boundaries

Spreading too thin

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

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

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

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

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

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

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

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

Why is there always a can of worms?

I’ve run http://www.clinpsy.org.uk for 9 years now, and built it up to 6900 members, 600,000 users and nearly 10 million page views per year. I’ve put enough hours into that site to add up to more than two years of full-time work, and I’m proud of what we’ve achieved. It is an informative, welcoming community that allows people to network and ask questions. It also levels the playing field of information and reduces the impact of personal connections within the early stages of the profession, and I hope that this will in the long-term act to increase diversity in the profession. Over those 9 years, members have written upwards of 135,000 posts on the forum, and our wiki of information and answers to frequently asked questions has been viewed millions of times, with some posts about preparing for interviews, the route to qualifying, formulation, writing a reflective journal, and transference proving particularly popular – the latter having been read over 115,000 times.

In all of that time we have had remarkably little need to intervene in the forum as moderators. We remove the occasional bit of spam, and we have sometimes anonymised posts in retrospect on the request of the author, and from time to time we have to explain to service users that this is not an appropriate place to ask for advice, but we rarely have to warn or ban forum users. I think the total to date is seven banned individuals and one banned organisation. Not bad when we’ve had 10,000+ sign-ups, and 135,000 posts! This is perhaps a reflection of our clear guidance about how we expect users to behave on the forum, and also of the large number of regulars who act as a more informal feedback loop. We also have quite a large number of qualified clinical psychologists who log into the forum regularly and often act to provide information and correct misconceptions. This is a very important function, as the pre-qualification arena can often become an anxiety-provoking echo chamber, where rumours are propagated and exaggerated without being confirmed or refuted. It also allows us to have a (hidden) peer consultation forum, which is a very good place to discuss concerns with peers in a safe environment in which every member is an HCPC registered clinical psychologist.

However,  the few times when intervention is necessary always tell an interesting story. And the strange thing is, that every single time somebody has been a persistent concern on the forum, this has opened a can of worms that makes us worried about wider ethical issues for the same individual. We had someone who was very unboundaried, and at times threatening to their colleagues and other members in the LiveChat space, and transpired to have caused concern with aggressive conduct in real life. We had a member who was somewhat grandiose and wanted to be a moderator, who attempted to delete and vandalise site content. They later had issues in their workplace, with a similar theme of acting beyond their level of competence. One poster lied to persuade successful applicants to share their applications for clinical training and plagiarised them, and when we identified them it transpired they had plagiarised site content into a publication without acknowledgement and had been unprofessional in numerous other ways. Another odd poster used the same username to post topless pictures on another website. And most recently we have had an organisation recurrently attempt to circumvent payment for advertising on the forum by signing up stooge accounts to promote their service, where it would appear that the appearance of an ethical non-profit organisation instead covers a profitable privately owned tour operator.

It has made me wonder whether ethics and professionalism are the kind of thing people have or they don’t, and that show in numerous domains of their life. Or, is the seeming anonymity of an internet forum a place where traits are exaggerated and played out. Either way, the association between inappropriate use of the forum and inappropriate professional behaviour in other domains seems too high to be a coincidence.

Yet the ethical and professional guidance for psychologists has little that applies in our context. We have had to work out our own boundaries amongst the moderating team (we now comprise ten qualified psychologists and a lay member, although many joined the team as APs or trainees). It makes me realise how much unique our position is, on the technological frontier, and how we are learning case by case. For example, we have had to interpret the balance between confidentiality and risk to apply to our unique setting. We settled on a position that is broadly consistent with what I’d do with clients in real life; we would identify and report a member if we felt they were at risk or presented a risk to others, but otherwise aim to respect the pseudo anonymity of using a posting ID, where only a minority of people choose to be identifiable as a specific professional, or in a way that could be recognised in their workplace. Likewise, we have learnt to log everything typed into our LiveChat space, so that we are able to review the usage of particular members, or read the content if a report is made of inappropriate behaviour. I’d like to think that we’ve reached a good place, and have always been transparent in how we behave. It has been an interesting process though, so I’m thinking of presenting some of the ethical dilemmas and our process at the CYPF conference later this year.

If you build it they will come: The impact of making space in my professional life

When my personal development coach told me that the first steps towards having a happier working life and better work life balance were to a) figure out what I wanted to do most and b) clear out some space in my life for it to fit into, that seemed a bit back to front and almost too obvious.

Although I’ve always known that I want to apply clinical psychology to helping the most complex children and families, I felt a real lack of clarity about what I wanted to do. I think in retrospect this was because I’d originally envisaged nothing more creative than a career in CAMHS in the NHS. But even once I was outside the NHS I still felt this lack of vision for my ideal future, perhaps because I wanted to choose it from the options available to me, and I hadn’t explored what those might be very far beyond returning to the NHS or continuing what I was doing already (court expert witness work, with a side helping of trying to influence policy and practise by being involved with national committees, standards groups and supporting the next generation of CPs).

I had also internalised the idea that the right process was to build up my investment of time in what I wanted to do more, until that took off and allowed me to do less of the other stuff. I felt like clearing out space from my established work streams was of no value (or even a potential risk to my income) unless I had figured out what I wanted to do, or ideally created the alternative channels already. But slowly I realised that if all my time and energy was being consumed by my current workload, then there was no capacity to imagine anything better, to seek out any opportunities or plan any change, and I’d still be overloading myself and worrying about my work life balance in a year from now, or five, or ten.

So I decided to take a gamble and cut down my work commitments for a while and give myself thinking space to figure it out. Of course, being me, I took on the new part-time consulting role that was going to pay the bills whilst giving me time to think before I had managed to reduce my existing workload. So I had six months in which I had to overlap this new role with my all my ongoing court and committee work, before I was able to wind them down very much at all, and then a minor RTA to contend with (see previous blog). So I sure didn’t take the easy route to cutting down.

But the physical jolt was the final straw to help me to realise that I needed to change my work patterns and I have been able to spend more time with my family, and have now stepped down from almost all of my committee roles. This is an enormous change after 4 or 5 years on the BPS CYPF committee, nearly double that of being involved with CPLAAC, and more recently being part of the BPS/FJC standards group for psychology experts to the family court and the NICE guidance development group for attachment interventions, and a rep from the BPS to BAAF. I am now at the very tail end of the court work, with just three small pieces of work to complete (each an addendum to prior work or work that was delayed after I agreed to complete it) and a couple of single days in court.

