I am not a therapist

I’ve always been someone that likes to keep busy, and has a lot of ideas about places where psychological thinking can make a positive impact. The aspect of my character that I now identify as entrepreneurial and put to good use in my business has always led me to want to try new things and create innovative solutions to problems. I like a lot of things about being a clinical psychologist, and particularly our ability to turn our hand to multiple types and levels of work. However, unlike many other clinical psychologists, I don’t really see myself as a therapist. In fact, I haven’t seen more than a handful of clients for individual therapy over the last decade, and even before that it was a pretty small proportion of my qualified jobs. I’ve always had more of a focus on the other facets of being a clinical psychologist. I think the picture of a clinical psychologist as a therapist is so strong that a lot of people will now be wondering how I fill my time!

So I will answer that question: I have done loads of highly specialist assessments (of neurodevelopmental concerns, attachment, parenting capacity, mental health, life skills, self-esteem, wellbeing etc) and lots of formulating and report-writing – some in collaboration with psychiatric or medical colleagues or within a wider MDT, but more as an external expert or second opinion. I have advised the family courts as an expert in care proceedings and complex custody disputes, and completed numerous pre-court assessments for local authorities to help inform their care planning. I’ve managed teams and services, and supervised from 2-20 other staff at a time, along with sitting in various organisational/management structures. I have designed and delivered training to parents, carers and professionals, and I have done lots of consultancy to various organisations and professionals (mainly those providing health and social care services, or involved in the family courts), and help placement providers to improve their services. I design and deliver group programs (eg Managing behaviour with attachment in mind), but then rapidly cascade train other staff to continue to deliver them. I wrote a book about attachment/developmental trauma, and lots of papers and policy documents about Looked After children, and acting as an expert witness to the family court. I sat on a BPS committee and I contributed to NICE and SCIE guidelines. I’ve designed, managed and evaluated therapy services (but employed others at lower bands to deliver the therapy). I’ve been an expert advisor to the HCPC in a fitness to practice case and to the team investigating a death in public care. I’ve done loads of practice-led research about each client group I’ve worked with, from looking at the psychological and health economic impacts of offering brief therapy to hospital users with diabetes, to commissioned evaluations of other services. So I have plenty to fill my days despite not having a therapy caseload!

I have reflected on why it is that I don’t feel drawn to therapy, and reached the conclusion that, whilst I see it as a very worthwhile endeavour, I don’t really have the patience for resolving difficulties one person at a time over sessions spanning many months. I’m always more interested in grappling with the bigger questions of why people are in distress, and what we can do to most effectively prevent or ameliorate those difficulties. When I’ve solved the riddle (or at least, reached a plan that improves upon existing solutions) I like to evaluate its efficacy, modify it if necessary and then disseminate the learning and/or train others to replicate the solution. I try to step outwards from the individual issue to the broader themes and ways that we can intervene on a wider scale. To use a visual metaphor, if dealing with mental health problems is like bailing out a ship, then rather than scooping out water one cup at a time, I am trying to work out how to plug the leaks, and to design boats that won’t have the same vulnerabilities to leakage in the future. It also helps me to avoid feeling hopeless about factors outside my control and demand exceeding supply, or burned out by an accumulation of traumatic stories.

Jenny Taylor, a past chair of the Division of Clinical Psychology, once described our profession as the structural engineers of the therapy world. Unlike a therapist trained in a single modality of therapy, we can survey the landscape and assess the need, then design the intervention that best meets that need – even if we are not always best placed to deliver it. We can base that recommendation on our knowledge of the current evidence base, which can change as new information comes to light.  If we consider the challenges people face as a river they need to cross, a therapist trained in a single model of therapy might be a bridge-maker. A psychodynamic therapist might be a mason who can build traditional stone bridges and claims that this design best stands the test of time. A CBT therapist might be a carpenter with a set of designs for wooden arched bridges that he claims are cheaper and quicker to erect. Each sees their own skill as either suitable to solve the challenge or not, but also has some incentive to sustain their own livelihood by continuing their tradition. A clinical psychologist can survey the land either side of the river, the span length required to cross it, and the materials available in the locality. They can then advise on the various options, including the relative costs and the evidence of how they fare in different conditions. They may or may not feel that bridge required is within their own skill-set to erect, but have a reasonable overview of other bridgebuilders in the area to recommend. If new designs of metal suspension bridges are developed, this is not threatening to the structural engineer, who can adjust their recommendations to incorporate the emerging evidence base.

