are preventing you getting there. If you wanted to lose weight you could picture yourself thinner and see how it would play out in your life, then think about what you need to do to consume less calories or burn off more. Then see what is stopping you. You could identify that you aren’t getting to the gym if you go home from work first, or that you are always tempted when there is cake in the office, or buy unhealthy snacks when you don’t take a lunch to work. Once you recognise them, you can then make an informed choice, and if the benefits are worth the extra effort you then need to address the barriers. One of my goals is to make my business self-sufficient enough to continue even if I went off long-term sick, and could provide me an income in retirement. So I have been thinking about how to recruit and train others to sustain the business, and create products that can utilise my skills and knowledge without me having to deliver everything in person (eg can I train others to deliver training, deliver it as a webinar, or make videos of the training available to subscribers).

8) Get a better bubble. They say that we are the average of the five people we spend most time with, and whilst that isn’t a scientifically validated concept, I think that it has some merit to it. We are all normed by those we spend most time with, so I’ve actively chosen to seek out the company of people I admire and want to learn from, and who will challenge my assumptions and habits. More specifically, I’ve been trying to spend more time with other social entrepreneurs, rather than the long-term NHS, education and social care professionals I already know, so that I move away from the common assumptions of this kind of work, and can be more creative and less risk averse in how I look to create impact. You also need to enlist the support of the key people in your life so they reinforce your goals, rather than unwittingly draw you back into old habits.

9) Get reflective. Use your supervision, your trusted confidants or keep a journal. If you want to take it one step further, why not seek out therapy, or coaching, or personal development opportunities. Give yourself time to think and regroup, particularly after stressful or emotional experiences. As well as the benefit of some wonderful supervisors, I’ve had various coaches and mentors since I left the NHS, and I’ve attended various groups and training programmes. Each one has helped me understand myself better, and refine my plans to make them more likely to success. It is really good to take time outside the pressure of spinning all the plates to look at why you are spinning them, which are most important, and how they make you feel. It can help you to consider the pros and cons of different options, and to identify goals and actions.

10) Be kind to yourself. Remember that you need to attach your own oxygen mask before you can help others with theirs. Take time out when you need to, and find the things that replenish you. Be realistic about what is possible or what you have capacity for, and learn to say no to unreasonable demands. Don’t be too self-critical. Seek out and remember the positive feedback, and the things you have already achieved. Take the time to note the positives and be grateful.

And above all: Enjoy the journey. There is no rush to get to the destination. Dance whilst the music is playing.

 

*with the agreement of your manager, of course.

The attraction of small rewards

I went to the Y Not Festival last month. It was a bit of a mixed bag because of the weather, and the terrible app that was supposed to function as a map and timetable was a daft idea on a site with limited mobile in the first place and totally useless in practice as it wasn’t updated when things changed. But we saw some good bands, and ate some good food, and it was only half an hour from home so we also slept in our own beds! But the reason I mention it was because of a trivial but unexpected thing: They had an incentive to recycle the plastic pint glasses that were being used and dropped on the floor. They offered 10p per glass to take them to a recycling point in sets of five. For the most part that wasn’t enough for people drinking to bother keeping and pooling their glasses to cash in. But a small economy developed amongst people who found it worthwhile to go around collecting the dropped cups. There were some sets of kids excitedly supplementing their pocket money by collecting piles of cups during the day, and also a few adults who increased in numbers in the evenings.

At £5 per pint the beer was not cheap, and I joked with my husband that I’d see if I could collect 10 cups to offset the cost each time he drank one. But as soon as we started collecting cups, we realised that there were loads of them, and it was easy to make quite good money from them. In three hour-long collecting binges, and whilst listening to bands I enjoyed, I stacked and recycled well over 500 cups. That was enough to pay for all our food over the weekend, and the couple of drinks my husband had. Of course my legs ached like crazy the next day, after all that walking around punctuated by 500 bodyweight squats. But I felt good about being part of the efforts to clear up the site and recycle the cups.

