Well-being check-ups

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

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

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

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

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

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

When thinking about mental health and therapeutic interventions, we could probably learn from the maintenance model of dentists (or the regular intervals of car servicing) that keep an overview of how things are going, give preventive advice and identify the need for more in depth work. It would also take away the stigma of talking about mental health if it was something universally considered at regular intervals. Of course it will never happen, at least not under this government which is trying to strip away essential health and social care services, increase the wealth gap and the vulnerability of socially excluded groups, and blame individuals for the way they respond to experiences outside of their control. But it is nice to think now and again about what things could be like if we strip away the constraints of austerity. And I’d like to have an annual well-being check up where someone with a mental health qualification starts by asking “so how are you feeling at the moment?” and actually cares about the answer.

 

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

Six degrees of separation

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

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

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

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

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

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

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

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

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

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

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

 

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

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

Wisdom, sycophants and advice that won’t work

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

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

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

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

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

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

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

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

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

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

Wisdom and reflection

Every now and again I stumble across something that makes me think “yep, that’s true, that explains something really profound”. I want to record that bit of wisdom, and hang on to it, and pass it on to others. So this blog is partly to fulfil that desire, as well as to meander through some of my own experiences and ideas, which are less well-formed and still open to the process of being improved through constructive challenge. There is a certain vulnerability when expressing ideas that are not yet thought through from every perspective, but I think that reflection and feedback is an important component of personal growth. I believe that beliefs can and do change according to your knowledge and experiences. If you look at life as a journey towards wisdom, then each interaction and experience is an opportunity for reflection and learning.

One example of a simple piece of wisdom I like comes courtesy of Michael Specter’s TED talk about the danger of science denial. He says “everyone is entitled to their own opinion, but they are not entitled to their own facts”. It is a helpful thing to remember, because people believe all kinds of disagreeable things that make them prejudiced, intolerant, selfish and lead them to act against their own best interests. As therapists, we are taught to give our clients unconditional positive regard, but what do we do when people have harmful behaviour and offensive beliefs? Do we just ignore them and try to work as normal? Do we pass the client on to another therapist? Do we try to find (or fake) respect for them despite the parts that are uncomfortable? Or do we challenge their beliefs? And what if we as therapists have our own prejudices, or see them in colleagues?

The first step is to recognise and acknowledge the underlying beliefs that are at play. We can then formulate to understand where such beliefs might come from. That will increase our empathy for the individual, but it isn’t an excuse. It doesn’t make the beliefs or behaviours acceptable, just as we can understand why a person might learn to use violence or abuse substances, without endorsing that choice. Sometimes our job as a psychologist is to go back to the facts, and then explore how they fit with the opinion, and what the costs and benefits of maintaining that opinion are. This can true be from the typical inward-facing cognitive distortions of depression or anxiety, to the outward facing generalisations behind racism, misogyny or homophobia, or the poor choices that lead to substance misuse, offending or aggression.

When a colleague of mine declared some of the narrative techniques I was using with a child to be “one step away from tarot cards and the work of the devil” and a non-judgemental discussion about a young person’s self-identified sexuality and gender to be “encouraging an abomination”, it was somewhat mind-boggling to try to understand where those beliefs came from and whether or how to challenge them. Had I known Specter’s quote then, I think it would have given me some guidance. She was entitled to her beliefs, but the service needed to operate on the basis of facts. The facts were that the therapeutic technique I was using had been used thousands of times before causing outcomes ranging from neutral to positive, and had published studies of efficacy. And it is evident that large numbers of people identify as LGBTQ, and that this occurs across the animal kingdom, suggesting it is an innate drive (although the evidence suggests that early experiences do have some influence). It is not a choice. There are enormous risk factors in not accepting that and responding with empathy and compassion (including appalling levels of self-harm and suicide where such identities are rejected/devalued, or there is pressure to act like they are heterosexual and cis-gendered).

I found the beliefs that colleague expressed repugnant, whilst I was also trying to respect her culture and choices, which included the right to participate in a charismatic Christian church that held these beliefs (and no doubt many others) as doctrine. Thankfully I had a wiser supervisor I could take the issue to. Fifteen years down the line, it might be that I would be the person who had to address such a concern about an employee in my company or line management. I think that where beliefs get in the way of facts sufficiently that they interfere with your work, this raises issues about competency to fulfil the role. This should be dealt with much the same as if the person was failing to do their paperwork, or wasn’t dressing appropriately for the job – with feedback about the requirements of the role, an offer of support to develop new skills, and a timescale in which change is required. This might lead to recognition by either or both parties that the person is not suited to the role.

A past supervisor once told me another wise thing: “It is easier to grow the things you like than it is to shrink the things you don’t like”. Whether that is in terms of the balance of fun and frustration in your job, or the way your children behave, a focus on growing the good can lead to more positivity, progress and creativity.

Another piece of wisdom that I have found helpful is the serenity prayer: “Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference”. This is helpful as we lose a lot of energy trying to change things that are immutable (or at least moaning about them), when we would often make more progress by focusing on the things we can do, even if they seem much smaller. We only have finite time and emotional/physical resources, so we have to prioritise. As Dave Allen said, “you can do anything, but not everything”.

On the other hand, Emma Watson’s powerful questions “if not you, who? If not now, when?”, Ghandi’s instruction to “be the change you want to see in the world” and Nelson Mandela’s observation that “it always seems impossible until it is done” are reminders that we each have responsibility for progress and the power to make change. We shouldn’t be overwhelmed by big challenges and can’t rely on other people to get things done, so we need to stop procrastinating and take action to step up to the plate for things that we care about.

I’ve ended up making a website and forum that get 10 million page views per year because it seemed like a good idea and I was in the right place at the right time for that to be a possibility. I am active with my professional body and contributing feedback to national policy, because someone needs to do it and I can just about eke out the capacity. I’ve supervised Assistants and Trainees, and done personal and professional development coaching for early career stage psychologists for many years, because it feels like a helpful thing for me to do. I’ve left the NHS and set up a company and a social enterprise that have survived through a recession. I sometimes get to hear how little things I have done have rippled out and influenced people or events in ways I didn’t expect, and there are people who cite me as influential on their lives personally or professionally. Yet when people ask how I manage to do all these things, it seems like a strange question, as I feel like they are all things any of my peers could equally have done.

Duncan Law, a Clinical Psychologist who has been instrumental in setting up CYP IAPT, said recently (in the context of successful bids for service development) that it is only looking backward that things look like a straight line, because when you are doing them it seems like you are just trying lots of options in the hope of finding a path forward. I feel that about my career. Looking backwards it seems that every component of my experience has culminated to prepare me for the things I am doing now, as if I planned my career methodically. However, at the time I was just taking the most interesting available option, in ways that often seemed to deviate from what I really wanted.

I’ll give the last word to Steve Jobs, who said “the only way to do great work is to love what you do. If you haven’t found it yet, keep looking. Don’t settle. As with all matters of the heart, you’ll know when you find it”. For all its periodic frustrations, I feel very privileged to be able to earn my living doing something that is interesting, worthwhile and rewarding. I wish that everybody had the same experience in their working lives.

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 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 had written down the contact details of their GP for me during the conversation. 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 to become friends with the IT guy who covered CAMHS. It was clear he had a specific deficit with his memory 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. They asked me to be with them in the room and share some of their abuse history with the assessing clinician, but I had to be very clear to identify as someone from the personal network. I was not a professional to them, but I was also 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 third 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.