I really like this metaphor and strongly identify with the role of structural engineer rather than bridgebuilder. I had always thought that this was instilled in me by my first graduate job, where I was an assistant psychologist on a research project about improving quality of life in residential care homes for older people, and I could see how the research and clinical work were closely tied together and built on each other reciprocally. But now I think my love of data and the scientific method runs deeper than that and I can see it infused throughout my whole approach to life since childhood. When it comes to my work I am a scientist practitioner down to my bones, as I always collect data as I go along. Where I don’t feel like I understand the situation well enough, I first look to the literature and then to gathering data and doing my own analysis to try to gain insight. When I develop something new to try, wherever possible I try to evaluate what we are doing, and refine it through an iterative process until we can prove maximum efficacy. I see that process as being part of the USP of a clinical psychologist – that we think like scientists and gather data to inform our interventions.

But I’m not sure that we communicate this mindset well enough, or that it is universal amongst the profession. It certainly isn’t what draws people into the profession in my experience. Too many clinical course application forms I review could be paraphrased as “I want to learn to be a good therapist” with an afterthought of “and do/use research” because they think that is what selectors want to hear – but in my view therapy can be done by lots of cheaper professionals, who might do an equally if not better job of it. I believe that clinical psychologists should be more than well paid therapists. We should know the evidence base and be able to take on the most complex assessments and formulations (even if others then deliver part or all of the treatment) but also to be able to develop, refine and evaluate novel therapeutic interventions, supervise other staff, improve services, consult, train and manage – things that extend beyond the skillset of most therapists. I’m sure it is clear by now that this is where my own interests lie. And I think it shows through in everything I do.

For example, when I was asked to lead the CAMHS service providing neurodevelopmental assessments I started with a literature review and current policy and best practice guidance. I then conducted an audit of the existing pathways, then tried to make things better. We set up a new clinic system with more rapid throughput and more thorough assessments, and then re-audited showing a reduction from an average of 18 months of input to five, with increased clinician confidence in the service and higher client satisfaction. I also wrote a booklet to help provide the information to parents whose child received a diagnosis of an Autistic Spectrum Condition. Although it required dedicated clinician time for the multi-disciplinary clinic and for the psychometric assessments generated, overall the new pathway freed up capacity because less cases were being held open by other clinicians whilst waiting for assessment, or kept open for prolonged periods afterwards to help the family understand the diagnosis and connect up to local sources of support.  I also sat on a multiagency strategy group to look at establishing best practice standards for the county.

I had the same approach when I was asked to support the adoption and permanence service. I initially set up a consultancy clinic, where social workers could bring cases to discuss or book in families to see jointly. I found that I was explaining similar information about attachment, trauma and neuroscience to multiple professionals, parents and carers in the consultations. So I designed a group to share this content. I called it “Managing Behaviour with Attachment in Mind”, and developed some “doodles” I would draw on flipchart paper to explain the concepts more accessibly. I evaluated the impact and showed it to be an effective format for supporting parents in this situation. The groups were popular and over-subscribed, so I trained others to deliver the group to keep up with demand, first in my service and then more widely. Many people in the groups liked to photograph the doodles to remind them of the topic, so I decided to write a book to share them and Attachment: In Common Sense and Doodles was born.

But I also wanted to know about how we could achieve permanence for more children. I started by looking at the literature about what makes effective adoptive matches. Very little information was available, so I systematically audited the paperwork from 116 adoptive matches and followed them up over 7 years to see what factors influenced the placement outcomes. I was able to look at whether the innovative adoption project to place children with more complex needs had better or worse outcomes, and was able to explore the impact of different motivations for adopting. Whilst to me this was just a natural process of answering the question as an evidence based practitioner, it transpired that these studies of adoption risk and resilience factors were amongst the largest ever done, and I have discovered unique findings that I really should publish*.