Of course I’d much rather they used reusable cups as they did at Timber festival, or ones that are biodegradable as they did at Woodside. And it doesn’t really make much sense to pay random people more per hour than they pay their bar staff or rubbish pickers, let alone to pay the people who were simply emptying out the plastic recycling bins, stacking up the plastic cups and taking them to the recycling point like their own little black market scheme. And I wasn’t persuaded that they were actually going to recycle the cups at the end of the weekend. But I was interested in the fact that I somehow found it fun to do a dirty, smelly, physically demanding job earning way less than I can earn from work. Apart from the novelty and fact it filled in the gaps between artists, the reason was as obvious as those demonstrated in Pavlov and Skinner’s seminal experiments: The small but proximal rewards were enough to reinforce the behaviour, and make me want to repeat it over and over again. In fact it became quite addictive. The small payments made it feel like a game in which I was succeeding and earning five to ten pounds per trip to the recycling point made it really tangible that I was being rewarded. I could have spent the entire weekend picking up those crushed and broken plastic cups and straightening them out into stacks to cash in, and my kids were jealous that they’d missed out on the opportunity to earn cash because they had chosen to go to their grandparents rather than the festival.

In another example, I’ve been playing a really rubbish game on my iPad called Hidden City. It is a hidden object game, where you have to find items within a picture of a scene before the time limit runs out. For example, there might be a picture of a greenhouse full of caged birds and exotic plants, and you will then be asked to find a pair of binoculars, a fan, an oil lamp, a walking cane, a string of rosary beads, a bunch of chilli peppers, a pair of shoes, a turtle, and various other objects to click on and collect. Each will be visible within the scene, some in plain sight and others tucked away or masked by being in front of similarly coloured items. In certain quests there are also keys to find in the scene that are smaller and better hidden. Whilst this has some inherent mental challenge and novelty, it really is a very simple premise for a game, and quickly becomes repetitive, so you’d think the game would be very boring – in fact it seems boring to have explained it in writing, so I hope I haven’t sent you off to sleep! You would therefore assume that people would drop out of the game very quickly, but that doesn’t appear to be the case. In fact, the makers are so confident that players won’t be bored enough to drop out that they make you search each scene for objects selected from the same list and placed in the same range of places in the scene many times. In fact, to complete some quests you search the same scene over a hundred times. The task becomes more difficult because you are expected to find more objects in a shorter time interval, and the scene becomes more cluttered so it is harder to pick out the specified items, and you have to alternative with searching other scenes to get the tokens required to go back to the main scene. To compound that, there are multiple locations in the game, and each needs to be searched a large number of times, so to complete the whole game you probably have to complete about ten thousand search quests.

It sounds like an enormous and monotonous task, and the game itself is full of bugs, glitches and poor translations, yet it is the most popular hidden object game in the world. More than half a million people have played it, and there are tens or maybe hundreds of thousands of players active at any one time. They are not only signing up to play in huge numbers, they are choosing to pay for the optional purchases to assist their searching, making this game and the multiple other games by the same company, and the multitude of similar games available, highly profitable.  Estimates suggest that over £3 million of in game payments have been made since the game launched four years ago, and tens of millions of pounds are being spent in in-game micro-payments across all the games by this maker each year. It seems illogical, but many players spend way more than they’d need to pay to purchase a really good game to play this glitchy game that is constantly interrupted by advertising for in-game purchases and other games by the same company.

