Our relationship with alcohol

Today an article from WHO about reducing the harm caused by alcohol around the world has got people all fired up on social media. The article has slightly clumsy wording about prevention of harm to unborn babies from alcohol, that some people have interpreted as a recommendation to prevent women of child bearing age from being allowed to drink. In response people have jumped in as much to defend/normalise drinking as to stick up for women’s rights (and to rightly criticise the way certain other types of risks from alcohol are only mentioned by reference to other documents, such as the risk of interpersonal violence, or not mentioned at all, such as the risk of perpetrating or becoming a victim of sexual assault). Having tried to reply on twitter but ended up with a mega-thread, I thought it might be preferable to respond fully in a blog post about our relationship to alcohol, including some links to relevant psychological theory.

Before I begin, I should note that I’m not an unbiased observer on this topic. For the last 30 years or so, I have chosen to drink very little alcohol (typically about 5 units per year) as I don’t particularly like the taste of most alcoholic drinks, or the way I feel after the effects have worn off. I also had a very negative experience of being drunk early in my life (see this blog entry, which comes with a trigger warning about sexual assault). That led me to often choose to be the driver or the person who stayed sober on nights out, which also gave me a rather atypical perspective on alcohol – as I was often the person who was looking after the person who had puked up or passed out, or was vulnerable to sexual assault. Speaking of which, I have previously expressed some strong opinions about whether alcohol is an excuse for behaviour (it isn’t; blog also deals with sexual assualt).

So, I am fully on board with the criticism that any global policy about alcohol needs to mention its association with interpersonal violence and sexual assault. We know that drugs and alcohol are often the source of disinhibition for abusers (and can be a step used in overcoming inhibitions for those who feel guilt or social pressure, such as in Finkelhor’s model of factors neceesary for child sexual abuse to occur). We also know that they are often used to create vulnerability in victims (eg with use of drugs in alcoholic drinks by rapists like John Warboys and Reynhard Sinaga) and that the vulnerability of intoxication is frequently exploited as an opportunity for sexual assault. As BPAS say in their response to the document “In the UK alone, more than a third of sexual assaults, more than 39% of all violent crimes, and nearly 1 in 5 incidents of domestic abuse are committed under the influence of alcohol” and this clearly needs to be mentioned in a document about reducing the harm caused by alcohol around the world, more than by passing references to other WHO documents about violence.

However, I’m also someone that believes in preventative and health promotion interventions like schemes to provide healthy food for pregnant women and young children, or the tax on sugary drinks. So it should come as no surprise that I’m broadly in support of measures to reduce problem/excessive drinking and tackle the culture of binge drinking amongst young people. I think a minimum price per unit of alcohol, and more education about alcohol (and drugs) and their risks and benefits would be a good starting point. This should ideally be part of the national curriculum for children, and something that is revisited at developmentally appropriate levels.

So, with my general opinions laid out, let us return to today’s publication. The WHO document is called “Global alcohol action plan 2022-2030 to strengthen implementation of the Global Strategy to Reduce the Harmful Use of Alcohol” and is clearly marked as a first draft. The statement that has been perceived as controversial is that they recommend we “raise awareness among decision-makers and the general public about the risks and harms associated with alcohol consumption. Appropriate attention should be given to… prevention of drinking among pregnant women and women of childbearing age”.

To state something I hope would be obvious: Taking a literal interpretation of this sentence to mean that all women of fertile age should be prevented from drinking alcohol would be ridiculous and awful. I strongly agree with the critics that women are more than just breeding vessels, and that it would be massively disproportionate and set back women’s rights to prevent all women of fertile age from drinking on the basis of potential harm to a foetus. There are many complex and interwoven issues here, the way that gender and fertility have been conflated ignores the presence of anyone trans, intersex or with any of numerous medical conditions that can create infertility. It also assumes that all women are sexually active and none are using contraception or taking any control over their ability to conceive. Taken literally this therefore extends guidance that is perfectly logical for sexually active women who are fertile and not using contraception to every person identifying as female under the age of 50. However, I hope is a thoughtless omission in their wording rather than the intended meaning. It also assumes that any consumption of alcohol at any stage of the pregnancy is potentially harmful to a foetus, which does not appear to be entirely supported by science (where to the best of my current knowledge it would appear that low consumptions of alcohol have not been associated with harm and there are particular windows during pregnancy in which harm to the developing foetus is more or less likely to occur). Thus advice to avoid excessive or chronic consumption of alcohol during pregnancy appears to have been extrapolated into advice for all women of fertile age to consume no alcohol at all. And that clearly needs to be clarified as this first draft is developed into the final published document.

However, I genuinely don’t think that is the intended meaning here. The document doesn’t mention the rights of the foetus being more important than those of the mother as some critics have inferred (in fact it doesn’t even use the word foetus). Nor does it call for bans on the sale of alcohol to women (in fact it doesn’t even expand on the topic of female alcohol use at all). It only uses the word “women” four times, twice in that sentence, once in relation to mortality and once when talking about the incidence of alcohol use disorders. It literally just says the one sentence I quoted above.

I can see that the wording of the relevant sentence is slightly clumsy, perhaps because of international authors, but It is my belief having read the full guidance that this document is not advocating an unreasonable curtailment of the freedoms of women. Whilst it mentions “prevention” of women drinking, this is in a section entitled “Advocacy, awareness and commitment”. It is written in the context of preventing harm by reducing the social pressures encouraging excessive drinking and providing information about risks that would lead to informational campaigns discouraging children and pregnant women from drinking. It is not an assault on feminism or suggesting that states increase authoritarianism.

And importantly, this isn’t a personal message to individual female readers. It isn’t some jumped up know-it-all judging you for having glass of wine or two in the evening to unwind. It is a draft policy statement proposing educating people around the world about the risks of drinking whilst pregnant in the hope that more women choose to abstain. If you are past menopause, or not sexually active, or use contraception, or drink little/no alcohol, or for any of a myriad of other reasons aren’t going to end up binge drinking before realising you are pregnant, this message to reduce or cease alcohol consumption is not for you. You can let go the anticipated reproach and stand down.

Whilst the tabloids are trying to make this into a big deal, this fits with their xenophobic British exceptionalism agenda, whereby they are dismissive of international bodies, experts and science and try to frame them as limiting personal freedom and autonomy. So when they use stories like this to fuel the “nanny state curtails our rights, its political correctness gone mad” narrative, remember that each of these little fires is built to distract from the way the government are slowly attacking our rights and the safeguards over their power like the right to call for judicial review of government actions, GDPR and the protection of our data from commercial exploitation. Like the fantasy that conservative voices are being cancelled/silenced by an oversensitive generation of woke snowflakes rather than that market forces mean racists and sexists are increasingly feeling the rightful consequences of their repugnant views, or the way that taking the knee to acknowledge racism exists and needs to be tackled has become some unpatriotic politicising of football, this is just a distraction technique. These stories distract from the unlawful crony contracts that have funnelled public funds to friends of cabinet members, the way politicians no longer resign when they are found to have been dishonest, the failure of Brexit, growing inequality, the mess they have made of the pandemic and all the other ways the Overton window has shifted right and the current pack of corrupt incompetents are making a mess of governing the nation.

I think the best way to look objectively at the issue here is to let go of the wording and look at the overall tone of the message. WHO advisors are trying to reduce rates of death, disability and children harmed by foetal alcohol exposure. Surely that is a good thing? It is directly parallel to trying to prevent cancers/disease and harm to others from smoking (including during pregnancy or around young children) – something that was socially acceptable until surprisingly recently. Smoking is (or at least was) another choice that some people find enjoyable, but scientific studies associated with excess mortality. If we saw a publication warning women about smoking harming an unborn child it would probably not immediately make people want to post “oh just reading this makes me want to smoke a whole box of cigarettes”. So I wonder, objectively, why a twitter post replying to the report saying “I’m not sure where to start with this. Maybe by opening a bottle of wine?” has received so many likes?

For context: Alcohol causes 3 million premature deaths a year – that is more than tuberculosis, HIV/AIDS and diabetes. This includes 13.5% of all deaths among 20 to 39-year-olds in the world. In Russia and eastern Europe, nearly a third of people’s lives are shortened by alcohol use, though the rate in the UK is about 3.4%. In the USA research shows that alcohol contributes to about 18.5 percent of emergency room visits and 22.1 percent of overdose deaths related to prescription opioids. Around the world about 1.4% of people are considered to have an alcohol use disorder, with the highest prevalence in Russia and neighbouring states, where it is about 5%, and Brazil and Greenland, where it is about 3%. In America the diagnostic rate is higher (at about 5%), but it is unclear whether the prevalence is higher or the thresholds for diagnosis are lower. Globally, alcohol use disorders lead to 185,000 deaths per year, with around 2300 in the UK. This number has increased considerably since the 1990s, but has been fairly steady for the past 15 years. Few of these people receive formal treatment, with only 5-6% getting treatment in the UK. The incidence of alcohol use disorders increases significantly for those with mental health problems, showing that either the same stressors can lead to both outcomes, or that mental health problems can increase the risk of alcoholism or vice versa.

Problematic alcohol use can either take the form of binge drinking – where the drinking is excessive in quantity, but happens intermittently, perhaps once or twice a week, or on particular occasions or where the individual gets together with a particular social group – or chronic and excessive consumption (where the individual drinks every or almost every day over a protracted period of time). Both patterns are surprisingly common.

About 25% of the population meet the criteria for binge drinking on surveys about alcohol consumption, whilst around 7% report heavy drinking (5 or more units per day on 5 or more days during the last month). Even within geographic regions, there is a high level of variation between countries: in Italy, only 6 percent of drinkers had a heavy episode of drinking during the past month in contrast to nearly half in Ireland; 42 percent in Belgium one-third in the UK and France; and 20 percent in Spain. Binge drinking is particularly common amongst students and young adults, with around 50% of those who have ever drunk alcohol reporting in surveys they had drunk to the point of blacking out at least once, and 10% reporting a blackout associated with drinking in the prior two weeks. If some of those young women are becoming pregnant (perhaps due to sexual encounters when intoxicated), that level of drinking could potentially be a significant risk factor for the unborn babies.

Drinking alcohol to excess can also lead to other additional risks for the drinker. Whilst the immediate effects of alcohol are usually perceived as pleasant, and resolve fairly quickly when drinking stops, they can lead to memory lapses, poor judgements and an increased risk of accident and injury (as well an increased risk of sexual assault). Blackouts can involve potentially dangerous behaviour and loss of consciousness. Binge drinking is known to increase the risk of medical crises, and is a significant contributor to the number of people who present at A&E. Studies show that compared with people who did not binge drink, people who drank alcohol at twice the recommended thresholds were 70 times more likely to have an alcohol-related A&E visit, and those who drank three times as much as the recommended limit were 93 times more likely to present there.