Although my time is still very fraught for another couple of weeks and we will then segue into Christmas (meaning my winding down schedule will have taken me almost a year to achieve), I’ve managed to get onto some tasks I have been avoiding for a long time. I’ve started to work my way through the financial tangles that constantly stop things running smoothly – this is mainly the enormous pile of unpaid invoices where parties to court work have disputed their share, gone bust, or just not paid for years and years, but also includes the un-invoiced work that we have completed, expenses I have not claimed back from the company, and the administrative task of reconciling our records with the bank statements. My team have stepped up to help me and as I have made sense of it bit by bit it feels like that tangle is turning into a single logical thread I can follow and wind up as I go.

As I sort and put away the clutter that consumes my time and energy step by step, I am starting to feel less overwhelmed by running the business. As the volume of court work I undertake reduces, so does the emotional weight of the work. And as the burden I am carrying gets lighter, psychologically at least, some small gaps between the demands on my time and energy are already starting to appear. Into those gaps has come the beginnings of the vision I lacked of where I want to take my career in the future, and what kind of life I want.

I’m sure I’ll talk more about that next time. But for now I just wanted to share that it feels great to put down some of the load I have been carrying, to untangle the frustrating little issues that have been tying me up, and to create space for the stuff that I care about the most. With the help of a new business mentor I’ve been able to connect with the motivation that started me on this journey, and to finally work out where I want to go both personally and professionally. And that makes all the steps I have to take to get there much clearer.

I made the space, and sure enough, the goals of how I want to fill it have come to me.

To the parent in the changing rooms this morning

It made me sad to hear you repeatedly criticise your child for minor things, and then conclude “you’ll go straight to bed when we get home”. When I came out the shower to see the child concerned was 12-18 months of age, and having to sit patiently on the counter whilst you did your hair and makeup, I wondered whether I should have said something. But being British, I bit my lip.

Here is what I’d have liked to have said:

Firstly: A child of that age won’t be able to sit still without making a noise for 20 minutes. It isn’t a realistic expectation, so you as a parent should bring along things to do or a snack for times like that. If the issue is that being up on the counter means they need supervision, use the playpen provided, or leave the child in the creche until you have got dressed. If you took the child swimming then make the whole outing fun, and recognise that after an energy-consuming activity a child might be more frazzled than usual, so prepare for this.

Second: A child of any age needs lots of praise and encouragement to learn how to behave, and to feel that they are a worthwhile person. You teach children best by showing them what you want them to do, not telling them what not to do, and praising any approximation of it whilst giving encouraging feedback until they get it right. Can you imagine teaching an adult to drive by saying what not to do? “Don’t hit the pedestrians… no, don’t mount the kerb… don’t hit that other car… don’t go so fast… don’t use that gear”. Would it work? Then why do you think a child can learn much more complex and subtle social and life skills based on what you don’t want them to do? Like a learner driver, they need to be told what to think about and prepare for, then given guidance how to do it, and feedback about how to improve their attempt next time, whilst making them feel okay about the fact that they are still learning and things are pretty hard until they become intuitive.

At this age, you also need to ensure your expectations are realistic – instructions for a child with a limited vocabulary are like trying to follow directions given a foreign language, whilst you are still learning how to use your body and interact with the world. Set simple clear rules and then be consistent in how you react to them. Hurting others or yourself, or breaking things on purpose are not okay, but the way you manage these has to be age appropriate. With a toddler, being told what they have done wrong and/or removed from the situation is the simplest response.

Third: Using sending to bed as a consequence for undesirable behaviour is a really bad choice for several reasons. Most obviously, it isn’t an immediate consequence. The child will not link the behaviour with the punishment if there is a gap of more than a few minutes until they are much older (even at 4-7 children will normally need an immediate consequence like a sticker to help them understand the longer term gain or loss is related to the behaviour). But it is also really silly to link going to bed with being punished. It sets up a negative reaction to being put to bed, which will increase arousal at exactly the time you should be helping a child to feel soothed and start winding down to sleep, and set up expectations of resisting going to bed or staying awake and active/noisy which are likely to lead to more negative feelings. If it is normally nap time just after lunch, make that a pleasant time, not a punishment. If it isn’t a nap time, then don’t use it at all.

Being put in isolation feels like being rejected and neglected and is a very serious consequence, even if only for a minute or two (which is why it works so powerfully in time out with older children). A preschool child being shut in their room for longer than a few minutes is abuse, and with an older child I’d still advocate for the shortest possible length of time. Consequences should last no more than the child’s age worth of minutes and be proportionate. Never deprive a child of food just because they have done something irritating – for most things your displeased facial expression and tone of voice are enough. With little ones you may have to physically intervene to make them safe or to take away something being used inappropriately (eg a crayon that is being drawn onto the table) but make sure to repair the relationship after you’ve given that consequence, and to praise the behaviours you want to see instead. Choose your battles wisely. Ignore the little stuff, it doesn’t matter compared to your child having a positive experience of themselves, others and the world. A positive relationship with their primary caregiver is the biggest gift you can give them and makes them resilient for the rest of their lives.

Finally, if you are stressed or unhappy, or lack parenting skills or support, do something about that. Your child sees you as the centre of their universe, and deserves to experience warmth, safety and love rather than recurrent criticism. If other stuff in your life or your mental health or experiences of being parented are a barrier to providing the kind of care you want to provide for your child, get some help. Ask your GP or speak to your health visitor. Lots of good parenting services exist, and it really is a sign of strength not of weakness to seek them out when it might benefit your child.

I hope I observed an unrepresentative sample of the relationship today, and that there was something the child did that merited the negative feedback, like trying to touch the hot hairdryer or the plug sockets. We all have bad hair days and moments when we aren’t the kind of parent we would like to be. But it made me realise how much of the maltreatment I see in the histories of people through work is the chronic, insidious, low-level kind, and how we all turn a blind eye to that every day. Maybe I should have spoken up to ask whether I could help, rather than being caught up in my own discomfort and feeling it would be difficult/inappropriate to criticise.

Sadly, I am sure there will be another time in another situation with another parent, so hopefully I can give that a try.

Siblings, friends and vampire bats: a story of reciprocity

I don’t remember that much of my undergraduate psychology degree. This may be because I wasn’t paying enough attention at the time, or because it was two decades ago, or because I have built so much later knowledge on top of it that the foundations are no longer visible, or some combination of the three. But I do recall that for the most part it didn’t feel that relevant to what I was most interested in – how I could help to alleviate human distress. I didn’t really care much for the mechanics, chemistry or geography of the brain. The seminal experiments that built our knowledge of human behaviour felt more about history than something I could apply in my daily life or future clinical practise. However, one course surprisingly caught my interest: behavioural ecology.