So why do people keep playing, and why do some of them keep paying? I think it is the same idea of reinforcement through small rewards. As a player you experience a lot of small successes. They make the first few searches really easy. Then each time you search and don’t find all the items you are told to try again. If you find them all you are rewarded by a random selection of small icons, and you can collect these items in sets. Completing the set gets you a rarer icon, with some bonus points or magical powers to boost your energy or increase your ability to find other bonus items. In the bigger quests you might also get tokens to unwrap gift boxes containing more icons. You also get overnight bonuses, daily bonuses and components of a magical piece of jewellery each time you play again after more than 8 hours but less than 24 hours. They compound so an unbroken chain of about a month gets you the finished item, and 12% more items to find for a 10 day period. If you break the chain you either have to use or buy in game currency to restore it, or you lose the components you gained. Something about our psyche likes gaining these pseudo possessions and dislikes missing out or losing them, enough that these games are quite addictive. But they are all just small pictures of random things. Why should I care if I have a magical tuning fork in my collection, or whether I get the apple strudel icon that completes the huntsman set that gives me the Austrian clock? There is no intrinsic value in the drawing of the clock, or the strudel or the tuning fork. They bear little relation to the scenes I search, or to the token plot about the magical city trapping people, or the candy-crush style mini-games. My life is not better in any tangible way if I collect 75 keys and open the golden chest to receive 6 bonus items, or if I play the scene 100 times and get a new avatar of the lady of the manor, or the Samuri, or the gardener. Being at a higher level on the game doesn’t convey any greater skill that would garner respect from other players, let alone in the real world, nor does it teach me anything I can generalise outside the game.

So why is a badly made game with such a simple and repetitive premise so popular? I’d suggest that is intentionally designed to be rewarding to play, and to tap into what we know about reinforcement with the number of small rewards it offers. Our brains are set up to love rewards, no matter how meaningless they are, or what the longer-term cost is. Like scratching an itch, or eating something tasty but unhealthy, using drugs or smoking cigarettes, the immediate rewards are often much more effective as an incentive than the longer-term consequences are as a deterrent. The logical decisions we make about changing our behaviour struggle against these proximal sources of gratification. It doesn’t feel like a big effort or commitment, because we are only playing a three-minute mini-game. We are tempted to take the small action to sample the reward, but this then lures us in to take the next step with another small effort, and the result is that we repeat that for far longer than we planned. Even if this means losing out on sleep, or getting things we objectively rate as more beneficial or necessary done.

The same is true of our online behaviour. We chain from one news article to another, or one social media post to another, or one youtube video to another until whole evenings disappear into a black hole. Even when we are going about our daily lives, we constantly check for the small rewards of messages, likes or responses on social media. For many people this becomes something done obsessively, to the detriment of other activities in our lives. As well as hitting our reinforcement pathways, these small social connections also fire up our desire to feel belonging and acceptance in a group, and to gain the approval and/or attention of others. I’ve blogged before about the toxic aspects of social media. Studies have shown that stopping using social media, whether for a couple of hours per day, a day per week, a longer block of time, or permanently, makes people happier (journal articleanecdotes, article citing studies, more anecdotes, even more). Yet for most of us, we are enticed by the sense of connection (albeit often a much more distant and less authentic connection than we make in real life) and the promise of these small rewards.

It makes me think how despite all the progress of technology, we really are quite primitive creatures in some ways, tied to the way our biology has evolved to reward behaviours that had some adaptive function that had evolutionary benefits. So can we make a conscious choice to use these inherent reward systems for more positive purpose? Possibly. For example, we can benefit by building chains of positive behaviours that we don’t want to break – like a colleague who told me he hasn’t drunk alcohol for 92 days after realising he was drinking almost every night. That challenge of having a dry month, or to do without meat, or caffeine, or cigarettes for a set time period seems an effective way to change behavioural habits. It is less final and impossible sounding to have a break from something than to give it up permanently, but it can give you a chance to see what life is like without it, find alternatives that fill that gap and build up some of these rewards for going without. It then becomes easier to continue that pattern, and there can be a reluctance to break the chain, particularly if there have been social or financial or health rewards for the change.