You could argue that I was using a sledgehammer to crack a nut by doing all this research and trying to change process when organisations are notoriously slow to change, and that I could have spent my time more productively working with more individual adoptive families. But that’s not how I’d see it. The research I did helped me to understand what the key variables are when considering whether a child can achieve permanence, what kind of family we need to look for to place them successfully, and what kinds of support might ensure that the placement succeeds. I hope that I have fed that knowledge back through my court work, and into various organisational and policy work over the last decade. I have also disseminated it at conferences. However, I would still like to spread it further, because it is my belief that such knowledge can have positive impact at multiple levels – it can help to inform individual placement decisions, service-wide strategies for helping optimal numbers of children to access permanence, and national policy about adoption.

That work led naturally on to developing our services for Looked After Children when I left the NHS and set up my own company, LifePsychol Ltd. We provide training and consulting to foster carers and residential care staff, the social care organisations that support them, and the wider professional networks surrounding them, including education and health staff, police, lawyers, magistrates and judges. As I started to get more immersed in working with children in and on the edge of Care, it led me to recognise that there was a lack of validated and reliable tools to identify the needs in these populations, no outcome measurement tools that could reliably measure change over time in a way that was sensitive to the context and type of life events these young people experience, and a dearth of clinical governance in terms of the efficacy of both placements and interventions for this group of children. That seemed shocking to me, given their highly complex needs, and massively elevated incidence of mental health problems, challenging behaviour, risk to self and others, and prevalence of intellectual or neurodevelopmental difficulties.

As well as the human cost of not being able to identify the best choices for people, it seemed unacceptable that huge amounts of money were being spent on placements and specialist services for this group without any evidence of them changing their wellbeing or life course for the better. Placements seemed to struggle to identify what to work on and how, and there was little objective indication of what defined a successful placement, beyond annual visits from Ofsted (who were predominantly focused on process and procedure). The high level of need and the lack of clinical governance in the sector has allowed various specialist therapists and services to spring up that are virtually unregulated, and many placements have adopted terms like “therapeutic” without these having a consistent definition or meaning. So I wanted to see whether I could make any headway in changing that.

Meanwhile there is pressure from the government to improve outcomes for children in public Care, because they are seen to fare badly compared to the general population of children the same age. The difficulty is that this isn’t comparing like for like – children in care have many more adversities to face, both organic and in terms of their life experiences, that mean they often deviate from the norm. For example, I found that there was a 20 point skew downwards in IQ distribution in children in residential care compared to population norms, meaning that 20-25% of children in this setting had a learning disability, compared to 2% in the general population. Likewise the incidence of Autistic Spectrum Conditions and other neurodevelopmental difficulties amongst children in Care is more than triple that in the wider population. The same is true of young offenders. If we don’t acknowledge that, then the sector is being asked to seek impossible goals and will inevitably be seen as failing, even if placements and services are performing optimally and adding a lot of value to the lives of the children they work with.

To state the obvious, children in care are not just randomly drawn from the population – by definition their needs have not been met, and this can mean both the presence of additional challenges and exposure to harm or deficits in care. I believe that to look at the needs of this population and the degree to which these are met by placements or interventions, we need to either compare them to carefully matched controls or ensure that outcomes are always considered relative to baseline. The latter seems more pragmatic. Scores for young people also need to be considered in the context of what is going on in their lives – as changes in placement, daily routine, contact arrangements, or the arrival or departure of other children from the home can make big impacts on the child’s functioning.

So I’ve been beavering away exploring these issues and developing systems to measure needs and make the data meaningful for those providing care and services. The impact might not be as obvious as delivering psychological therapy directly, but I’d like to think that over time it can improve services for thousands (or even tens of thousands) of children, and make a greater net change in the world.

 

*Maybe I’ll write more about this in a future blog. But the short version is that I have been trying to secure some funding to complete the statistical analysis and disseminate this information, and would still like to do so, so if you have any ideas or useful connections to assist with this please let me know. Failing that I hope I’ll find enough time to write a book on making better adoptive matches at some point in the future.

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.