Alcohol also presents other less acute risks of harm. The effects of alcohol on the body become more severe with larger volumes consumed over extended periods of time – with particular risk to the liver, heart and brain. Changes to the brain can eventually disrupt memory and lead to Korsakoff’s syndrome. Alcohol is also physically addictive, with greater risks associated with sudden withdrawal than most drugs.

There are no hard and fast rules, but chronic excessive use appears to follow a different pattern to binge drinking, which is typically social – perhaps because the cost of alcohol in quantity soon prohibits this being consumed at pubs and clubs, or because of the pattern of drinking, or the impact of the level of intoxication on social functioning. The reality of problem drinking is, like most things in life, a bit more complicated than simply being the upper section of a spectrum of consumption. It seems to have some biological components, marked social components (eg when alcohol is used to cope with social situations or fit with peers) and is often cumulative over time. As with most addictions serious alcohol issues are often rooted in combinations of learnt behaviour and exposure to trauma. Impoverished or abusive relationships in childhood set a harmful template that can lead to dysfunctional coping strategies and relationships later on. These can create patterns that reinforce problem drinking, and masking the drinking can disrupt supportive relationships.

However, it is not just in the context of alcohol misuse disorders that alcohol causes harm and excess mortality. Alcohol also increases mortality via road traffic accidents. In South Africa and Papua New Guinea more than half of all traffic deaths are attributable to alcohol consumption. In the US, Canada, Australia, New Zealand, Argentina, and many European countries alcohol is responsible for around a third of all traffic deaths. Alcohol is also implicated in more than half of all crimes in the UK – either because the crime involves alcohol (eg drink driving, drunk and disorderly, theft of alcohol) or because the person committing the crime had consumed alcohol (eg in violent crime, assault or criminal damage). This is higher than elsewhere in the world where this has been studied.

Alcohol also causes Foetal Alcohol conditions that can have a lifelong impact on the brain. NICE say the exact incidence is unknown, but it was thought that about 7.7 people per 1,000 worldwide are affected, and 32.4 per 1,000 population in the UK. A study following up a cohort of births looking at possible symptoms suggested the prevalence could be as much as 6 to 17% of the population. The official UK advice is that the safest approach for women who are pregnant is not to drink alcohol to minimise risks to a baby. However, multiple sources suggest that 41% of pregnant women in the UK consume alcohol, and research shows women are not universally given information about the risks of alcohol during pregnancy (with 30% of those who drank before pregnancy reporting getting no information on this topic from maternity services, and only 29% of midwives saying they routinely share this information). The messages about how much alcohol is safe are unclear. There is a consensus from the stakeholders that NICE consulted that education and raising awareness of the risks of drinking alcohol in pregnancy is necessary, and 91% of alcohol bottles sold in the UK now warn against drinking during pregnancy. So it should be no surprise that the WHO also feel that women around the world who are pregnant or who may become pregnant (because they are of fertile age and are having sex without contraception) need to be aware of the risk posed to a baby by excessive alcohol consumption. Reducing alcohol consumption in these groups will reduce harm.

Yet as soon as reduced consumption of alcohol is mentioned, it brings out an almost reflexive response. I think some of that is “anticipated reproach” – the defensive (but often antagonistic) response people have to anyone they feel may judge them negatively, which can sometimes be combined with “do-gooder derogation” the feeling that anyone taking the higher moral ground about an issue personally, or taking action to resolve it, must be pompous and judgemental. Anticipated reproach has been studied by Benoit Monin, who has shown the effect in relation to everything from vegans to racism. We can see that playing out in the response to this WHO report. People want to speak out for their right to consume alcohol, and don’t perceive it as harmful (except in others with obviously excessive drinking).

The pandemic has also conflated unrestricted access to alcohol with the idea of personal freedom and agency. Closing pubs has been seen as more of an imposition on our rights than closing schools – particularly for the vocal anti-mask/anti-vax brigade (I wonder if there is some overlap between views about pub-drinking and a rejection of broader progressive values? It certainly seems to be associated with covid denial, Brexit-voting, and dismissal of expert advice, which I associate with a kind of disenchanted malaise that comes from underachievement and a feeling of being cheated by the changing social contract that makes people vulnerable to alt-right propaganda).

But I think this positive and normalising view of alcohol long predates the more recent changes to the socio-political environment, and the increasing polarisation of society. Alcohol has been embedded in our culture for thousands of years, and it holds an important role in social engagement and special occasions. So for most people it has positive associations. It is also an example of something where many people use the substance, yet comparatively few are harmed by it (the same could be said of illegal drugs like cannabis). So (as with the “just say no” campaigns that portrayed illegal drugs in entirely negative terms) dramatic warnings about potential harms don’t tend to chime with personal experience, which may be another reason for the defensive response.

The annual global average alcohol consumption is equivalent to 6.4 litres of 100% proof alcohol per adult per year. This is equivalent to 53 bottles of wine or 225 pints of beer (a bottle of wine or 4.5 pints of beer per week). In the Middle East and north Africa (which contain many Muslim nations where alcohol is frequently prohibited for religious reasons), consumption is much lower than average and often close to zero. In eastern Europe (and Nigeria) consumption is typically double the global average, and western Europe is not far behind. The UK, Russia and Australia are also well above the global average. However the type of alcohol, age and gender of drinkers, and the patterns of consumption vary from place to place. Broadly beer is quite widely consumed outside of the middle east, wine is most popular in Europe, Australia and southern South American nations, whilst spirits are most popular in Asia and Russia. In the UK the consumption of wine has increased steadily over the past three decades, whilst consumption of beer has reduced. The highest percentage of income is spent on alcohol in Europe and Australia – with Ireland being an outlier where around 7% of income is spent on alcohol. In general wealthier individuals drink more, although there is not a higher incidence of problem drinking.

For most people alcohol is a pleasurable mild intoxicant. And most people consume alcohol in moderation, where the impacts on health are more debatable (and in some cases even suggested to be positive – especially when it comes to wine as a component of a Mediterranean diet). So we do have to set the concerns about harm in context with the fact that many people derive pleasure and little or no harm from their alcohol consumption.

However, even when it comes to foods, consumers are increasingly given a warning of the fat, salt and sugar content, so that they can make informed decisions about their health. This balancing of benefits and risks is also something we are familiar with when it comes to the leaflets enclosed with prescribed medications, and has been in the spotlight in relation to the coronavirus vaccinations – where potential harms, like the tiny proportion of people who have had blot clot related complications, have dominated the discourse, despite the fact that for the vast majority of people it is protective and side effects are relatively trivial. Perhaps it is a good precedent that the benefits and risks of something have to be clearly explained even when there is widespread consumption?

After all, alcohol gets lots of positive messages to the public every day. There are numerous adverts showing beautiful, healthy, happy people engaging in social drinking. But on top of this, alcohol gets advertised from peer to peer. I see lots of social media posts about drinking, and almost all have a positive or light-hearted tone. Research corroborates this – surveys of social media show that posts which picture or talk about alcohol use show happy social occasions, groups of people interacting, romantic settings and chilled nights in. They talk about fun and exciting experiences, celebrating, dancing, dating. Posts rarely show risks or consequences. There are numerous memes like “wine o’clock” or “just a little glass” with a picture of an enormous glass of wine, as well as many references to alcohol as a survival strategy or a means to cope with parenting. Comedians joke about binge drinking and Irish weddings. I’m not sure people think about the impact before sharing posts or memes that feature alcohol, but studies show that exposure to alcohol posts on social media leads to increased alcohol consumption (why else would alcohol companies spend billions on advertising?). This means that seemingly harmless posts can potentially have negative impacts on others. This might particularly be an issue for those who have a problematic relationship with alcohol. Studies have also shown that people who post about alcohol consume more of it.

Yet it seems we each normalise our own consumption. Alcohol consumption and related risk is influenced by how the person perceives they compare to others in the population (if they believe others drink as much/more than they do, they believe their drinking is less risky). This is compounded by overestimating norms. So the more we drink, the more we assume others drink to subconsciously justify our own drinking (the same pattern also appears to be true of drug use, or sexual behaviours). The influence of social norms is a whole field of psychological research.

But I think that this can also happen at the societal as well as the interpersonal level. There has long been a tendency to encourage/normalise drinking in the UK that leads to people not recognising excessive/harmful use. Perception of alcohol use varies by drink, context, time and characteristics of the drinker. Adults typically regard themselves as moderate drinkers and disapprove of excessive drinking by others. We are not very good at judging the threshold at which alcohol use can be harmful, particularly when we are amongst others who consume alcohol in large quantities. I’ve met many who normalise drinking vast amounts (eg >40 units in a day). So maybe, like smoking and sugar consumption, and our lack of physical activity and increasing obesity, we do need to think more about harm minimisation?

Alcohol causes 24,000 deaths and over 1.1m hospital admissions each year in England, at a cost of £3.5bn to the NHS. Yet at the moment, the only labelling of alcohol to indicate risks is voluntary, as is the industry funded Drink Aware campaign (which sprung from the Campaign for Smarter Drinking instigated by my business mentor and NED Richard Evans before he left the drinks industry). Like the similar Gamble Aware campaign, the aim springs from corporate social responsibility and is intended to maintain profits and consumption whilst reducing harm – which could be considered to be competing interests. Experts say that the drinks industry would lose 38% of their income if drinkers kept to recommended guidelines, losing £13 billion per year of sales, which is why they are so reluctant to promote accurate information about the risks involved. So once again, there is a weighing up of corporate profits against public health. A minimum price per unit of alcohol and increased duty to subsidise costs to the NHS and the impact of alcohol-fuelled crime (eg police, services for sexual assault, refuges for survivors escaping domestic violence) might seem to be appropriate steps towards getting that balance right, but the public really don’t seem to like the idea of raising the cost of their simple pleasures….

Coping in a time of coronavirus

Are you finding it hard to adjust to the impact of Coronavirus policies on daily life? If so, you are not alone.

If you aren’t too saturated with top tips for wellbeing type posts, I thought I should share a little bit of basic advice compiled from my knowledge as a clinical psychologist and what I have read on science twitter, in case others are also struggling with the impact of social distancing and experiencing changes to their daily life that are causing high levels of anxiety.

Note: This blog is mainly targeted at those people who are staying at home and trying to comply with social distancing, rather than those of you who are doing the kind of essential work that has to continue to involve direct contact with others. If you are in that group, I’m incredibly grateful to you, but I don’t feel skilled enough to provide specific advice. If you have greater knowledge than me and would like to improve this blog (particularly in terms of the physical elements, which I appreciate will change as the situation and our knowledge base evolves) please let me know and I can fix things.

So, with that said, on with the blog.

It is a worrying time for many people, and there is a real threat that we have very little control over, and a lot of misinformation on social media. However, there are things that we can do, and you are not alone – we are all facing this together. So this is my very simple advice of where to start to ground yourself and remain as psychologically healthy as possible in these challenging times.