Likewise we can gamify exercise. When I used to weight lift I would share my achievements with a group of other weightlifters online. This gives a sense of a peer group who can reinforce your behaviour and some social pressure to sustain the pattern (though I was never one to post every gym visit on facebook the way that many runners/cyclists use their apps to, or to post lots of philosophy and photos the way that yoga fans seem to – I just posted to a weightlifters group when I made gains, and could compare my progress to others in the group). But even without this online support I had a sense of achievement each time I went to the gym, or completed my routine, or increased the weight I could lift in a specific exercise. I liked to record my weights in a journal and to feel that I was making measurable small gains. I also liked confounding expectations by being an overweight middle-aged woman who had hidden physical strength. I’ve mentioned my joy in having “ninja muscles” before. I’d like to get back to it, and I’m sure my core strength would return. I’ve still got surprisingly muscular legs, though I wouldn’t risk picking up an 18 stone barbell these days!

So I guess the knack is working out how to make our innate reward systems work for us in a modern world. I’m certainly far from achieving that. Change is hard. But maybe I can at least recognise the patterns better now I’ve thought about it more. Maybe I’ll come back to that theme in a future blog.

 

 

Solve for happiness: Some thoughts on big data/AI and mental health

We are hearing a lot about the use of big data at the moment, mostly that it has been an underhand way to manipulate people politically, that has been used by those with no ethical compunctions to get people to vote against their own best interests*, and in favour of Brexit and Trump. Cambridge Analytica and AIQ seem to have commercially exploited academic research and breached data protection rules to try to nudge political behaviour with targeted messaging. Whether or not that was successful is up for debate, but to the public the narrative is about big data being bad – something technocrats are exploiting for nefarious reasons. I can understand that, because of the associations between gathering data on people and totalitarian political regimes, and because of concerns about privacy, data protection and consent. There is increasing awareness of what had previously been an unspoken deal – that websites harvest your data and show you targeted advertising, rather than charge you directly for services, and the new GDPR means that we will be asked to explicitly consent to these types of data collection and usage.

But what about the potential for big data to do good? I know that DeepMind are doing some data crunching to look at whether AI algorithms can help identify indicators that determine outcomes in certain health conditions and point doctors towards more effective treatments. Their work to identify warning signs of acute kidney injury was criticised because of breaches to data protection when they were given access to 1.6 million medical records without individual patient consent, but whilst the data issues do need to be sorted out, the potential for projects like this to improve health and save lives is undeniable. Computers can look through huge amounts of detailed data much more quickly and cost-effectively than humans. They can also do so consistently, without fatigue or bias, and without a priori assumptions that skew their observations.

Research often highlights findings that seem counterintuitive to clinicians or human researchers, and that means that using the data to generate the patterns can find things that we overlook. One example I read about today was the fact that admitting offending behaviour does not reduce the risk of recidivism in sexual or violent offenders (in fact those who show most denial offend less, whilst those who demonstrate more disclosures and shame are more likely to reoffend). But this is also true about telling people they are being given a placebo (which will still produce positive placebo effects), using positive mantras to enhance self-esteem (which seem to trigger more negative thoughts and have a net negative impact on mood and self-esteem) or about expressing anger (rather than this being cathartic and leading to a reduction in anger, it actually increases it). Various fascinating examples are listed here. There is also the well-known Dunning Kruger effect, whereby ignorance also includes a lack of insight into our own ignorance. As a population, we consistently overestimate our own ability, with people in the bottom percentiles often ranking themselves well above average.