In this class, the text by Krebs and Davies, was a joy to read and full of fascinating insights into how human behaviour is very much just an extension of animal behaviour. Altruism in particular may feel like a sophisticated moral drive, but is in fact just a sensible survival strategy within a community of related individuals. I wrote essays that argued that religion and law were ways to formalise the reciprocity of altruistic behaviour. I particularly remember about vampire bats, and how donating blood to a peer who has not fed is a mutually beneficial strategy within the community. Such apparently selfless acts become a worthwhile investment when there is reciprocity, as one day you may need to be the recipient rather than the donor.

This came into my mind recently when I asked my brother if I could borrow some money. I was surprised that he hardly seemed to think about it before saying yes, until my parents pointed out that I had loaned him money and otherwise put myself out for him many times in the past. Similarly I asked old friends whether I could stay over with them when visiting a different part of the UK, and they were super accommodating to me. Both times it was interesting to have the experience of being the recipient of selfless kindness, as I very rarely make demands on others, despite constantly expecting myself to be a giver (perhaps because I feel that I am lucky enough to have plentiful resources myself both physically and emotionally most of the time). However, it felt very good to be the receiver for a change, and reminded me of the fact that there is pleasure on both sides of the relationship, and that reciprocity is the marker of the best relationships. Being helped is obviously a positive experience, but the act of helping a loved one is also rewarding in and of itself, and makes it more possible to ask for their help in the future.

In the bigger picture, my tendency to be a donor rather than a recipient is also one that I have been thinking about in a work context. I’ve clearly chosen a line of work in which I am acting to support those in need, and where I put some of my own emotional resources into my job. I’ve blogged in the past about times of feeling quite burnt out by my work (particularly my expert witness work for the family courts, as it contains so much grim content about child abuse) and the lack of nourishing and supportive experiences provided by certain employers or employment experiences (where good work doesn’t seem to be valued, and people are expected to live up to unrealistic expectations despite being sabotaged rather than supported to achieve them). I find myself wondering: where is the reciprocity? What do we get back when the positive feedback loops are absent? I read an excellent article about sick systems, and I found parts of it eerily familiar when I think back to my NHS days. I’m not in a sick system now, as I run my own company. Most of the time I can do work I enjoy and be rewarded for it (in terms of positive feedback, thanks and payment), but I do sometimes still feel somewhat exploited. I end up doing lots of committee work, policy documents, best practise papers and making contributions to the work of others (mostly unpaid and in my own time), and often those who promise input to these things, or to my work, don’t deliver. So why do I keep doing it? I wonder whether it is echoes of that culture that I carry with me, or my own unrelenting high standards and expectation I can always be a donor, or some combination of the two…

Confessions of a workaholic

Hi, I’m Miriam. I’m a workaholic.

I face that fact with insight that it is somewhat akin to an addiction. But there is no 12 step program for this (and I’m an atheist so it probably wouldn’t suit me if there was) and total abstinence is not an option. There is little around in terms of evidence-based intervention either. This might be due to the lack of stigma involved in working too much, and the way that having a job at all is a mark of relative success. In fact society somehow endorses overwork, and there is almost a culture of humble-bragging about how much we let work take over our lives. Our phones and computers bring us calls, emails and texts 24/7 and it is hard to know where work ends and our lives outside of work begin.

So let me start by describing the problem: I have too many plates to keep spinning. I take on much too much at work. On top of all the psychology work I am struggling to get on top of the invoicing and the finances of the business (I don’t really enjoy doing that side of things, but I haven’t found a successful way to delegate it yet). I bring work home. I work as if its a hobby by running a website, a blog, several twitter accounts and now a patreon service in which I offer personal development support to early career stage psychologists. I am making an app, developing an online outcome tracking system and writing a book. Plus I talk at conferences and do training. And I do court work. I provide supervision and personal development support. I sit on numerous committees and working groups. I fill my diary chock full of commitments and let the admin spill outside working hours. And I am writing grant applications (I’ve got one, part-written, on my screen at this very moment). But it is not just in work that my workaholism shows. I create little work-like activities to populate my life. We have some investments that I manage. I used to trade on eBay and at sci-fi fairs. Even giving stuff away to charities and freecycle takes time to organise. I do little fundraising activities for good causes. I’ve done up a series of houses (and even helped friends to do up theirs when I have spare time).I grow vegetables. Even the way I shop is influenced by my business brain, so I’m very conscious of relative prices in different supermarkets and I like to get reductions and offers.  There is a half-written novel too (but everyone has one of those, right?).

Since I’ve left the NHS to set up my business I’ve worked many more hours than I did before that. But even in the NHS I’d often stay late to finish admin, and I took on court work outside of my NHS hours. I’d guess I worked 40-45 hours per week then if I averaged it out. Last year I would work from waking up until the kids needed putting to bed, when I’d stop for an hour to chat and then sing to them, then I’d make a meal and eat with my husband before resuming work again until I couldn’t stay awake any longer. I’d fit in bits of work (and catching up on sleep) at the weekend. There were many weeks I probably clocked up over 70 hours of work. And that leaves very little time for anything else.

I’ve come to think of the space that work takes in my life being like that expanding foam filler you can use to fill the gaps where pipes enter your home. At its worst, every minute of my time that isn’t taken up with something else gets filled with work, or work-like activities. The only spaces that are protected are for the things that I value more than work and have defined really clearly – the hour in which I put the kids to bed is sacrosanct. As is an evening meal with my husband. If I have made arrangements with friends or family then work has to fit around. On the times when we go out for meals or do things as a family, I try to make sure work does not impinge. I’ve also tried to carve out time to get to the gym three times a week, and only miss this when working away from base or where there is an immediate deadline. Some things that waste a lot of time for other people, I have simply chosen not to do (for example, I haven’t watched any live TV in over five years now). But many things that should be prioritised are not. I stay up late and sacrifice my sleep pattern far too often. I work through meals. I miss out on relaxation time. I haven’t found time for my hobbies in years. I don’t take a full quota of leave. Nor do I have as many holidays as I would like. Plus I’m embarrassed to say I’ve taken reports to finish with on several UK short breaks with my family. Once we went somewhere without wi-fi and I ended up driving around and using the BT hotspots from domestic customers to work in my car for 3 hours to get a report in, because a colleague had sent me their contribution 2 days later than planned and it didn’t meet my standards without substantial editing.