How to recruit (and what to do with my therapy company)

My working life has been increasingly focused on improving outcomes for Looked After Children. I deliver training and consultancy to care providers such as residential care companies and fostering agencies, as well as to health, social care, education and legal sector professionals. I have also developed a suite of online tools to help commissioners and providers to assess needs, track progress and evaluate outcomes for Looked After Children, including www.BERRI.org.uk  I think the introduction of clinical governance processes to the social care sector is long overdue, and I’m hoping that I can contribute to a culture change that drives up standards for Looked After Children. Signs are good, in that Jonathan Stanley chair of the Independent Children’s Homes Association (ICHA) said “you have set the gold standard for care providers” and Sir Martin Narey said “this is the missing link” when it comes to residential care. So I am trying to make this my business.

I’d like to find someone to help me take that forward, who has the kind of financial/business/admin skills that will complement my clinical skills and ensure we run efficiently as a company. Perhaps a business graduate with lots of energy, or an experienced admin who wants a new challenge. Ideally able to come to meetings in Derbyshire at least once a week. I’ve been inundated with demand, which is great, but it means I need help to keep organised and on top of all the competing demands in my new line of work. And that means that I need to give up, hand over or sell on other things I have been involved in.

With that in mind, I am wanting to make a plan for what to do with my existing therapy and court work business in Milton Keynes when I move out of area in a month from now. It’s a profitable business, and meets the needs of a client group who fall between health and social care. We offer edge of care assessments, psychological therapy and support to prevent kids coming into care, to support placements, enable rehabilitation to family, or for children and families who want help with parenting or a mental health issue. We also do court expert witness work for the family courts, and provide consultation into two sets of children’s homes.  However, the only other qualified CP involved is going on maternity leave soon and there is nobody else to provide cover. If I was staying in the area and/or had the time and mental capacity to continue running it myself, I would. But given I can’t, I want to make a good landing for it. And that means either recruiting a temporary or permanent clinical psychologist, or selling the business on to somebody who has the capacity to build on it.

I also need to recruit to provide cover for the services that I supervise within Keys group whilst various staff are on maternity leave, as well as to new vacancies within Keys. But despite the enormous importance of the work, and the fact it is highly valued, and as part of a well-equipped team without many of the niggles of the NHS (for example, we provide tea and coffee, you get your own desk and computer, and the caseload is manageable) recruitment pathways are not as easy when you are outside of the NHS and the first point people look at when seeking work is NHS jobs. We’ve tried BPS appointments memorandum and various recruitment agencies and websites, but so far nobody suitable has applied. So what now?

If anyone has any ideas, the company information is below:

1) My company in Milton Keynes

Lifepsychol/Evolving Families offer therapy to about 10 families, some court expert witness work, and consultation at a day rate into Keys in south Bucks and Peterborough. The qualified CP is going on maternity leave and I am moving out of area. We therefore either need to:
a) sell the business as a going concern to somebody or a company who can pick up the clinical provision (this could potentially include the evolving families business name, bank account, social media, website and email address, with ongoing referrals and enquiries – to run either as a traditional company or as a social enterprise)
b) recruit a member of staff to pick up this work and be an ongoing employee
c) recruit sessional cover of 2 days per week for 6 months to cover the maternity leave

2) To help run my BERRI project

A business graduate or experienced admin who can turn their hands to all kinds of tasks to make a small business work effectively, from responding to email and telephone messages, to keeping on top of the finances, client account management, customer support and converting enquiries into subscribers. Basic salary, plus bonus related to success of company, and the chance to grow with us and earn ‘sweat equity’ in year three. We are flexible and family-friendly. May be able to work some hours from home, but must be able to meet in Derbyshire at least once per week. It may be possible to start part-time and build up, if you are returning to work after a career break.

I would welcome enquiries about any of the above options to lifepsychol@gmail.com

2) Within Keys we have several vacancies to deliver consultation as part of our psychology pathway, and to supervise the APs doing assessments. There may also be scope for some direct therapy. We would either be able to offer permanent contracts for full or part time work, or sessional work which would be contracted for six months initially and then potentially extended.

Vacancies include:
– Full time or part-time posts to cover Warrington/Manchester
– Full or part-time post to cover Shrewsbury area
– Full or part-time post based at Sheffield/Chesterfield/Peterborough
– Full or part-time post to cover Taunton and/or South Wales (we have about 2 days work in each location, but can top this up to full-time with input into another project)

With all of the above, hours, location and salary are negotiable dependent on experience. Email lifepsychol@gmail.com and/or juliehamilton@bettercare.co.uk

Also, if anyone has any contacts to circulate the same around the clinical courses, we would be interested in prospective applications for trainees due to qualify this year.