First the physical health stuff:

1) Do everything you can to remain safe and protect those around you. First and foremost: Get your vaccination when it is offered. Don’t be put off by scare stories about side effects, as a day or two of aches in your arm or a few hours of flu-like symptoms are a small price to pay to reduce the risks of a deadly disease. Staying safe also means following the latest guidance about lockdowns, masks and social distancing. This applies even after you have had your jab! It is still possible to get covid after you have been immunised, and whilst it is much more likely to be symptomless or very mild, you can still be part of the chain of transmission to others, especially with more contagious variants like the delta strain.

So what do we need to do? The government have put a focus on hand washing with soap for 20 seconds (make sure to wash between fingers, around thumbs and wrists and under fingernails if you have had any contact with someone who may be contagious), and remind us to cough or sneeze into a tissue or your elbow rather than onto your hands. There has also been a focus on cleaning surfaces – however the evidence of fomite transmission (droplets on surfaces) has been minimal, whilst the evidence for aerosols (tiny particles exhaled by an infected person that are airborne for several hours and accumulate in enclosed spaces) has become overwhelming. Thus the key prevention strategies are to wear a mask when entering shops or public indoor spaces, and to follow the rules about physical distancing. This means not greeting people with handshakes, hugs or kisses and standing or sitting further away from them than we would previously have done. Minimise your face-to-face social interactions with people outside your household bubble, and try to ensure you only interact with larger groups of people in a safe way – ideally outdoors or in a well-ventilated space. Unless you work in an essential role this means avoiding crowded events and places, not meeting up in large groups, and trying to remain 6 feet away from others, especially anyone outside of your minimum necessary network. Wear a well-fitted mask in any enclosed space apart from your home – try not to put it on and take it off more than you have to, and avoid touching the mask except by the strings.

2) Be aware that Covid-19 is potentially dangerous, so it is really worth preventing contagion if possible. Even if you are not concerned about the impact of covid on yourself, each of us interacts with people who are older or clinically vulnerable – whether that is elderly parents or grandparents, people with chronic or acute medical conditions (eg cancer, heart disease, diabetes, immune disorders, physical or learning disability, obesity, asthma) whether we are aware of them or not. People we know might also be carers for individuals with these clinical vulnerabilities. In fact 3.7 million people in the UK are regarded as clinically extremely vulnerable, and many of them remain very anxious about the risk of catching covid, even if immunised, despite the fact that the official advice to shield has been lifted.

Covid is worth avoiding as even if you are not in a vulnerable group you can pass it on to others, plus – even within the group that are considered to have had only mild symptoms – it makes some people feel like a very bad flu with aches and serious chest pain/breathing problems, and can lead to weeks or even months of tiredness or recurrent symptoms in some people known as “long covid”. However, for many/most people it may not be obvious that you are ill at all, let alone with a serious condition.

If you test positive, or if you have a dry cough or fever, or if you lose your sense of smell or taste, or if you feel suddenly exhausted/weak, you need to get rested and to self-isolate to prevent spread of the virus. You must also minimise risk of transmission until you have been tested if you have had contact with someone else who has subsequently tested positive for covid, to break the chain of transmission. If you have school aged children you will be asked to complete lateral flow tests twice a week, but be aware these are not as reliable as other tests and can lead to both false positives and false negatives.

3) Take extra care over social distancing if you have an existing health condition or are elderly, or if this applies to anyone else in your household or if you are interacting with or providing services to someone vulnerable (as well as older age this could include more serious medical conditions like cancer, but also ones that are not normally seen as a big impairment to daily life like asthma, heart disease or obesity, particularly in combination). Ensure you have enough medication, and keep taking preventers if you are asthmatic. If you are in a high risk category and there is a high level of prevalence in your area, then where possible have deliveries dropped off without interpersonal contact. If you need to interact with others or use shared facilities, wash your hands and surfaces that others touch frequently (eg door handles, railings, keypads, taps, etc) with soap or sanitiser regularly and wash your hands after using them.

4) Remember that viral load may be important in how severely people experience the virus, and ensure that you take precautions when caring for a dependent with possible coronavirus, or if you think you have it, even if the symptoms are mild. A mask is particularly important in this situation, along with good ventilation, careful handwashing and ensuring you avoid physical contact, which can be challenging with a loved one or small child. Anyone ill or who knows they have been exposed to someone who definitely had Covid-19 should stay separate from the rest of the family as much as possible. This needs to be for at least 7 days after testing positive if you have had no symptoms, or for 7 days after you stop having symptoms. Where someone is ill but needs care use PPE such as a well fitted mask and disposable gloves, use as much ventilation as possible, and keep washing your hands.

5) Although the government are telling us to act as if covid is no longer a problem, we don’t know if there will be additional waves of new variants of covid, or whether future variants will break through the protection offered by immunisations. Covid is also still causing preventable deaths and lasting health impacts for large numbers of people, as well as causing large numbers of people (including health and care staff) to self-isolate. Combined with the impact of Brexit and chronic underfunding the NHS is creaking at the seams. We need to ensure that the NHS can catch up with the level of need for other conditions, and is ready to cope with an increase in demand if required.

Politicians and NHS managers need to act to grow the capacity of the NHS by addressing the funding and recruitment issues. However, each of us can play our part by reducing our risk of spreading the virus or adding to NHS demands in other ways. This means we should aim to slow the spread of coronavirus (by getting immunised and using sensible precautions) so that the rate of people requiring hospital treatment doesn’t exceed NHS resources, and lower the baseline demand for NHS services. We can do this by avoiding preventable reasons for requiring hospital care. This means taking care of your physical health and existing health conditions (eg taking preventative medication/inhalers, following dietary advice for diabetes or high blood pressure), being mindful to reduce risk of accidents (eg drive slowly in built up areas, be extra cautious to avoid falls and injuries) and improving your respiratory and cardiovascular health (eg give up smoking, increase exercise, eat healthily, and attempt to lose weight if you are obese).

But importantly you need to care for your psychological health too.

6) Connect with loved ones (physically if you are in the same household and nobody has symptoms, but virtually or with social distancing precautions otherwise) so that you do not feel alone. Hug your kids or your partner if you are together, or speak to them as frequently as possible if you are apart, and listen to how they are feeling. Check in with people who might be isolated and with those who have been bereaved or have had serious ill-health, traumatic experiences, or have lasting symptoms from covid. Keep in touch with your relatives and usual network via phone, social media, email or video chat. Make the effort to speak to your colleagues even if you are all working from home, keep in contact with your friends even if you can’t gather in person. Confide in the people that you trust.

7) Acknowledge that what we are going through is tough, even if you feel lucky not to be having to deal with it face on like those working in health and social care or doing supply chain or deliveries. Trust your own gut about what level of potential exposure to the virus you feel comfortable with, and don’t let anyone make you feel bad if you don’t want to go back to face-to-face work or social events. Change is challenging, the perceived threat is intangible and unknown, so it is hard to reason with the anxiety it provokes, and uncertainty is stressful. The changes imposed on us to manage the outbreak take away some of our comforting routines and our expectations of the immediate future, and it is normal to worry about the impact on ourselves and loved ones. It is absolutely normal to feel shock, denial, anger, fear, grief, or a mixture of feelings and for these feelings to ebb and flow or change unpredictably (think about the Kubler-Ross stages of grief). You might find yourself literally shaking and/or crying at the idea of having to do something you don’t feel ready for, or you might feel nothing at all. Be kind to yourself, and give yourself time to adjust.

8) Manage your own anxiety. First and foremost, breathe (there are some good little graphics and apps about). Then make sure that you take care of yourself by doing all the basic things that we need; eat, sleep, exercise. Try to avoid increased use of alcohol or drugs, including smoking. Give yourself a routine. Confide your feelings in those you trust, or seek out support if you need it. Join in online mindfulness or therapy groups, or – if the anxiety is becoming a problem for you – seek out personal therapy from a suitably qualified professional. If you have a garden or safe outside space, get out there and appreciate the elements. If you don’t, try to sit near a window and let some fresh air in as often as possible, and leave the window open when the weather isn’t too cold. Exercise and relaxation are both important. The former can burn off negative neurochemicals and produce more positive ones, and the latter can help you to soothe yourself (so indulge in a long bath, or listen to a relaxation video). Likewise sex (or masturbation) is good for our neurochemistry, can maintain intimacy in a relationship through a stressful period and/or help you to sleep.

9) Limit news consumption and stick to reliable sources. If you are feeling anxious you might want to learn everything about Covid-19, but whilst this can bring some temporary relief, too much focus on the potential threat can be counterproductive and increase your anxiety. So try to limit how much time you spend on news sites or social media, and ensure that you check the sources of what you do read as there are many seemingly plausible articles and posts that are not true doing the rounds. The BBC, World Health Organisation, official government sources or a trusted newspaper (for me that means the Guardian or the Independent) are probably more trustworthy than celebrities, social media influencers or some politicians. Don’t get your information about the outbreak from social media unless you have personal connections with medical/epidemiology experts and are very skilled at evaluating the quality of the sources and understanding the limitations to individual studies. If covid content makes you anxious but you like connecting over social media, you might wish to use your preferences to tune out posts using terms like “pandemic”, “coronavirus” and “covid”, so that you can focus on more positive content.

10) Keep busy. Give yourself small goals and structure your time into small chunks, rewarding yourself for small achievements. Be mindful about what you are doing, and give it your full attention. Don’t let yourself ruminate, or slouch about in your pajamas all day. If possible, make sure that you sleep when it is dark and are awake for natural daylight. Stick to routines of mealtimes and maintain as many of your normal activities as possible. If you are unable to work or have less work to do, see this as an opportunity to do things you wouldn’t otherwise have time for. Try to find enjoyable activities or those that keep your mind occupied, whether that is arts/crafts, reading, gaming, sorting/tidying, decorating, programming, writing, making or listening to music, watching films/telly or learning something new (there are loads of fab free courses online).

11) Turn your focus towards the practical things you can do. For me that means trying to increase my cardiovascular fitness and lose some weight, because my pre-existing conditions mean I’m at greater risk, and my lack of fitness compounds this – so I’ve been trying to run up and down the stairs first and last thing each day, and each time I feel particularly anxious. This gives me a sense of doing something positive and it can be rewarding to see yourself making progress. You can choose an activity that suits your starting level of fitness, get out and walk or cycle or there are fantastic exercise videos of all sorts on youtube, so why not try some zumba or yoga or calisthenics. Or improve your living environment, or create or improve a garden or vegetable bed. These kinds of things will give you a tangible feeling of achievement and improve your quality of life.