So, given there was no risk of getting fired or not being able to pay the mortgage, why would I give work such precedence against everything else in my life?

I keep asking myself that, and its a tough question to answer. I am not hugely motivated to maximise my income and I’m not competing against someone else. I’ve never had ambitions to drive a porsche or own a huge house with a swimming pool or any form of status symbols – in fact I hate ostentatiousness. I don’t have a goal for turnover, or numbers of employees, to win a particular contract, or to take over the NHS. I just want to do worthwhile work that improves life for people who have been dealt a bad hand, in a way that is delivered to them for free and according to need. I want to spend my working time with people I like around me, and to have shared goals and achievements.

I think the things that motivate me to work hard are complex and interwoven. Part of it is my heritage, and the stories about the importance of work that have carried through the generations in my family. My dad rebelled against expectations to be a doctor, and has always been creative, which is a much harder niche in which to find success (he has written many children’s books and has latterly become a skilled photographer). He spent much of his working life as a house husband, dealing in antiques or doing jobs he didn’t like, and had a lot of time off with ME like symptoms when I was a kid. My mum has always been a hard worker and the main provider in my family. My maternal grandmother was a hard working single mother in an era and cultural group where there were not really single mothers, and remarried unhappily but wished she hadn’t (and probably impressed upon my mum at some level the value of supporting yourself and marrying for love). Plus my heritage is as an immigrant squared – my great grandparents/grandparents were persecuted Jews who earned their way up from nothing when they fled from Russia to South Africa, and then my parents came to the UK and built a new life here from scratch. There is a high value placed on taking advantage of the opportunity for a good education that people take for granted in the UK, and there are many examples of the value of hard work. The family is very well educated (my dad is the only one who didn’t finish his doctorate) and has implicit ethical rules about the kind of work that we do. I’d think about these as stepping up to the challenge, and seeking to advance knowledge or make people happier, rather than maximising profit or power. There is a definite drive to achieve, though no-one would explicitly want to pass this on to me and I know they would want me to prioritise happiness.

Another part is my moral values, approach to life and personality. Being a psychologist is core to my identity, but so is a sort of entrepreneurial view of the world. I approach everything with curiosity and a desire to problem solve. When it comes to issues that lead people to be less happy or achieve less than optimal outcomes, I genuinely love the process of formulating what is going on, designing innovative solutions that might be effective, evaluating whether they work and disseminating the results. I gain satisfaction from the intellectual challenge, being able to influence practise. I like getting positive feedback for good work, feeling that I have been helpful to others or had a positive impact on systems or decisions. I like the fact my reputation means I am constantly in demand – interestingly in the public sector a waiting list feels like a sign of failure, of not keeping pace with demand, whilst in the private sector it is a marker of success as people are prepared to wait to see you, and the demand for your services exceeds your capacity to supply them. I also feel that people who are gifted with the resources of resilience, intellect, empathy and knowledge should put them to good use, and that the value of my life and the legacy I leave behind will be the impact I have had upon the happiness of others. I’m not a perfectionist, but I do set myself high standards. Finally, it is hard to turn down work that is so badly needed or that you feel might be done poorly in your absence. I know that sounds grandiose, but I’ve seen really bad examples of court reports that led to ill-informed decisions, and it adds to my sense of responsibility to do things well.

I also think that the nature of being self-employed, and of feeling responsible for employees has added to my pressure to work. I feel like I need to put the effort in to establish the business, to ensure we have enough cash flow to pay everyone, and to feel I am pulling my weight. I also feel there is something difficult about turning down work that pays amounts of money that seem almost obscene when compared with what some of the population have to live on. Doing this kind of work is such a privilege compared to having to work in a factory or doing hard physical labour or monotonous office work, or having to do voluntary work experience to claim their benefits. I compare myself to someone trying to eke out £150 of job seeker’s allowance to pay for a fortnight of food and fuel and think how bizarre it would seem to them that I had turned down work that would earn that in just a couple of hours. Or I compare what I earn now to myself as a graduate psychologist earning £9500/year and self-funding an MSc from it. I think about how that extra money could keep on the assistant who really needs the work, or pay for us to have a holiday, or a cleaner, or how far it would go if donated to a charity.  It just seems so ungrateful and lazy not to be willing to do the extra work in that context.

It is also to do with how I think about my own work. I always try to help others and say yes to requests unless I have a reason to say no. I’m dreadful at thinking “oh it will just take me a couple of hours” and taking on new responsibilities without being realistic about my existing commitments. I don’t put sufficient value on my time. And I hide the amount of work I do from others (and myself) by flexing my working pattern. I’m a night owl. I can work until I get things done, into the small hours of the morning taking advantage of the quiet solitude that gives me, and being self-employed and having a sympathetic partner I can often work a late start into my week or lie in at the weekend to catch up. But it makes me tired/hungry/cold (which are all very connected for me) and sabotages my daytime activities if I do it too much. From lying in rather than being up with the kids in the morning, to being grumpy and half-focused during interactions later in the day, there is always a price to pay on those nights that I’ve worked too late. But my tendency to put things in to this quiet time, or to need it to catch up with things I have taken on means that I don’t stop at bedtime, and I certainly don’t stop in time to wind down for bedtime. I don’t think it makes me a very good role model. My kids ask why I am up late at night, or sleep in during the morning, and I feel embarrassed that I haven’t organised my time better. My colleagues are used to me taking work home and end up adding things to my calendar to fill up all the gaps, reinforcing the pattern that the 10 hours it takes to write a court report is outside of my working hours, and that no admin time is scheduled for writing bids, contributing to committee work outside of meetings, catching up with email or making calls.

Ironically perhaps, my internal sense of myself is of a lazy and disorganised person. It has been interesting to me to have friends, colleagues and online folks reflect how they perceive me as hardworking, organised and successful. The contrast between my sense of self as never doing enough, and the external perceptions that I do more than is necessary is something I have been increasingly reflecting on. I recognise that my pattern of work is quite masochistic at times. I’m also aware that my expectations of myself are unrealistic and can’t be sustained. Overworking means I end up feeling like I end up with no down time, or at least very little that is entirely disconnected from my professional role or being a mum. I sometimes hit a kind of gridlock where there are so many demands I don’t know where to begin and end up doing none of them! And, like the emotional burnout I wrote about in an earlier blog, this has to stop.