I often refer to the importance of knowing the boundaries of your own competence, and identifying your own “growing edges” when it comes to personal and professional development. We talk about the stages of insight and knowledge developing from unconscious incompetence to conscious competence, and finally to unconscious competence where we can use the skill without conscious focus. Confucius said “Real knowledge is to know the extent of one’s ignorance.” And it may well be that when it comes to solving some of the big problems we are limited by our own frame of reference, what we think of as relevant data, our preconceptions and our ability to build complex models. Using giant data sets and setting technology to sift through and make sense of them using various paradigms of AI might help open up new possibilities to researchers, or find patterns that are outside of human observation. For example, certain medications, foods or lifestyle traits might have significant impact on certain specific health conditions. I am reminded of a recent article about how a third of antidepressants are prescribed for things other than their primary function (for example, one can seemingly help with inflammatory bowel disease that has very limited treatment options). A computer sifting through all the data can pick up both these unintended positive effects and also rare or complex harmful side-effects or interactions that we may not be aware of.

What difference could this make in mental health? Well, I think quite a lot. Of course many predictors of mental health are sociopolitical and outside of the control of the individual, but we also know that some small lifestyle changes can have very positive impacts on mental health – exercising more, for example, or having a healthy diet, or getting more sleep, or using mindfulness, even just getting outdoors more, learning something new, doing something for others, or spending more time with other people (and less time on social media) can have a positive impact. There are also many therapy and therapist variables that may make an impact on mental health, for people who engage in some form of talking therapy, although variance in outcomes seems to actually boil down to feeling heard and believed by a therapist who respects the individuality and cultural context of the client. And of course there are many medical treatments available.

So is there a way of using big data to look at what really works to help people feel happier in their lives? I think the potential for apps to collect mass data and test out what makes impact is enormous, and there are a proliferation of apps in the happiness niche and more that claim to help wellbeing in a broader way. They seem to have found a market niche, and to offer something positive to help people make incremental life changes that are associated with happiness. What I’m not sure of is whether they reach the people that need them most, or if they are evaluating their impact, but presumably this is only a matter of time, as real life services get stripped back and technology tries to fill that gap.

I think there is huge need to look at what can make positive change to people’s wellbeing at a population scale, and I think we need to be tackling that at multiple levels. First and foremost, we need to make the sociopolitical changes that will stop harming the most vulnerable in society, and encourage greater social interconnectedness to prevent loneliness and isolation. We need to increase population knowledge and tweak the financial incentives for healthy lifestyle choices (eg with much wider use of free or subsidised gym memberships, and tax on unhealthy food options). And we need to invest in preventative and early intervention services, as well as much more support during pregnancy and parenting, and in mental health and social care. But I can also see a role for technology. Imagine an app that asked lots of questions and then gave tailored lifestyle recommendations, and monitored changes if the person tried them. Imagine an app that helped people identify appropriate local sources of support to tackle issues with their health and wellbeing, and monitored their impact when people used them. As well as having a positive immediate impact for users, I’m sure we’d learn a lot from that data that could be applied at the population level.

*I think the evidence is strong enough that the demographics who voted for these people/policies in the greatest numbers are the very people who have come out the worst from them, so I am just going to state it as a fact and not divert into my personal politics in this blog, given I have covered them in previous topics about Brexitmy politics, “alternative facts”, Trump, why and what next, the women’s march, and Grenfell and the Manchester bomb.

Well-being check-ups

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

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

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

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

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

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

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

 

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

Six degrees of separation

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

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

Wisdom, sycophants and advice that won’t work

I have been watching and reading a lot of Brene Brown stuff recently, and for the most part I feel like she has been able to identify and tap into some important concepts that chime true with my own understanding of attachment, shame, perfectionism and self-compassion, but there is a part of me that is a bit uncomfortable. When I’ve watched recent interviews, such as this one with Oprah I find myself responding to the comments like “that is so powerful”, “right, right, right” and “there are so many things I love about you” with a bit of a cringe. I think it is partly that it feels like a sycophantic mutual love-in amongst a particular group who have formed their own self-improvement echo chamber, and partly that the whole American over-the-top-ness of it makes it come across as less than sincere.