12) Be kind to others. Manage your anxieties before you speak to children, answer any questions they might have and help them to feel safe and loved. Try to be kind and patient if children are off school, and don’t put too much pressure on them to do academic work until they are in a calm enough emotional state to do so. Listen to loved ones and empathise with their experiences, even if they feel differently or are responding in a different way to you. If there is a spate of panic-buying (whether of toilet rolls, fuel or fresh produce) try not to buy more than you need, so that others can get some of key items too. Thank delivery workers, supermarket staff, carers and other essential workers, and don’t pass on frustrations about lack of stock or delayed/cancelled deliveries to them as they are doing their best. Reach out and make connections to those who might be lonely. If you are young and healthy try to be particularly considerate towards those who are not – keeping in touch with older relatives and friends or those with disabilities and/or health conditions whilst keeping them away from contagions. Join neighbourhood networks or the NHS volunteers list. Leave a note with contact details for vulnerable neighbours in case they need help with shopping or collecting prescriptions, or someone they can speak to on the phone or through the window if they feel isolated. Donate to food banks and local charities if you can afford to do so. Shop with smaller companies and local traders where possible.

13) Take time to be grateful for what we have. If you have people who love and care about you, appreciate them. If you have pets that share your life, pamper them. If you can access nature, take time to enjoy that. If you have had the opportunity of education and can continue to learn, value that. Remember that we live lives of relative plenty. Most of us have relatively secure places to live in locations with relatively good health services to fall back on if we need them. Many of us have meaningful work to be involved in, and live in developed nations with some form of social security to fall back on and/or within networks that would support us in a crisis. So although there are greater challenges in our daily lives due to the pandemic (or Brexit and an inept/corrupt government), we still have a lot to feel grateful for. Focusing on the positives helps you put the challenges into perspective.

14) Know that we’ll solve this in time. So many brilliant people are working together to address this new disease. Health care professionals are doing brilliant work all around the world. Scientists are hard at work exploring faster and more effective tests and treatments. New drugs are being developed at a faster pace than ever before, and well-established medicines have been found with positive effects on disease severity/duration. Uptake for immunisations has been good enough to massively reduce mortality. We have tests to show who is contagious. Immunised people (and those who have had covid) are less likely to be a vector for transmission, so rates of infection are likely to fall over time. Air filtration devices are being tailored to removing the aerosols that increase risk of transmission in indoor spaces. Advances are being made all the time.

15) We all know the death rates and current numbers of people infected. The negative stories are spread far and wide, but some good things will come out of this too. Pollution has been reduced by the decreased travel and factory activity, saving lives of vulnerable people, especially in the developing world, as well as helping the environment. Reduced car journeys might mean reductions in accidents. Political recognition of changing public perceptions should lead to greater investment in health and social care, as well as increased funding for medical research and response-readiness for the future. The pandemic has also shown that all nations face the same threats, and all people are the same, so (with the exception of some racist idiots) it has increased international cooperation and the knowledge that we are all interconnected. This has the potential to allow greater collaboration on international issues in future. Mass working from home has shown that it is possible for more people to work remotely, meaning there are likely to be reductions in travel and more adjustments for people who need it available in the future. It has also highlighted the value of essential workers in supply chains and delivery as well as in health and social care, raising their status and priority in public perception. The economic impacts have shown the value of universal health coverage, social safety nets, and minimum income guarantees. It has reduced the mindless consumerism of recent years, and made us conserve resources and reduce food waste. So hopefully we will come out the other side having learnt some important lessons and can genuinely build back better (and not just use this as a vacuous slogan to cover for government inaction).

The rise of the bad guy

Trigger warning: first two paragraphs mention paedophiles, middle section is about racism and sexism, later content is political

The first time I met a paedophile I had no idea. He didn’t wear white towelling socks that showed below his slightly-too-short trousers, he didn’t wear a dirty trench coat, and he wasn’t a socially awkward man with greasy hair, unflattering glasses and a slight squint. Quite the contrary. He was a well-groomed, educated, articulate, middle-class man. He attended appointments to express concern about his grandchildren, and appeared supportive to his children in trying to sort out their problems. He was polite to professionals, and always thanked us for our time and expertise. I later found out that he had sexually and physically abused several members of the family. Looking back, our only clue (beyond the fact the children referred to us were evidently troubled and failing to thrive) was that the receptionist in one clinic said that she didn’t like the way he spoke to his wife in the waiting room, saying “I wouldn’t talk to a dog that way”. But we didn’t know how you could appropriately record that in the notes, given only the children were open to the service. So we didn’t record it.

The next time I met a paedophile he didn’t fit my stereotype of a creep or bad guy either. In fact, he tried to be my friend and find areas of common ground. If I hadn’t met him in my professional capacity and known of his conviction in advance, but instead had met him socially under different circumstances, I suspect we would have found some. Perhaps we would have had a pleasant conversation about politics, video games or running internet forums, and I’d have left thinking he seemed like a nice person. He was young, outgoing and wore a colourful T-shirt referencing a slightly crude meme. He was charismatic, informal and irreverent, and he flirted with the admin staff. However, I might have picked up on something when I found out his partner’s IQ was more than 60 points lower than his, that she had a serious trauma history, and they had met on a dating app for single parents where his profile bragged of how much he loved children. But I doubt his attraction to vulnerable single mothers is something apparent to most people that meet him, at least until they know him well.

The opposite face of this coin, where people assume they can judge a person’s character accurately from superficial appearances, almost certainly contributes to a lot of prejudice and discrimination. So many people from specific population groups are assumed to be aggressive, untrustworthy, or unacceptably different because of their culture or religion – but whether people experience these prejudices or not doesn’t reflect their behaviour or beliefs (or even whether they actually belong to the assumed demographic). Think of the prejudice about gypsies and travellers, or Muslims, or young black men, for example. Likewise the stereotypes about gender, or age. As I mentioned in another blog post, women in the public eye get judged for how well they conform to societal expectations of women – to look decorative at all times, to not be perceived as “aggressive” and to look after others. Any emotional expression is seen as a weakness compared to the perceived standard of cold logic that is perceived as more masculine and therefore preferable. There is a whole lexicon of words used to put women down when they step up to the plate.

Again, most of us are blind to our prejudices and we are also blind to our privilege. We assume an equal playing field when we congratulate ourselves for our achievements, and we don’t see the constant attrition that marks facing prejudice that contextualises individual incidents. This forum conversation (from post by mr0860 near the bottom of page 2 onwards), this twitter thread and this twitter thread show exactly what happens when the recipient flags sexism or racism, but those in the audience who have not experienced it do not pick up the same cues. You end up with a split between those who think it is legitimate behaviour/debate and those who are fed up with it (the recipients of the behaviour). The former group are disproportionately white men who have never been on the receiving end of the issue they cast doubt on. In fact they often haven’t even witnessed the issue first hand, giving them the false impression that it is rare, due to the false belief we all hold to some extent that our own experience is universal. The latter group are then branded as over-sensitive snowflakes stifling debate (though ironically it is those bandying those terms about who cry the loudest if they feel they are being criticised or their voice isn’t being given enough credit, see Stephen Yaxley Lennon or Milo Yiannopoulos).

Meghan Markle has been a particular victim of this pattern, as a mixed race woman that has used her platform to speak up for feminism and against racism and inequality, so it is no surprise that the vested interests of the British tabloid press dislike her and want to put her in her place. Yet there are still those who claim it isn’t racism, or that she brought the problems on herself in some way. In this brilliant clip Dr Shola Mos-Shogbamimu calls it out perfectly. The emotional labour of explaining or performing inequality is exhausting, and falls disproportionately on those who are subject to the prejudice in the first place, who already have additional burdens to carry.

My point is that we all make assumptions about other people, and often we aren’t as good as we think we are at picking out people’s true character from their appearance or what we get to see of them before we know them well. In fact sometimes we can know people very well and still miss huge facets of them, as is often evident in the terrible guilt and grief post-mortem when someone dies by suicide. The same thing might also contribute to why people enter relationships with partners who later become abusive toward them. Yet we are often blind to what we don’t know – I had someone on twitter recently claim to be certain that nobody in her extended network of over 100 friends and family members has ever experienced mental health problems. Statistically that’s as probable as a lottery win on a day you get struck by lightning, unless her family deviates very far from the rest of the world population in some way.

That isn’t to say there aren’t horrible people who are outwardly and obviously bad. There are. And I’ve met plenty of them, both personally and professionally. But I don’t think we can always pick them out from a line-up. And even when we can, it doesn’t seem to always hold them back. After all, we’ve had some very popular and powerful men come to light after many years of sexually abusing people on a massive scale (eg Weinstein, Epstein, Savile). There are also more than a few repugnant men in prominent political positions at the moment. Somehow being a division-stoking, lying, philanderer who will take whatever political position is expedient to him or his far-right paymasters, or a hate-mongering, tax-dodging, cheating, sex-pest who has asked foreign powers to interfere in his country’s elections hasn’t blocked two rich, overweight, blond men from some of the most powerful offices of power in the world. Far from it. Instead of their moral character being a barrier to office it is a selling point. Rather than denying or attempting to mask their true nature, they have started to double down in the knowledge that it isn’t reducing their popularity. Perhaps their carefully constructed persona of being harmlessly dim keeps them filed under ‘amusing oaf’ rather than ‘dangerous autocrat’. It is clear that their simplistic slogans have appealed to populations fed up of being ignored or talked down to, and made them seem more down to earth, whilst their decisions (no matter how hypocritical or founded on lies) make them seem like men of action.

I can’t be the only person that finds this incredibly frustrating. Surely we need to value truth and honour and block bad people from power? We need to stop it being amusing or acceptable to lie, express prejudice, exploit others, or to foment hatred of vulnerable people, and that means challenging the way that this is reported. Critical in this is the regulation of social media, and the support of journalism that is ethical and independent, rather than being reliant on social media, misleading narratives from biased sources and badly checked hearsay that spreads more rapidly and widely than the corrections that follow. I’m with Carole Cadwalladr that this is key to helping the public understand the truth about key issues and allowing democracy to function. If everyone who wanted progressive values to stand a chance in the world boycotted Facebook and lobbied for better regulation, their advertising revenue would fall and their business model would have to change. The million dollar question is whether we want things to change enough to take action, even if this means we have to find alternate ways to journal and share our lives with our networks*. Otherwise the bad people might tighten their hold on power and lead us in increasingly worrying directions.

 

*If that feels too much of a step, then I’d recommend you take three simple areas:
  1. Increase your privacy. On Facebook change your name and set your privacy settings higher so little or no information is public. Be wary of services with poor privacy and data protection.
  2. Be more data savvy. Watch The Big Hack. Be aware of what data you are giving way. Be mindful of what data your mobile phone and/or internet browser is collecting and what “personalisation” of advertising you are allowing, read what you are consenting to in the user agreement for apps and software
  3. Install apps that block advertising and show who is funding the adverts you do see. I use FB Purity and Who Targets Me?