A previous supervisor once talked to me about needing balance between multiple roles as a professional, a parent, a partner and a person. I’m trying to take stock and to chase work back into working hours so that I can focus on the other roles. I think they get more and more neglected as I go down the list. But kids grow up fast, and time with loved ones is precious and shouldn’t be put on hold for some imaginary future point at which there is more time. And I need to also find better ways to care for myself, so that I am happier and have more emotional resources to share with those around me. No more postponing going to the optician or physio. No more working through lunch, and no more super-late nights. I need to set aside time in my diary for all of my work commitments, including those that are currently invisible, and to prioritise better amongst what I take on. Instead of being pulled in all directions I need to work out where my highest point of contribution and greatest enjoyment are, and concentrate more of my efforts in a single direction. I need to have firmer boundaries and say no more often.

I read an article recently about a man who was diagnosed with cancer and given a very poor prognosis who then made a very positive response to treatment. When his cancer was treated and doctors said he had returned to a normal life expectancy he said that the experience had given him an unexpected gift – the insight that time is a precious and finite resource. He recommends that everyone thinks about what they would do if they had only a week to live, or only a month, or only a year, or only five years and identifies their priorities for this time. He points that at best we only have the remainder of our lifetime to live (in my case, probably another 50 years) and that now is the time to do the things that are the most important. So many people on their deathbed look back wish that they had recognised what was really important while they still had time, but we have this time ahead of us, and the option to choose to use it wisely. So whilst I have time, I am going to work out how I want to spend it. And that doesn’t involve work filling up all the gaps in my life. I suspect it involves more cuddles, more singing, more making things and cooking. More time socialising. More walks in the countryside. More holidays and travel. Regular exercise. Relaxation. Going to watch gigs, films, comedy and shows. Finishing my Adventure Diver certification. Making a mosaic. Laughing.

Work isn’t really so important. It doesn’t have the right to crowd out all the fun.

Between a rock and a hard place – when friendship and your professional role overlap

I’ve always tried hard to keep a clear distinction between work and non-work stuff in my life. I expect my friends to be able to offer, on balance, a similar level of support to me than they require from me. If the relationship is too skew then it will be meeting one person’s needs at the cost of the other, and that isn’t a friendship. Friendships are reciprocal, and allow me to trust enough to show facets of myself that I might not want to reveal in the context of work. In the safety of such a relationship I can have my own vulnerabilities. I can worry that I am less than a perfect parent, or talk about my relationships with other members of my family. I can joke, swear, drink wine, express opinions, or laugh at the contestants on The Apprentice without fear that this will tarnish my professional reputation. The rest of the time I feel like I have my professional hat on. I am in a position of responsibility and power, and I am bound by a code of conduct. When I talk or post online as a psychologist, I run the risk that my comments will be brought back against me when I’m in the witness box, or be taken out of context and misinterpreted by a present, past or future client or colleague.

I am friends with some psychologists and other colleagues from work and via the clinpsy forum. That’s a good thing. We share common values and experiences. We have shared stressors, and we spend time together. I am also friends with other professionals that know me as a psychologist, like lawyers, paediatricians, psychiatrists and social workers. Again, our work overlaps and becomes a topic of mutual interest. I also have non psychology friends. That’s a good thing, as they bring different ideas and perspectives. They let me relax, share other interests and remind me of the other parts of me outside of being a psychologist. We can cook, eat, play, exercise, explore, talk. We can play video games, make music or art, debate politics and current affairs. As a prior supervisor would say, we are people, partners, parents and professionals as well as psychologists, and we need to pay attention to each of those roles. What marks it out as a friendship is that there is trust, and that the relationship is enjoyable or nurturing.

The difficulty comes when you feel like you ‘click’ with someone who you are seeing professionally and feel that had you met outside work it could have been a friendship, as that makes it harder to stay within a work role and remain within the more neutral and guarded boundaries that a professional relationship entails. A therapist needs to respect their clients, be curious about them, accept them, hold them in positive regard and see their potential. The relationship may be very important for the client, who may idealise you and want to bring you into their life. But that doesn’t make it a friendship. The power balance is different in a professional relationship. Within therapy the client is expected to disclose a lot about their life whilst the therapist discloses little. It is not a reciprocal relationship, and the relationship is not there to be enjoyable or nurturing for the therapist. Having started from there it is not possible to reach a place of reciprocity (at least not without a lot of time and distance after the end of the therapeutic relationship). So if you find yourself acting too casually, sharing too much information, or wanting to step outside of your normal professional role, this is definitely something to discuss in supervision.

Likewise, if someone in your personal life starts to use your professional skills, this needs to be handled very carefully. Parents asking for advice about their child’s anxiety or poor sleep may not differentiate whether you are giving advice as a friend and fellow parent or as a professional. A friend who wants guidance how to access IAPT, or is feeling suicidal and needs to be taken to A&E needs to know you can support them as a friend, but not as their psychologist. We may well know the system and the right things to say, or the right people to approach, but it is important not to end up muddling the role. You can’t ring up someone you know’s treating clinician and say “Hi, this is Dr Silver and I’m wanting to ensure you understand my formulation about my friend Jane”. They are entitled to confidentiality in their therapy and trust within their friendship. But you may also feel a greater obligation to act on concerns about someone’s mental health, or a child protection concern, than a general member of the public.

It is all too easy to get sucked into an uncomfortable place in between. What of someone that approaches you in a way that appeals to both the personal and the professional? They just find you so easy to talk to that they tell half their life story, and next thing you are feeding back a formulation at a dinner party. Where do you go from there? Do you reciprocate and tell the ins and outs of your life, or give them a business card if they want to follow up the conversation with a formal session? Or the friend who just can’t get an assessment for their dyslexia, but is self-critical about how stupid they are, when you have the psychometrics needed in the office and your assistant has a spare hour on Friday. Surely that’s not so personal? Or the friend of a friend that never seems able to access the services they need. Do you step in and advocate for them? Its a very difficult decision to call sometimes. But in my experience it is these situations that are most likely to fall down around your head.

A colleague of mine was concerned that a friend of a friend (lets call her Sarah) was discharged from an inpatient stay without proper risk assessment or follow-up. He spoke to the GP and inpatient team to raise concerns, but nothing was done. Sarah later committed suicide, and my colleague was interviewed in the enquiry that followed. The coroner did not seem able to differentiate between a concerned friend who happened to be a professional, and someone with professional responsibility, and he got given a really hard time. This was on top of the guilt he felt for not having been able to prevent Sarah taking her own life.