Obviously Oprah is in herself an incredibly impressive person: She is self-made despite horrible early life experiences and someone who adds welcome diversity to the line-up of bland white males and slim, magazine-beautiful young women that populate American TV, she has popularised acceptance of LGBT people and been empathic about a wide variety of life experiences and mental health problems. Plus she is a significant philanthropist (albeit that her charitable activity in itself is not entirely without criticism). However, Oprah and her ilk are so non-critical of patent nonsense from self-help books about spirituality and positive vibrations to dodgy hormone treatments that it feels like a huge missed opportunity to have not put a threshold of scientific scrutiny (or at least critical thinking) to claims when she has such an enormously influential platform.

Likewise it is hard for me to reconcile why a credible researcher like Brene Brown would be prepared to be thrown in that mix and start marketing self-help courses for Oprah watchers. It doesn’t seem to make sense without attributing a financial motivation for accessing the wider audience that is more powerful than professional ethics.

I’m going to read all her books and then I’ll be in a better place to comment, but I’d like to think I’m not being naive or rigidly judgemental here. I’m sure if I felt that I had an important message to share and Oprah offered access to her audience of millions, and I felt that would help to change the world I would make compromises too, both to get the message out and to get the book sales, raised profile and funds that would enable further work. And I fully accept that there have to be coffee table books that are accessible to wider segments of the population than the referenced texts of scientists and clinicians that are more closely tied to the evidence base from which they are drawn. But something still feels uncomfortable.

So, is it just a cultural divide or my own hatred of insincere praise, or is it something deeper that is rotten about the self-help culture?

I’ve started to think that the self-help world, like the diet industry, is rotten at the core because it is invested in failure. I don’t mean the books often recommended by mental health services as ‘bibliotherapy’ that address mental health problems based on well-evidenced psychological techniques like CBT here, which are predominantly helpful. I mean the 2000+ books per year of home-brew wisdom about how to be happier, grasp control of your destiny, be more successful, fix your marriage in a week, get more energy, unlock your chains! Most of these have no evidence base whatsoever, and the authors often have no scientific or mental health credentials. A cynic might say they are selling false hope. Yet the same unhappy people try again and again to change their lives by reading the next book, spending more and more money to make changes presented as easy that are actually unsuccessful for the vast majority of those that try them out.

Just like the diet industry, self help is an industry that has had meteoric growth. Yet little of that is based on any evidence of either the underlying principles or the efficacy of outcomes. There is minimal evaluation, and what there is isn’t promising. In fact, recent research (albeit on a very small sample) has shown that reading self-help literature actually makes people more depressed and anxious!

“The sale of self-help books generated over $10 billion in profits in 2009 in the US, which is a good reason to find out if they have a real impact on readers,” said Sonia Lupien, Director of the Centre of Studies on Human Stress (CSHS). The results of the study showed that consumers of problem-focused self-help books presented greater depressive symptoms and that growth oriented self-help books consumers presented increased stress reactivity compared to non-consumers. No difference was found in any variable according to whether people had read self-help books or not, suggesting they have little impact on functioning. In fact “the best predictor of purchasing a self-help book is having bought one in the past year” suggesting that the same group of people repeatedly buy self-help books but aren’t actually changed by reading them.

In the same way, every new year consumers with weight-loss resolutions in the UK spend £335 million, yet a month later for more than half of them there is no measurable impact on their weight or fitness. Overall the diet industry has an incredible failure rate: 95% of people re-gain the weight they lose. Yet the consumers keep on spending. In the USA consumers spend more on diet-related purchases than the combined value of the government’s budget for health, education and social care. And yet a little basic knowledge of the subject could inform them that most of the things they try won’t work, and that there are very well established links between diet and health.

It seems I am not alone in this discomfort, and Brene Brown herself has felt it and responded. I still think she is one of the good guys, and clearly there are gender politics and marketing influences she struggles to counter, but it remains a fact that there is little to distinguish the good from the bad in the self-help field. I wonder if it is time for those of us who write from an evidence base to respond to that and to start a website to evaluate claims from self-help literature?