The misrepresentation of evidence

About a week ago I was involved in a heated twitter debate about this blog post. I felt, as I said on twitter and in my extensive comments about the blog, that it entirely misrepresented the evidence about Adverse Childhood Experiences by implying that because of risk multipliers within particular population groups, certain negative outcomes were almost inevitable for people with multiple ACEs. The author repeatedly asks rhetorical questions like “If 1 in 5 British adults said they were abused in childhood in the last CSEW (2017), why hasn’t our population literally collapsed under the weight of suicides, chronic illness, criminality and serious mental health issues?” Likewise, she asks how anyone can be successful after childhood abuse if the ACEs research is correct. I replied to explain that this simply isn’t what the data tells us or what risk multipliers mean, so the exceptions are expected rather than proof the finding is incorrect. For example the claim that a 1222% increase in the risk of suicide amongst people with 4 or more ACEs meant these people were doomed, in reality means that the odds increase from 1 in 10,000 to 1 in 92, meaning that 91 of every 92 people with 4+ ACEs do not die by suicide.

ACEs are a very useful population screening tool, and have provided incontrovertible evidence of the links between traumatic experiences in childhood and numerous social, psychological and medical outcomes that has been highly informative for those of us designing and delivering services. To me it seems like an example of how a simple piece of research can have a massive impact in the world that benefits hundreds of thousands of people. Yet that blog repeatedly implies ACEs are a harmful methodology that “targets” individuals and to is used to “pathologise and label children, arguing that those kids with the high ACE scores are destined for doom, drugs, prison, illness and early death”. It has been my experience that ACEs are used not to pathologise individuals, but to to highlight increased vulnerability, and to identify where there might be additional need for support. For example, I have used this data to argue for better mental health services for Looked After Children.

I felt that the repeated misrepresentation of the maths involved in interpreting risk multipliers undermined the entire message of the blog, to which I was otherwise sympathetic. (For the record, it is entirely appropriate to highlight bad practice in which it seems certain professionals are applying ACE scores to individuals inappropriately, and making people feel that their life chances are restricted or their parenting under scrutiny purely because of their childhood experiences of trauma). But unfortunately the author took my polite, professional rebuttal of elements of her blog as a personal attack on her – to the extent that she misgendered and blocked me on twitter, and refused to publish my response to her comments about my reply to her on the blog. That’s a shame, as the whole scientific method rests on us publishing our findings and observations, and then learning from the respectful challenge of our ideas by others with knowledge of the topic. But I guess we are all prone to defending opinions that fit with our personal experience, even if they don’t fit with the evidence.

Thinking about how uncomfortable it felt to see someone I considered to be a peer whose expertise I respected misrepresenting the evidence and being unwilling to correct their misconceptions when challenged, but instead trying to discredit or silence those making the challenge, it struck me that this was an example that highlighted a wider issue in the state of the world at the moment. Evidence is being constantly misrepresented all around us. Whether it is the President of the USA saying there is a migrant crisis to justify a wall (or any of the 7644 other false or misleading statements he has made in office) or the claims on the infamous big red bus that Brexit would give the NHS £350 million per week, or Yakult telling us their yoghurt drink is full of “science (not magic)” now that they can’t pretend live cultures are good for digestive health. There are false claims everywhere.

I stumbled into another example just before I started writing this blog, as I (foolishly) booked accommodation again through booking.com, despite the horrible experience I had last time I tried to use them (which remains unresolved despite the assurances from senior managers that they would reimburse all of my costs). The room was terrible*.

So I felt like I should be able to reflect my negative experience in my review. But oh no, Booking.com don’t let you do that. You see, despite seeing that properties appear to have scores out of ten on every page when booking, you can’t score the property out of ten. What you can do is to determine whether you give a smiley that ranges from unhappy to happy for each of their five ratings (which don’t, of course, include quality of sleep or feeling safe). So if you think the location was convenient, the property gets a score above five out of ten, no matter what other qualities mean you would never wish to sleep there again. But worse than that, the Booking.com website forces reviewers to give a minimum length of both positive and negative comments, but only displays the positive comments to potential bookers. So my “It was in a quiet, convenient location” gets shown to clients, but you have to work out how to hover in the section that brings up the review score, then click the score to bring up the averages, then click again to access the full reviews, and then shift them from being ranked by “recommended” to showing them in date order to actually get an objective picture. Then you suddenly see that at least half the guests had terrible experiences there. However, there is no regulator to cover brokers, and fire regulations and legal protections haven’t caught up with private residences being divided up and let out as pseudo-hotel rooms.

But just as Boris has faced no consequences for his bus claims (even though he stretched them further still after the ONS said he had misrepresented the truth), and Trump no consequences for his lies, and the consultants selling contracts worth hundreds of thousands of pounds of public funds to children’s social care departments proudly told me they didn’t care about evidencing their claims, so the world carries on with little more than a tut of disapproval towards people and businesses who intentionally mislead others. Maybe I’m in the minority to even care. But I do care. I feel like it is the responsibility of intelligent people and critical thinkers, people in positions of power, in the professions and particularly in the sciences, to ensure that we are genuinely led by the evidence, even if that makes the picture more complicated, or doesn’t confirm our pre-existing beliefs. To counteract this age of misinformation, we all need to be willing to play our part. That is why I have always placed such a focus on evaluations and research, and have developed my screening tools so slowly and thoroughly, despite the fact that potential customers probably don’t see this as necessary. I believe that as much as possible, we should be promoting the value of evidence, educating the public (including children) to be able to think critically and evaluate the evidence for claims, and stepping up to challenge misleading claims when we see them.

*I booked a room in a property in London which they have euphemistically called “Chancery Hub Rooms” to stay over whilst I delivered some training in Holburn. It wasn’t a hostel or a hotel, but just a small terraced house. This time it had keypad entry to the property and to the individual room, which is a system that I have used successfully several times in Cambridge. Unfortunately it didn’t work so well in London, as they changed the codes twice without informing me. Once this resulted in locking me out of the room on the night of my arrival (and meaning that the beeping on the door as I tried the various codes they sent me woke the lady in the neighbouring room, due to the total lack of sound insulation in the property) and then by locking me out of the property the following evening, when all my stuff was locked inside. It also had glass inserts above the room doors that meant your room lit up like Times Square when anyone turned the landing light on. I then discovered that the building (which I already recognised to be small, overcrowded and not complying with fire regulations) had walls like cardboard, when the couple in the next room had noisy sex, followed by noisy conversation and then a full blown argument that lasted from 3am to 4am – despite me eventually in desperation asking them quite loudly whether they could possibly save it for a time that wasn’t keeping everyone else in the building awake. Of course Booking.com didn’t see it as their problem, and the property management company just blamed the other guests for being inconsiderate.

The elephant in the room: Mental health and children’s social care services

I heard a few months ago that the Housing, Communities and Local Government Select Committee were undertaking an inquiry to look at the funding of local authorities’ children’s services, and thought that sounded like an interesting topic that might relate to my areas of interest. I therefore met with a local MP about the topic, contributed to the BPS response to the inquiry, and (on the request of the committee) submitted my own response in relation to my innovative work with BERRI. I have subsequently been called to give evidence in person to the enquiry in a few weeks time.

Given I’ve been so immersed in this issue it seemed a good topic for a blog. I’m going to start with the evidence that this sector is in crisis, before thinking more about what a clinical psychologist like myself can contribute to addressing elements of this need. Hopefully I can then write another blog in a few weeks time to talk about my experience of giving evidence, and report back about whether the politicians grasp the issues and appear motivated to do something about it.

It didn’t surprise me that this was an issue that the government wished to give more scrutiny, given the steep increase in need in this area over the last decade, whilst funding for local authorities has been substantially reduced by the government’s austerity agenda. Human distress and unmet need rarely seems to gain political attention unless it is in such a crisis that the public are aware of the issues, or it has financial implications for the public purse, and children’s social care has suddenly hit both of those thresholds in the last year or so. 

A number of factors have combined to increase need in children’s services. This includes growing awareness of child abuse and its impact (particularly emotional abuse which has long lagged behind the more tangible forms of abuse), along with reduced stigma in disclosing having been abused (due, for example, to the publicity surrounding the Jimmy Saville scandal, the various institutional abuse enquiries, and the #metoo movement) and a reduced tolerance for forms of abuse that had been normalised or ignored in the past (due to cases like Baby P and the Rotherham child sexual exploitation trials, and subsequent prosecutions in many other areas). A lot of teenagers who had been allowed to remain in unsuitable living circumstances because of the belief that they would “vote with their feet” if removed are now appropriately protected and brought into Care, perhaps because of some precedent setting cases in which people have taken successful legal action against local authorities and have been compensated for failures to protect them in childhood. This includes an enormous legal settlement for two Care leavers from Jersey, who have received tens of millions of pounds compensation.

Children in Care are also entitled to stay in their foster placements up to the age of 21 where they want to and it would be beneficial for them, and to have support after leaving Care from a personal advisor until the age of 25. Another pressure is the reduced use of secure units on welfare grounds, and a reduced willingness to incarcerate children in institutions for recurrent minor offending. The increased stress, shame and social hardship of benefit changes and increases to cost of living has led to move children growing up in poverty, and more families developing the risk factors that can cause harm to children, such as drug or alcohol use, mental health problems, domestic violence and family breakdown. This has had a particularly negative impact in families in lower socioeconomic groups.

It is therefore unsurprising that over the same period of time the demands for social care services have risen steeply. Over the last decade there has been a 9% increase in referrals to social care and numbers of children considered in need, but there has been a 84% rise in child protection cases, and 26% more children are in Care. This creates a lot of additional workload for children’s services, with a 122% increase in demand for section 47 enquiries, and a 125% increase in Care Proceedings (as less children are now informally Accommodated with parental consent). Yet the budgets have shrunk, so there is no resource available to meet this need.

The financial picture is genuinely shocking, and yet it has hardly made the news (perhaps because looking at the numbers is considered too technical or boring for the lay public, and the political and news agenda has been hijacked by the continuing debacle of Brexit). But reviewing the figures makes sobering reading. The cuts to local authorities since 2010 are unprecedented. The National Audit Office highlighted the extent of the shortfall in their report on the financial sustainability of local authorities published last year. They point out that central government spending on social care has halved. This has been masked by changes in how funding is delivered, and some additional funds from council tax being made available to spend locally, but the cuts are still enormous and amount to a real terms reduction of nearly one third of the entire budget for local authorities, but the burden is again being disproportionately felt in more deprived areas.

Such cuts are unrealistic and unsustainable, as they make the total budget too small to cover anything other than statutory services, which are legally protected. This means that councils have no means to make ends meet without dipping into their savings. The report shows that two thirds of local authorities had drawn from their reserves by 2016-17, so there is an ever decreasing amount left in the pot for contingencies, and the audit office predicted that 11% of authorities will empty that pot by the end of this financial year. Councils are having to sell off properties and come up with increasingly radical plans to try to fulfil their minimum duties. Recently Northamptonshire County Council had to declare themselves bankrupt as they had no means to cover statutory services from the available budget.