Another colleague ended up having to drop everything to collect a friend from various complex situations all over the country as she had psychotic episodes, and would not trust professionals when she was not taking her medication and did not have a good support network.

I ended up writing to the GP of someone I shared an office with early in my career, to report an eating disorder, suicidal ideation and risky behaviour. I felt like there was little else I could do after a supervisor said it wasn’t their problem, because their actions were placing other people at risk. I wanted to be supportive, but at the same time I felt like it was unfair to burden me with the information without allowing me to act on it. I was very clear with the person involved that this was what I was going to do if they continued to confide this type of information, and they chose to write down the contact details of their GP knowing that I would share this information. Thankfully, they went on to get appropriate therapy.

When I first met my husband it was evident he was dyslexic. I did some informal assessments so that I was sure my hunch was correct and then pushed him to get formally assessed at university. This confirmed the diagnosis and enabled him to get concessions made about his spelling and handwriting in exams, and I learnt to help by proof-reading his course work. I felt like the assessment needed to be independent to have any authority, and that I could not take on this dual role.

A decade later, I started at a new post and started talking to the IT guy who covered CAMHS, who was concerned about his memory. It was clear he had a specific deficit that had never been assessed, and I owned the WAIS and WMS that were current at the time. With the consent of the directorate manager and my supervisor, I did a full psychometric assessment. We have gone on to be lasting friends, and he credits me with helping him to understand that he is a bright guy with a specific deficit, rather than a guy of mediocre intellect who has done well for himself. However he has never wanted to use the assessment formally.

More recently I spent 24 hours taking an acquaintance to A&E after they confided detailed suicide plans in the wake of a relationship breakdown. After a long time talking in the waiting room before they were seen, they asked me to be with them in the room and share some of their abuse history with the assessing clinician. I agreed, but I had to be very clear to identify as someone from the personal network. Whilst the assessing clinician was keen to make me part of the follow up plan, I had to set out clear boundaries and decline. I was not a professional to them, and I was not somebody who could take responsibility for this person on discharge as I lived in a different part of the country.

Each of these has been a learning experience and shown the importance of differentiating the personal from the professional, but it is something I will continue to grapple with both personally and through supervising others. The nature of our skills and knowledge mean that there will always be situations in which people want to use our professional expertise, even when we are not wearing that hat. Whether that is the GP that wants advice about a patient when you go in for advice about your own health, or the business coach that wants to talk about their concerns about their child, or the friend who is giving evidence to a child abuse enquiry. We need to find a way to be both compassionate and pragmatic about the capacity in which we can be involved, to keep ourselves and the individuals safe and ensure they get the right kind of support. The role of speaking to other people on the internet is one I will blog about at some future point, and brings with it a plethora of new and challenging ethical issues, not just the way that the informality of the medium makes roles blur more between personal and professional.

Slow burn: Reflecting on the emotional impact of working with chronic trauma*

*This post contains vignettes of harrowing material which may upset some readers. Case examples are all anonymised.

When I decided to do work in child protection, people warned me it was the fast road to burnout. Twenty years later I think they are right about the direction, if not about the speed.

Burnout is an insidious thing. It sneaks up on you as a chronic accumulation of many tiny things, rather than having an obvious trigger, like a single life threatening event that causes PTSD. A thousand small examples of vicarious traumatisation. Experiences that I shouldn’t complain about as I’ve chosen a career that inevitably brings exposure to distress and tragedy. It feels like I’ve chosen to wade through the grottiest parts of life, until I’m normed on that 1% of stories that cause the most concern. It saturates me. Pollutes my perceptions of life. It has been building up for a long time.

Fifteen years ago my two specialist placements included post abuse work with survivors of sexual abuse, a group for non-abusing parents of children who had been sexually abused and work with “complex” children and families, such as those on the child protection register. I knew it was emotionally harrowing work then. I talked about it with a good friend, and concluded that my drive was to go where I was most needed, to grapple with the most complex cases, and that I’d worry about burnout when I got there. I graduated onto a clinic for children who were “failing to thrive” and most of my clinical time being with Looked After Children and therapeutic work with those who had experienced trauma or maltreatment. Right from the start, it was an induction of fire, salved only by the fact that it was important work that needed to be done.

It started with individual stories.

The sad silent child who ate 7 digestive biscuits and carefully stowed extras in his pockets during clinic, but whose parents claimed he had a digestive disorder that meant he wasn’t gaining weight despite eating plenty.

The young woman with learning disabilities who repeatedly played out how the daddy bear lay on top of the baby bear and thrust, but said baby bear was a liar and nobody believed her when she told.

The adult relatives who revealed at the last moment the sadistic physical and sexual abuse that their step-father inflicted, after he had charmed the professionals enough to get residence of his grand children, when their mother was unable to cope and had reverted to chronic drug use.

The maps of children’s bodies in medical notes, used for annotating injuries, including one for babies. The paediatricians sharing photographs of torn orifices, injuries, malnourishment and legs with rickets. “This one has burns on their hands up to a straight line on their arms, showing they were held in boiling water as a punishment”. No, I don’t want to see, thanks.

The little girl in a religious cult who couldn’t disclose her abuser as she had been taught it was as bad to think or speak badly of others as what they had done, and shown pictures of people rotting in the ground or burning in hell for their sins.

The boy who was conceived through rape, whose mother couldn’t look at him, and whose grandmother thought any challenging behaviour showed he was “living up to his genes”.

A girl asking how she got the zigzag scar on her stomach. The family didn’t want to tell her about how her mother tried to cut her open to let the devil out during a puerperal psychosis. They don’t want to spoil the relationship as she goes to Mum for alternate weekends. When I meet Mum she talked incoherently about spirits and auras, telling me she likes climbing on the roof to be nearer to God. She has no need of adult mental health services, thanks.

The young woman who always claims to be pregnant. Partners are less likely to harm her that way. She is couch surfing at the moment, which is the new name for homeless. Her only possession is a photograph of her son who was removed at birth and adopted. After physical and sexual abuse at home, and attempts to stay with numerous relatives, she grew up in care. She had a sexual relationship with her male carer at 14 which she views as consensual.