Gaining Influence

Quite a long time ago, I identified that it gives me most satisfaction when work gives me the opportunity to have 5 I’s: Intellectual challenge, Independence, Innovation, Income and Influence. This month I have really been working on the last of those, and trying to connect with the right people to make change within the Looked After Children sector as a whole, rather than individual by individual or company by company.

It transpires that over time I have accidentally built up a wide professional network, and a credible platform from which to connect with higher level influencers. It seems that all the time I’ve invested into unpaid stuff helps when it comes to connecting with new people and looking like I know what I’m talking about. This is helpful for me to hold in mind as committee work can all too often feeling like a drain on my time that is almost invisible to anyone else and may have little that is tangible as an outcome for what can be quite an onerous process. Logically I know that this type of activity is rewarded by the innate satisfaction of contributing to important work that needs doing, but this is something I find easier to recognise at the start of the process when I first put up my hand to volunteer and after the end of all the graft than whilst in the middle of it.

Being chair of CPLAAC, on the national CYPF committee for the BPS, part of the NICE guidance development group and the BPS/FJC standards group have let me contribute to various publications that will hopefully reach wider audiences and influence practice. Whether that is in terms of the support and interventions offered for children with attachment problems or the standards that should be expected of psychologists who act as experts to the family courts or the chapter on best practise for psychological services for children and families with high social care needs in What good looks like in psychological services for children, young people and their families, the paper I wrote about Social Enterprises as a vehicle for delivering psychological services or the CFCPR issue I edited on good clinical practise around attachment difficulties, I feel like I have been part of some good work that establishes professional standards and reference points.

And with those things on my CV and a network of allies who share my goals about improving outcomes for Looked After Children, I have been able to meet with various decision makers and influencers about my ideas. The first important contact I made was with Jonathan Stanley, the chair of the Independent Children’s Homes Association. He has been fantastic at promoting my work to residential care providers and helping me to gain a seat at the table. I then met Almudena Lara at the DfE, although she was very new to the role of being LAC lead, and moved on before she was able to pick up our discussion again. I have also met with Social Finance. More recently I was able to meet with Sir Martin Narey, the government advisor (and ex-chair of Barnardos) conducting a review of children’s homes in the UK, and a representative of the DfE. And latterly I had the opportunity to meet Lord Listowel at a recent conference and hope to speak with him further soon.

In all of these meetings, I have been promoting the value of clinical governance in the social care sector. That is, the importance of being able to evidence clinical outcomes and substantiate that you are doing what you claim to do – in this case, that placement providers are improving outcomes for children and young people in their care. My wider goal is to allow commissioners, social workers and Ofsted to be able to see what kind of placement a child needs, whether a placement is making positive change for a child and who can provide the most suitable and effective placement. I’m also keen that the idea of “therapeutic care” is better defined, and that therapists working within care organisations need to be qualified, supervised, regulated by a professional body and practice within their areas of competence. But my main goal is to stop the situation in which placements are paid to provide care for the most complex and vulnerable young people in society, and do so by providing accommodation, food and transport to education but do nothing to address their emotional, behavioural, mental health, developmental/learning needs, risk to self and others, or ability to form healthy relationships with others. I think the tools I have been developing, like http://www.BERRI.org.uk, and the training I provide for staff/carers can help with that, but my goal is nothing less than to change the culture of care in the UK.

Evidence has shown that money invested in the most complex children during their childhood is repaid tenfold in savings to the public purse in reductions in use of mental health, social care and criminal justice services over their lifetime. So why is it that the placements for the most complex children and young people are primarily provided by carers with very low levels of qualification and training? The first steps to improving standards are to ensure that all carers in the foster and residential sector get training about managing the impact of trauma and disrupted attachments, and that all children in public care are regularly monitored on outcome measurements. But these need to be meaningful, and linked into practice, rather than done as hoops to jump that are disconnected from daily care.

I can think of nothing more worthwhile to do with my professional life than to improve care for Looked After Children in the UK, and I hope that I can achieve enough reach and influence to make a genuine difference.