This mismatch between demand and resourcing has led to enormous cuts to non-statutory services, with two thirds of the spend on preventative and community children’s services disappearing. This means that, as with mental health, there is a minimal set of brief services delivered for milder or less entrenched difficulties, but that there is then an abyss in which no services are available until they reach the threshold for the crisis-focused specialist services – which are expensive and time-consuming to deliver and can’t keep up with demand. The focus has moved from collaborative work to assessments and interventions that are perceived as the end of the line, despite the absence of the precursor interventions that might have enabled change.

To me, the elephant in the room when it comes to children’s social care is mental health need. I don’t just mean the clean single-condition, diagnosable treatable mental health need that gets through the doors to CAMHS. That’s the need up on the sterile concrete plains of mental health research that Prof Miranda Wolpert describes so well. I mean the real messy need down in what Miranda calls the swampy lowlands where real complex people live in varied circumstances, where numerous issues intersect to create barriers in their lives that are not straightforward to address, and do not fall into the simple diagnosis to treatment pathway that currently gets through the doors to CAMHS. That’s the need that determines the outcomes for these children, and the pathway on which they leave Care and try to negotiate adulthood. It is that need which determines whether they can go on to happiness, employment and family life or whether they become one of the Care leavers who end up facing prison, homelessness, mental health problems, addiction, conflict and/or their own children going into Care.

So what are these broader mental health needs? In my experience, a complex and interwoven picture of trauma, adversity, behaviour problems, attachment difficulties, developmental disorders or delay and mental health needs is typical of children in Care or receiving social care services. As well as the traditional “mental health” needs of anxiety and depression I see a much broader picture that is expressed in a variety of ways. Some children act out with their behaviour, others withdraw and show signs of emotional difficulties (including low mood, poor self-esteem, and a lack of positive identity or perception of belonging). They often struggle to form healthy relationships/attachments to others, and can present a risk to themselves and others. They have an increased prevalence of conditions like Learning Disability, Autism, ADHD, or psychosis that add an additional layer of challenge in standard services effectively meeting their needs. That is why my BERRI assessment system attempts to cover all of these areas.

Seen as a group, children who are Looked After have high levels of mental health difficulties (45% have a diagnosable condition, and over two thirds have significant mental health need), so it would be easy to blame the Care system. However, this extraordinary level of need is predominantly caused prior to them coming into Care. It is well established that Adverse Childhood Experiences lead to multiple layers of vulnerability, and these are very prevalent for Looked After Children (my own research suggests an average of 4 historic ACEs per child, along with 2 current vulnerability factors at the point they come into care, such as involvement in gangs, sexual exploitation, school exclusion or the criminal justice system). Looked After Children are in the vast majority traumatised children, who have experienced abuse and/or neglect. But these problems don’t occur in isolation. They are contextually embedded. Children in Care come disproportionately from families that experience the adversities of poverty, crime, family breakdown, and poor housing. They are more likely to be born to parents who have lower education, higher risks of unemployment, and a higher incidence of mental health problems, substance misuse, domestic violence and a history of abuse or neglect in their own childhoods. As a result, their parents are less able to provide safe and stable care. Patterns of difficulty often carry through many generations of the family, and the problems they face are a symptom of our increasing social inequality. 

However, CAMHS are not really set up to meet these complex and interwoven needs, and cut off at 18 years of age, whilst children can stay in care until they are 21 and receive leaving care services until the age of 25. They also have ongoing needs that will need to be revisited over time as they develop or different themes emerge as they enter different life stages or face different challenges. It might be that a dental care model, in which there is long-term oversight but with responsive services as and when they emerge works better than the time-limited episodic care that is currently on offer. Likewise services need to be embedded so that they collaborate with placements and other support services, rather than stand in isolation.

The wider context of the underlying contextual and vulnerability factors mean that treating symptoms or even specific conditions might be an ineffective model of intervention. We need to think back to Maslow’s hierarchy. These children first and foremost need their basic needs met, and to have reliable food, shelter and warmth. They need safety and security, medical care and an environment that doesn’t contain ongoing risks. They need opportunities for identity and belonging, such as education, employment, hobbies, peer relationships, and family. They need intimacy and trust in their friendships, sexual/romantic relationships and relationships with carers. When that is reliably in place they need opportunities for achievement and being valued, so that they can gain self-esteem, confidence, status, responsibility and individuality. The icing on the cake is then self-actualisation, the chance to explore creativity, set goals, reflect on morals and values, and feel purpose and fulfilment. Mental health needs only fit in mid-way up that pyramid. We cannot expect a child to have a positive outlook and good coping strategies and social skills if they are not in a safe environment, don’t have their basic needs met, or cannot trust those around them. To see the point of going along to a therapist takes enough self-esteem to believe you deserve to feel happier, and you then need the organisation and social skills to get there, and the trust to confide your story, or a carer who will advocate for you and help you to achieve these steps. There are many building blocks that need to be put in place by the caregiver and environment before therapeutic interventions are possible, and it may be that when we get these other elements right, the child is able to recover using their own resources and that of their caregivers, without ever seeing a therapist.

My perspective is that if we can help to identify needs of children as early as possible and skill up the caregivers and the systems around the child, we can make the most impact. That is why I have increasingly moved from working with individual children to working with their caregivers and the systems that surround them, and have developed the BERRI system to identify needs and help carers understand them, as well as developing and delivering training to help carers and professionals understand the needs of the children and young people better. It doesn’t have the depth of working psychologically with a single individual, but it has the scope to make impact on a much wider scale, and it fits better with my personal strengths and interests. As I’ve said before, I’m not the most patient therapist to walk a long journey of recovery or personal development with a client, but I do have strengths with assessment and evidence-based practice.

My aims have always been to address human needs. I believe that Clinical Psychology in its simplest form is an attempt to make people happier and more able to lead fulfilling lives, and that is what drew me to this profession. And within that broader mission, my focus is to work with the most vulnerable members of society at the earliest possible point in the lifecycle, which has brought me to working with Looked After Children and the broader population of children and families receiving (or in need of) social care services. Recognising the mismatch between the level of need and the resources available to meet that need has increasingly led me to focus on systemic and population level interventions. Rather than drowning in the burnout that comes with trying to solve an overwhelming problem, I’ve tried to find a niche where my skills can make an impact. Having looked at this population group from multiple perspectives, and tested out projects in various settings, I have become increasingly persuaded that there is scope to make positive changes through the use of better systems to identify need, and increased clinical governance over the choice of placements and interventions. 

I have tried to develop practical, cost-effective ways to make a difference, and to gather evidence of their efficacy. I have then tried to share my findings, and what is already known from research, with the widest and most influential possible audience. That is why I have given so much of my time over to writing best practice papers and contributing to policy. Through these experiences I have gradually learnt to shape the messages I share to make them relevant and understandable to various audiences. After all, whilst most of psychology seems common sense to those of us working in the profession, once you have learnt about the main findings and the methodologies for gathering knowledge, to lay people (and professionals, commissioners and politicians) it might seem very complex and unfamiliar. Over time I have learnt that being able to articulate the financial benefits of improving people’s lives helps to get decision makers on board. So my goal in responding to the enquiry was to explain both the human and financial case for greater psychological input for children receiving social care services. I don’t know how well I have achieved that, but I’d be interested in your thoughts and feedback.

Drama vultures: Some comments on social media

For young people, social media can be a very significant part of their social life. As Mark Brown put it, “Social media went big at the same point that austerity did. We lost our libraries, youth clubs and schools funding but we got smartphones and snapchat instead.” It has also been a means of connection for people who were technologically savvy but socially isolated. This is a surprisingly broad group, including both “geeks” (with subgroups of angry young men who have been radicalised by anti-feminism and the alt-right), those with social communication deficits (who like entirely written communication, as it means that they no longer feel excluded by the pace and non-verbal elements of real life social interactions) and people who are socially isolated because of their geography, disabilities, sexuality, gender identity, culture or more introverted personality, as well as an increasingly broad demographic who have simply discovered the convenience of social media as a means to connect with likeminded others. It can be enticing as a way to gain some social validation, either through “likes” of your content or photographs, or through a sense of belonging to a community of people with shared values or interests. And with so many different platforms, there can be many different qualities to this interaction, and functions that social media serves in people’s lives.

With niche communities, pockets of self-referencing and self-reinforcing cultural norms appear. Whether it is the sensitive niche sexualities of tumblr, or the offensive-as-possible culture on 4chan, the visual memes of imgur, the glamorous selfies of instagram, the endless stream of headlines from twitter, the business focus of linkedin, the many facets of reddit, videos on youtube, livestreaming on twitch or periscope, various blog platforms, an almost endless variety of podcasts, massive web forums on every topic imaginable, or even the comments sections of various publications, each has a different personality and norms. Some are ephemeral, with content disappearing after a certain time. Others stand as searchable archive with a long-term record of past content. Some allow people to broadcast outwards and collect followers, whilst others are focused on more reciprocal relationships. Some allow privacy restrictions that mean you can limit access to friends and family. But most have some means for others to indicate their approval or disapproval. And that means that there can be a sense of being judged or rewarded according to what you post. Sometimes this is based on the quality of the content, but it can also be based on political/group affiliation or appearance – with attractive young women who post photographs or video in particular getting a lot of attention. Some sites allow interesting or amusing content to float to the top where more people will see it, allowing particular posts to be read by remarkably large numbers of people. These can include inspiring content like non-zero days or unintentionally hilarious content like the penis dunking thread on mumsnet (mildly NSFW) that had me failing to contain my laughter during a BPS committee meeting. Some people seek out notoriety by writing controversial or entertaining content. Others who feel they don’t get enough positive attention seek out more negative peer groups, or seek attention in less functional ways. There are also less healthy pockets of social interaction on the internet. There are pro-anorexia communities, and sites that discuss and even encourage self-harm and suicide. There are bullies and trolls, and even people who fake being bullied in order to seek sympathy or justify introspective disclosures*.

One of the great advantages, and problems, with social media is the potential to be anonymous. This is a great leveller because it makes other users blind to your gender, age, race, appearance, physical ability/disability, sexuality, wealth, social class or other sources of prejudice – although many people choose to display these characteristics anyway and seek out similar people for a sense of belonging within specific online communities. However, the very anonymity and ability to create a character for yourself online can be problematic, as anybody can pretend to be anything. As well as the proverbial middle-aged lorry driver pretending to be a teenage girl, there are people pretending to be of different social demographics to infiltrate or undermine these communities. For example, many alt-right trolls attempting to fuel the gamergate conflict signed up “sock puppet” accounts as women and people of colour to pretend that their movement was more diverse or to defend them from criticism for sexism and racism. More obviously there are trolls, who use the anonymity to bully, harass and try to get a rise out of others, safe in the knowledge that social media is functionally a lawless zone, where only the very most serious of attackers, who challenge national security or make repeated overt threats towards targets in the public eye ever see any attempt at identification or prosecution.