Since 2000 I have done expert witness work for the family courts. That means reading bundles of documents about trauma, child abuse, neglect, loss, violence, family breakdowns and mental health problems. It means speaking to parents who have been maltreated in their own lives, lack coping resources and instead of being able to create healthy relationships and flourish have limped from one bad experience to another. It involves speaking to children who have seen too much, had to cope with awful things and missed out on the love and nurture that you’d want every child to take for granted. I read about and sometimes see the state of the home, with rubbish heaped up and rotting, flies circling, dirty nappies on the floor, no clean clothing, nowhere to store possessions and no space that isn’t filled with clutter. I hear about broken bones, bruises, burns, rapes and assaults. Sometimes there are x-rays, photographs or medical records. I see sadness and anger accumulated over many years of getting a raw deal. I measure problems with learning, attention, behaviour, life skills, self-esteem and mental health. I observe who denies the problems, who spills over with them, and who recognises themselves doing as they were done by despite all their best intentions otherwise.

I read, and I listen. I measure and observe. I pull the pieces together to see what fits and what conflicts. It is an active process, trying to understand what happened, how and why. Evaluating insight and future risks. A computer couldn’t be programmed to do this. It takes empathy, curiosity, critical thinking and detective skills. I am the barometer of relationships, of what would feel okay, of what is causing harm. If I felt nothing, I couldn’t do the job. But there is so much pain to feel. So many sad stories.

A little girl with curly dark blond hair who the foster carer told me “shook with excitement to get her own dolly for the first time and promised to keep it pristine so that when mummy gives it to her little sister she will still think it is new”. I nod politely. Take verbatim notes. I have to stop the car on the way home for a cry.

A teenage boy tells me how his father often pinned him up against the wall by his neck or beat him with a belt. He wonders why he dissociates when he perceives threat or criticism now and worries that he is going mad. I try to explain his brain learnt to protect him when nothing else could.

I observe the baby that was rescued from the fire. Her scars are healing slowly, and the medical treatments are painful. She can’t bear to be touched. There is too much pain for someone so young.

A mother tells me how it hurts her watching the foster carer do a better job than she was able to at caring for her children. “I always swore I’d be different to my mum, make better choices of partner than she did, keep my kids safe from harm. I look at where we are now and see it has happened all over again and I can’t bear it”. And neither can I.

A teenage girl tells me she took the overdose because her step-dad broke the door down and overturned the bed to reach where she and her mother were hiding, and hit her mother repeatedly with the broken bed leg. She shrugs and smiles, and says “its just how it is, you know”. I don’t know. But trying to imagine it makes my guts curl and my eyes leak involuntarily.

A mother tells me about the culture she grew up in, and how grateful she is to be here, even though the whole family live in a single room in slum conditions, and it is hard to find work as an illegal immigrant. If her son is hungry, developmentally delayed, and being beaten for misbehaviour at least he is safe. I think that isn’t safe. It is all relative.

A father tells me that his uncle sexually abused him as a young boy, but there was too much stigma to tell anyone and he was afraid to lose this special relationship. He still spends time with his uncle now, and trusts him implicitly with his own children. A few sentences later he says he is baffled why the children are showing sexualised behaviour. I am baffled that other people can’t see how obviously the pieces fit together.

I assess a couple that smell so bad I struggle not to gag. I open the windows but it is not enough. I go out for air every hour. A social worker sprays perfume on my sleeve so I can raise it to my face to mask the smell. I learn the phrase “body odour to an extent causing discomfort to anyone in the proximity”. They don’t own toothbrushes and show me teeth rotting in swollen gums.

A woman tells me she has put on 9 stone as she needs to have fat deeper than the knife blade is long, since she was stabbed by her ex-partner. She wheezes for a long time after climbing the stairs at the contact centre, and she struggles to get down on the floor to play with the baby. I worry when she is slower than expected to return from the toilet, do I need to check if she is okay?

The child was born with HIV. His mother died of it. He lives with his grandmother. She doubts the diagnosis. “He doesn’t look ill, the English doctors don’t know about us”, she says when I ask why his prescriptions have not been collected.

A lady tells me that she must have had post natal depression. If she wasn’t ill she would keep the house clean, but when she is ill she can hardly get out of bed, and gets ideas that the world is very unsafe. That is why she kept the children in her bed with her, rather than sending them to school, until they were no longer able to walk. She’s on antidepressants now, and saw a counsellor for six sessions, so everything will be fine. The social workers are making a fuss about nothing.

A man tells me he has exercised to pass the time whilst in prison. He is proud that he is bigger and tougher than his father now. He says the robbery was the fault of the friends who bought him the beer and suggested the idea, and much exaggerated by the victim. I am glad I brought with a student to observe, as the room is quite isolated and his body language makes me tense.

This couple have managed to sustain the acrimony of their separation for five years. She says he was controlling, violent and obsessive about having every last penny accounted for. She tolerated his promiscuity for far too long. He says she was moody and manipulative, and it is probably her mental health that’s the problem, and her jealousy that he moved onto another relationship. It makes me cross that both of them seem to have forgotten the kids in the middle of their conflict.

A little boy tells me what it felt like to be buggered. I try not to think about it that night in bed. I play tetris on my phone until I fall asleep at 4am.

A woman tells me that all of her relationships have been with men who present a sexual risk with children. They are all so different, she says, that whenever she learns what to avoid the next one is nothing like it. And why wouldn’t you move in with someone you’ve just met? How else do you get somewhere to live after the last relationship has turned sour?

The story stems of a girl of eight show the family repeatedly pushing the girl off a cliff and laughing at her. For variation they poison her and laugh as she vomits. She repeats the loop for 90 minutes, then returns to lying foetal under the table as I leave, just as she was when I arrived.

“I had a cold, mum caught it, and it made her sick so she fell down the stairs” says the boy with autism. “That is why she had to go to hospital”. It wasn’t the head injuries her partner caused, it was his fault. But later in the conversation “Daddy gets out of prison soon. When he finds us he will kill us this time”. It is deadpan. An emotionless fact of life.

The girl in the children’s ward tells me “I didn’t want to go home. I jumped off the bridge because it would be better to be dead. They say I will need to be in hospital at least six weeks whilst my leg heals”. She smiles showing me the metal cage and all the pins reassembling her bones, and counts the pieces in the x-ray. She won’t say what is wrong at home.

“He spat right in my face and pushed me over. I was so angry then. I hit him with the lamp until it broke, then I whipped him with the cable. I could see the shape of the switch in the bruises when I was done. They might have seen it, but that’s not the same. I’d never hurt the children.”

A boy tells me what is different in foster care. “It was the best day ever. We went to the garden centre. I got to look at the fish, and we had a drink and a slice of cake at the cafe. We eat at the table with the grown ups here. I got my own coat too, nobody wore it before me! And my skin is better”. The carers tell me that they had to wash the grime off the bath after he arrived, replace all his clothes and do twice daily treatments of his infected eczema. They had to get a court order to shave off his matted hair as his parents would not give consent.