By contrast, if you slip up on social media and say something stupid or embarrassing it can be shared with hundreds of thousands of people, your identity can be outed, and the impact can spill out into your real life in unpredictable ways leading to a roulette of inequality in which an ill-judged racist or sexist joke having more consequences than a year-long campaign of rape and death threats.  Or, you can become a target whose personal details are released on the internet (known as doxxing) by someone who dislikes your opinion or feels slighted by you, or subject to “revenge porn” where intimate photographs are published by an ex-partner without the consent of the subject. In America you can even become the target of hoax calls intending to send in an armed response team (known as swatting). And (as in many things) it is women and people of colour who always end up being disproportionately punished.

Having been on the internet since the 1990s, I’ve had an interesting personal history on social media. I was part of the eBay forums around the launch of eBay.co.uk for several years. As well as giving advice about scams and using eBay to buy and sell, there were lively off-topic discussion, running jokes and fundraising activities. But even within a seemingly diverse and healthy community of strangers there were many interesting signs of dysfunction. There were cliques and factions with marked animosity between them. There were people who claimed to be things they were not, including a “detective” and a “vet” (who was so desperate to uphold the facade she tried to get the Royal College of Veterinary Surgeons to amend a register entry for a genuine vet to match her name). There was a lady who faked her own death and posted as her (supposedly bereaved) husband, but was rumbled by an astute poster spotting contradictions in her story. When I foolishly mentioned being a psychologist in a conversation that only contained four other active users, that information spread much more widely than I had expected. I started to receive disclosures and allegations, messages about distressing feelings and even what appeared to be a suicide note (with the help of moderators I alerted authorities, and the suicide was not completed) so I soon learnt to be much more private and anonymous.

On clinpsy we have also had our fair share of tea-cup sized dramas, despite having very little need to intervene as moderators compared to the large volume of members and posts. I blogged about some examples two years ago, and I can only think of two people we have banned since then (although I did block someone from registering after they were very antagonistic and inappropriate on facebook after we failed to activate their registration between 10pm one night and 4am the following morning). I did recently have the interesting experience of having someone apply to work for me who had been banned from the forum. They didn’t seem to think I’d know about that, despite the fact that they used the same email address in their application as they had when they had been banned. They withdrew their application when I said that I knew and we’d need to have a conversation about it if they wished to progress their application.

It is an interesting thing that social media crosses the boundaries of communication that we are familiar with. The written form seems somehow impersonal and emotionless compared to forms of communication that contain the non-verbals, and yet somehow emotions are conveyed and evoked. The nature of speaking to strangers who may or may not be conveying the truth, and where we know little about them except for what is posted, involves a lot of extrapolation and ambiguity. It is hard to judge the response of the audience or how far information will spread, and deceptive safe feeling that we are posting in our own homes and usually under pseudonyms, yet it can suddenly become very personal and intrusive. On the clinpsy forum we monitor usage quite closely, and have zero tolerance of personal abuse or inappropriate content. In order to avoid knee-jerk responses or being hooked into unhelpful patterns, and to help us keep on top of maintenance and development tasks on the clinpsy forum, we work as a team. We keep a log of moderator discussions, user reports of concerns and reasons for banning users in a hidden moderators area on the forum. We tend to have quite a rapid response time for removing content for moderator consideration, and quite consistent views about where to draw the line, which has made clinpsy relatively drama free.

That isn’t the case on other forums, where much more banter and jokes are let fly, and these can be quite offensive, particularly if the dominant demographic is young white men. Racism, sexism and misogyny are quite prevalent in some online communities. Many women hide their gender to avoid quips about getting back in the kitchen, or banter about rape (which can be a term used in video gaming communities to refer to trouncing another player). But in some places it can even go a step further than that. 4chan, for example, used to ask for topless photos if anyone mentioned being female with the delightful phrasing “tits or GTFO”, and provoked many young women (at least one of whom appeared to be below the age of consent) to share sexually explicit images of themselves. 4chan also had links to child pornography (although I believe that this was eventually prohibited and split off onto another forum). Reddit has subreddits for misogynist men’s rights activists, pick-up artists, and incels (men who consider themselves to be involuntarily celibate – that is, they are too unpleasant to attract consenting female partners but do not recognise this, and turn the blame onto the women instead, with extreme examples like Elliot Rogers and the man behind the recent Toronto van attack), although again some attempts at prohibition and moderation are creeping in after bad publicity following the recent school shooting.

As a female poster in some male-dominated communities it was initially quite a culture-shock, but it is good to socialise outside the same narrow bubble, and there are also very positive aspects of being part of an online community. There is a hive mind of information on every topic that means you can gain immediate and often highly skilled advice on everything from how to rewire a light fitting, or how to distinguish a wasp from a mortar bee, to which model of television has the best features within a certain price bracket, or how to complain if a parcel doesn’t arrive. The community might be a rapid source of news, or entertaining new memes. There can be reviews of films, music, events or games that lead you to try new things, and erudite discussion about politics, current affairs, history, different cultures, religion, sports, science, religion, mental health, relationships and any topic that takes your interest. There can also be mutual concern and support when things are not going well, and shared delight when people experience unexpected success. So there are definite positives. The problem is that they can come at a price, and some people are more likely to pay the price than others.

Anyone who has been part of an online community knows about how they seem to inevitably create remarkable interpersonal dramas. These are like road traffic accidents – as a neutral spectator they both repulse you and make compulsive viewing, but as a participant they have the ability to cause genuine harm. When a person starts posting erratically or there is public conflict, or even when a person or group is bullying a vulnerable member if they do so in a way that is seem as amusing, it is viewed as entertainment or public spectacle. And, like a fight in a school playground, they inevitably attract a circle of spectators who both encourage and influence the unfolding drama, both joining in to sub-conflicts in the audience, and throwing in more fuel if it seems to be petering out. I’ve been in that circle a few times for different reasons, and it isn’t a fun experience. And as it starts feeling more personal and more antagonistic emotions start showing in how you post, and that seems to fuel the aggressor to go in for the kill, and other posters to join in. Our ability to reason and to predict the way that others will interpret and react to our posts reduces, and the stakes start to feel higher, and yet it somehow becomes harder to leave the conversation whilst feeling threatened or misunderstood. So you get drawn in to the battle, trying to clarify your intended meaning, defend yourself from perceived attack, or persuade others to see your point of view. Perhaps you criticise the other person, who then becomes more antagonistic or defensive. By the time you are in the thick of things there isn’t an obvious exit without either victory or shame.

Walking away from an online community because you don’t like how you are treated feels a lot like social exclusion and can have a significant impact on your sense of self, but to stay once you have attracted negative attention can mean the slow attrition of insults and snide digs that someone once described as “death by a thousand paper cuts” (a less severe/more protracted version of the Chinese torture method death by a thousand cuts, in which it is hard to criticise any individual action as being unduly aggressive or breaking any rules). Frustratingly these can often be the kind of microaggressions that align with real life experiences reflecting the casual degradation of disempowered/minority groups. And, as ever, women and minority groups seem to be disproportionately the target for them. Even a phrase like “calm down love” is loaded with patronising layers of meaning about women being ruled by their emotions and lacking the calm logical analysis of men. It implies that caring about anything enough to show some emotion about it is already losing the battle.

There is little time for compassion or reflection online, and it is hard for an onlooker to intervene in a way that is helpful to diffuse conflict. Thus vulnerable people may end up re-victimised, and people with dysfunctional ways of relating often play these out over and over online. I can particularly recall one poster who had a distinct cycle of debate, feeling criticised, rage and then burning out to a final phase of being shamed and apologetic, trying to make amends to avoid rejection – and the community becoming increasingly intolerant of these emotional extremes. At times it felt like observing a digital version of a disorganised attachment relationship, with the forum community functioning as the inconsistent/abusive parent. It came as no surprise to read disclosures about an abusive childhood, use of crisis mental health services and a personality disorder diagnosis. But s/he was far from alone in having dysfunctional ways of relating to others online. In fact it seems that many people with such difficulties are strongly attracted to the accessibility and 24 hour nature of online communication, and can find significant support from strangers there. But it often comes at a high cost, or with significant risk, because of the prevalence of trolls and the way dramas are amplified by having an audience, and the way social media can serve as a written record of whatever unfolds that is hard to erase. There might be the right to be forgotten under GDPR, but how does this actually work in practise when comments are quoted and replied to, or captured in screenshots and posted elsewhere?

There are plenty of examples of how vulnerable people are enticed by the sense of belonging in a group, or the superficial success of social media influencers, but harmed by the messages they are given. This can range from unhealthy roles models such as the one I blogged about previously to being encouraged to harm others or given advice on how to harm themselves or commit suicide (the Daily Mail recently ran a scare piece on a “Blue Whale” game that culminates in telling children to commit suicide, though snopes felt there was little evidence to substantiate this). It would seem to me that the bigger concern is the indoctrination of larger numbers of young, socially isolated people in toxic beliefs such as alt-right ideologies, through writing that blames others for their ills. Whether it is “psychologist” Jordan B Peterson whose 12 rules for life serve as an introduction to his regressive beliefs including “enforced monogamy” in which he appears to advocate that to prevent male violence women should be allocated to partners and forced to remain monogamous to them (which is rightly being called out as sexist/stupid/victim blaming). It might have sold 1.1 million copies, and he might make £80k/month in patronage, but this isn’t a new enlightenment. Enticing simplistic sexist answers are not the cure for angry young men who feel left behind by progress, I would argue they are the very fuel that will convert them into the school shooters, rapists and perpetrators of future violence and harassment. But it is hard to offer up an alternative perspective or contradictory evidence when an angry mob descends on any divergent opinion, claiming that they are the true victims and that the sexist/racist drivel they promote is being censored by sensitive snowflakes (the new version of “its political correctness gone mad”). Ironically, these repugnant views that are allegedly suppressed/unspeakable are getting lots of airtime, whilst stifling free expression of opposing/alternative views** as progressive voices fear becoming a target of the mob.

In short, its a messy and unregulated space, and there are both interpersonal conflicts and large scale culture wars playing out in it. How to protect people in a digital age needs a lot more thought, both at the level of educating children about critical thinking and empathy, and in terms of regulation of social media, and enforcement of crimes committed via digital media. But with middle aged and older politicians doing the legislating it is hard to see how that is going to happen.