A five year old girl tells me about the day she came into care. “I could hear they had fish and chips in the front room. I could smell it. I tried to walk there, but my legs weren’t working and I kept falling over”. The medical records show that a visitor called an ambulance when they saw her unconscious and malnourished. Her blood test results are marked with blue biro. Haemoglobin is captioned “how is she alive?”. She dances when she shows me the foster carers have a rabbit run in the garden.

In each family I hear many of these stories from each individual, and I see several families each month for assessment. I’ve been doing this for over a decade now. I have banked hundreds of such narratives, maybe a thousand. All involve a child or children being harmed. The stories are each unique, but the themes recur. James blurs into Joshua and Jared and Jacob. Samira merges with Samantha and Saskia and Sasha. Depression and anxiety, broken bones and bruises, filth and mayhem, conflict and violence, cancer, obesity and sensory impairment, neglect and abuse heap up in my repertoire of human experience and leak out into my life. I see those stories lurking at the edge of my vision, in the arguments partially overheard in the shops, or behind the headlines in the news. I see their echoes amongst people that I know; my neighbours and colleagues and friends.

I set myself impossible standards. I worry if my child has messy hair when she gets back from school, or I notice mud under her fingernails. Will people think we aren’t taking proper care of them? Are we not taking proper care of them? We go to A&E after my daughter burns her hand. I ask her to tell the story before I speak and she says “it was your fault mummy, it was your drink that tipped over”. I feel like a failure and a hypocrite. My cat has a jaw infection and needs teeth removed and antibiotics. I should have known. He smells like the couple I assessed at the social work centre last year.

I say we need to leave the restaurant. I can hear a mother saying “ungrateful brat, I should never have had you” to her son. Outside the school a mother pushing a baby in a pram says to her friend “look at him giving me evils, he’s going to be just like his father”. I walk away. The couple outside the pub argue incoherently and their voices get louder and shriller as we walk back to our car after a night out. The child in the park approaches me and asks me to push him on the swings. People on the internet disclose abuse. In the supermarket I hear a slap and the child is crying. The woman walks past on the street with a fading black eye. They are anonymous and legion. The scale of the problem is overwhelming. I can do nothing.

Friends of friends ask for advice as they have heard I am a psychologist. Its important to try to point people in the right direction, but I am depleted. Another 2 lever arch files arrive at work. Its an incest case and mother is terminally ill. Surely there can be no more stories this bad, but there is a queue awaiting my attention. The next one has police transcripts of the interviews of all of Dad’s victims. He might be a paedophile but his daughter wants to see him anyway. The one after that they want me to see Dad whilst he is in prison for abducting the children to a different country. He believes it is his right; fathers own children in his culture. Then back to the bread and butter of court work, another family where neglect and maltreatment has been the norm through many generations. One of the children is the same age and gender as one of mine. Don’t make comparisons. Don’t go there. Change the subject.

A letter from a solicitor tells me that my invoice has been reduced by the Legal Aid Agency on appraisal. I will get £400 less than the total billed, despite not billing for 6 hours work already because of the fee caps. The hours were “not proportionate”. Do I explain again that it takes longer to do assessments via a translator? I don’t have the energy. Another one is querying the hourly rate. I should work for £7 less if I only see the adults as I won’t be a child psychologist. I ask if a psychiatrist gets paid the rate for a psychotherapist if they don’t diagnose or prescribe. The solicitor is sympathetic but says there is nothing they can do. A father doesn’t attend an appointment that is booked to fill a whole day. I have driven 2 hours to get here, and I wait for an hour whilst phone calls are made, then drive 2 hours home, exhausted. I can do nothing else with my day. Legal Aid say a psychologist can fill their time productively with other activities and refuse to pay anything over travel costs, even though the contract says that they will pay for any appointment cancelled with less than 72 hours notice. I can’t bill for materials, venues or typing. The questionnaires cost an average of £5.31 each. I used 6 per child and there were 7 children in the family. Does it add enough to my report to justify £220 of lost income? The LAA ask what ‘capacity’ is and why it took me 4 hours to assess it. Is it not embarrassing to work for the family court system and not to know this or to have the sense to Google? The self-funding father who was supposed to have lodged the cost of the report with his solicitor hasn’t. He now wants to pay in monthly instalments, but my staff get paid next week. I have to turn away two cases a day after reading about the plight of the children, because I am booked up too far ahead. The wealthy mother from abroad hasn’t paid her share of the bill from 4 months ago, but the court wants me to do more work for her case. There are 16 follow-up questions from the report I filed last week. Why do I do this again?

Tomorrow is the appointment to assess the teenage mother in the mother and baby unit. Yesterday her boyfriend told me about how they met online, and gave me their usernames. Google shows me his dating site entries seeking single mothers, Facebook posts about the violence in their relationship and a video of the baby’s “sexy dance”. A solicitor phones. Can I squeeze in one extra case this month? Mother has been evicted. She doesn’t want to see her child and is too anxious to talk to her lawyers. Could I fit the capacity assessment in this week? I get an email to my personal account. My builder’s sister’s son is feeling suicidal. I reply with the phone numbers for the Samaritans and the local crisis service. I watch the news story about the children in the refugee camp and am horrified to find I feel nothing. I have reached compassion fatigue. I turn off my phone and computer and go back to bed.

I am empty. My emotional resources have run out. Is this constant aching tiredness what they call burnout? I run on clockwork. I am a robot Mum and a robot wife. I fall asleep on the sofa. I am exhausted. At night when I finally fall to sleep I dream about children with their eyes sewn shut. I can’t save them all. When I wake I go to work and do it all over again. I’m good at this. It is important. It is needed. It is never ending.

Then I pause and take a few weeks off for a family holiday. Soon after we arrive the bubble of numbness bursts. I cry watching a video on Youtube. It segues into crying for all the children I’ve met, and all the children someone like me never met or didn’t reach in time, including the parents I speak to so often. I cry with frustration at my own limited reach. I cry for the selfishness of politicians, the broken systems and missing safety nets. I despair at how you increasingly need money to buy justice, and how hopeless and disengaged wide tranches of society are becoming. I click to sign petitions. I donate to campaigns. I counsel compassion in online debates. But I am tired. Achingly tired. Tired in my bones and my guts and my heart. I know how much this needs to be done. And I don’t know what else I can do. But I can’t do this any more.