*if you find this surprising, consider the bug chasing community, who are people actively seeking HIV infection in order to gain care, sympathy and a sense of belonging
**including me, as I avoid using certain terms on social media or in the tags and category labels for this blog, as I dislike the surge of abusive/antifeminist responses they trigger

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

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

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

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

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

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

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

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

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

Sticking plasters

I realise that this title won’t mean much to Americans or people outside the UK, so let me share a small anecdote by way of explanation before I get into the topic I want to discuss. I was on an American airlines flight back from New York in 2003, having done a lot of walking around the city over the preceding week. When I removed my shoes and straightened my socks it transpired that a burst blister had adhered to my sock, and it started to bleed surprisingly profusely. I asked a member of cabin crew for a sticking plaster, and got entirely blank looks in response. When I explained the situation, a steward showed a sudden look of recognition and sighed “oh, a Band Aid! I keep one of those in my wallet for my kids” and provided what I needed. So yes, a sticking plaster is a Band Aid – an adherent protective dressing for a small wound.

I found it quite an insight into American marketing, as I had also tried to buy antihistamine cream in a drug store to utterly blank looks, until someone realised I wanted “Benadryl”. I had also seen the TV advertising persuading people they had adult ADHD (with a symptom list that seemed to encourage false positives, and a link to a small quiz online that seemed to classify almost anyone as having ADHD), or that they needed Viagra (with the almost comical warnings that “erections lasting more than two hours can be dangerous and require medical attention”). Disease mongering is a pretty interesting phenomenon, and well worth reading about – Did you know that the vast majority of viagra prescriptions are “off label” and written for groups in which there is no evidence of efficacy (including women, when there is not a single study showing evidence of efficacy in this population)? And that the pharmaceutical companies are trying to medicalise “Female Sexual Dysfunction” to create mass markets to address lack of desire or lack of pleasure, with minimal consideration of the context or wider issues, because of the success of such marketing with men? Or that “restless legs” has been marketed to the public as a common condition requiring medication? It made me quite glad for our generics, and lack of medication marketing targeting the public.

But the reason I wanted to talk about sticking plasters is that they are a response after the event. A means of short-term management, and covering up of an injury, rather than preventing it. Like my blisters adhering to my sock, there were many stages at which that bleeding could have been prevented – by covering the blister earlier, or better still by taking the subway more and/or wearing more sensible shoes to explore New York. The problem is that if we become overwhelmed by demand for the reactive response, we lose the capacity to look at what underlies the demand. And if we spend too much time reacting to distress in health services, it can mean that we fail to do the preventative work that would reduce the need for such services. With austerity politics ensuring that the health and social care sector are too underfunded to be proactive, I think that is where the NHS is heading, along with most of the public sector.

Every single day I seem to read about travesties of social justice, and the lack of thought about the people that bear the brunt of them. Time and time again the most vulnerable members of society are being abused and neglected at a national and global scale. Whether it is the man who has paid UK taxes for 40 years who is being denied essential cancer treatment because he doesn’t have a British passport (due to a paperwork oversight when he arrived as a child with his parents from the Caribbean 44 years ago), or the deportation of a humanitarian/academic couple who are being told to leave because they went abroad for too many days – to complete a government study. Or how about the person that tweeted about having waited for over a year for support after a sexual assault, with rape crisis waiting lists closed for most of London for more than a year due to the scale at which demand exceeds supply?

Perhaps we should look at the rapid rise in mortality in the UK so far this year, falling life expectancy (especially in lower socioeconomic groups) or the rise in deaths amongst mental health patients – despite the falls in smoking and improved outcomes in many health treatments. A man/woman in an impoverished estate in the north of England can now expect to enjoy 32/35 fewer years of life in good health, compared with a counterpart in a wealthy suburb in London or the Home Counties. Or perhaps we can look at the impact of cuts to NHS funding (albeit masked by fake claims of record wage rises) record waits for A&E, the cancellations of operations, and the burnout of NHS staff.

Or look at the increase in homelessness over the last few years (it went up 16% in 2016 alone, with almost 50 000 families living in bed and breakfast accommodation and many more “hidden homeless” living on floors and sofas of friends and acquaintances) with the knowledge that being homeless can worse than halve your remaining life expectancy (homeless women die on average at 43 and homeless men at 47, compared with 77 for the rest of us). As the author of the BMJ article puts it “Homelessness is not an episodic event, but something systemic. It is a neon sign that something is fundamentally wrong with policy across health and housing”. This lack of provision doesn’t even save money as the cost to the NHS of society’s failure to deal with homelessness and other examples of inequality has been estimated at £4.8bn (€5.4bn; $6.7bn) annually.

These same austerity policies have a wider impact on mental health. Psychologists for Social Change have identified five ways austerity policies impact on mental health: 1. Humiliation and shame 2. Fear and distrust 3. Instability and insecurity 4. Isolation and loneliness 5. Being trapped and powerless. They remind us that “These experiences have been shown to increase mental health problems. Prolonged humiliation following a severe loss trebles the chance of being diagnosed with clinical depression. Job insecurity is as damaging for mental health as unemployment. Feeling trapped over the long term nearly trebles the chances of being diagnosed with anxiety and depression. Low levels of trust increase the chance of being diagnosed with depression by nearly 50 per cent”.

So we can’t see mental health in isolation. Whether it is the individual context (for example in the power threat meaning framework I discussed in a prior blog) or in the wider sociopolitical context, we are not brains in a jar, but socially connected beings with experiences that impact on our wellbeing. When we talk about the shortfall in mental health services, too often we are saying that in the context of demand for services exceeding supply, and feeling strongly pulled as psychologists to provide more of the same. That makes sense in at the coal face, where it is hard to have the energy, time or resilience to look at the wider picture beyond the demands hammering on our own door. However, it means that we are discussing the lack of sufficient reactive responses to a problem that could have been dealt with more effectively further up the timeline with proper proactive and early intervention work, and in a lot of cases could have even been prevented with better social policy and provision for vulnerable population groups.

Of course, doing preventative or early intervention work also takes resources, and we can’t take them away from the people currently in need/distress now. But instead of us constantly asking for a little bit more of the same to deaf ears who reply with excuses about finite pots and efficiency savings (and sarcasm about magic money trees), maybe we need to think more creatively about intervening at different levels and in different ways to the set up of existing services. I’d rather be providing sign-posts to avoid hazards than doling out sticking plasters when people trip over them – and best of all I’d rather be fixing the hazards, and helping vulnerable people identify routes that are less risky.

I’ll give Psychologists for Social Change the last word: “Mental health isn’t just an individual issue. To create resilience and promote wellbeing, we need to look at the entirety of the social and economic conditions in which people live”.

Well-being check-ups

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

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

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

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

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

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

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

 

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

My opinions about representing Clinical Psychology and the future of the British Psychological Society

I’ve probably been a member of the BPS for 20 years now, and with it the Division of Clinical Psychology and the Faculty for Children, Young People and their Families, and within that the network for Clinical Psychologists working with Looked After and Adopted Children (CPLAAC). I’ve been to the annual Faculty conference every year since I qualified, except for the one early in my maternity leave. I read some of the publications and I follow some of the social media. Over the last decade, I’ve done a long stint on the Faculty committee, and I’ve spent 5 years as chair of the CPLAAC network. I’ve responded to policy documents, represented them on committees, written papers and edited a periodical. So you’d think with all the energy and time I have put in that I am a great fan of the organisation.

Unfortunately, whilst I am hugely admiring of many of the individuals involved with the DCP and Faculty, and some of the recent Presidents of the Society, I’m pretty ambivalent about it as a whole. I think their website and social media suck. I spent ages looking at how to help them with that through the faculty, only to find out the scope for change was minimal and was within their user-unfriendly structure. Most of it was hard to navigate, and key documents were hard to find, the documents and information on the site were often out of date and much of the content was hidden behind walls for members and separated into silos by the Society structure that were impenetrable by topic. I was censored and then locked out of the BPS twitter account whilst live tweeting talks from a conference on behalf of the faculty because I quoted a speaker who was critical of the BPS’s communication with the media and public.

My experience of running clinpsy.org.uk is that we make everything accessible, searchable and google indexed (apart from the qualified peer consultation forum that is a closed group, and the archive of livechats and other member content that can only be seen when logged in). We are also able to respond to things immediately, and often talk about current affairs. So it is quite a contrast. The view of the BPS on the forum is fairly negative, despite myself and several other qualified members trying to put the advantages of having a professional body.

One theme comes up across both spaces – that lots of people like to moan, but very few are prepared to take the actions that help to change things for the better. So, when a document is put out to consultation, or members are canvassed for views by BPS Divisions or Faculties it may be that no clinical psychologists respond at all, or perhaps just one or two nominated by the committee, someone with a vested interest, or the same old voices who feel a greater sense of responsibility for the group. I’m sure the same would be true on the forum, as lots of people like to read the content, some like to ask questions but few actually write up content for the wiki, or help with the maintenance tasks like checking and updating links. However, people pay quite a lot for their BPS memberships, whilst the forum is entirely free and run by volunteers, so it is perhaps fair to have different expectations of service. The difficulty being that the BPS expect the few members who do contribute to do so for free, in their own time, over and over again. I worked out that one eighth of my working time as a self-employed person was being spent on unpaid committee and policy work, and I don’t think that this was unusual. Certainly the chairs of networks and faculties give up a large amount of their own time, and although higher up the tree some days are paid, these are not paid sufficiently to reflect the amount of time that is spent on the job.

So when the DCP sent me a link to a survey recently, I had to reflect my views and tell them that I don’t think that the BPS works for clinical psychologists in the UK, and this is predominantly because of the nature of the larger organisation.

I have witnessed time and time again that clinical psychologists, including those on faculty committees and in the DCP committees, are inhibited rather than facilitated in responding to topical issues, speaking to the media, expressing opinions or taking action by the slow, conservative and censorial wider organisation of the BPS. Even sending representatives to sit on government fora, guidance or policy making organisations involves an overly bureaucratic process of formal invitations and nominations that often means the window has closed to have our voice heard. Likewise the process for agreeing documents for publication is onerous and slow and means months of delay. The Royal Colleges and bodies for other health professions make responses to news items in a timely way, but we don’t. We are constantly told not to be political by expressing any opinion, when, as I understand them, the charity rules are not to be party political rather than not to express opinions that affect political policy at all. I would argue that our role as powerful professionals, effective clinicians, supporters for our clients and compassionate human beings requires that we are political in the wider sense, because we should be advocating for the psychological wellbeing of the population and putting the case for provision of adequate mental health services. I would consider that this includes an obligation to argue against policies that cause hardship and emotional distress, and to put forward a psychological understanding of events and individuals in the news.

Whilst there are great people involved in the committees and a lot of good will and energy, the BPS itself makes contributors impotent. It inhibits rather than amplifies the messages we should be sending outwards and it fails also to represent us as a professional group. It is not effective at representing our interests in government policy, national or regional workforce issues, professional negotiations, disputes about funding or other professional matters.

The structure of the BPS also drowns out the fact that the majority of practitioner members are clinical psychologists by giving equal weight to tiny factions and much too much weight to academics and students – the focus on the latter two groups means that the BPS failed to address issues of regulation properly and has left us with a legacy of problems with the remit and standards of the HCPC (including who is included and excluded in the scope of regulation and the criteria for equivalence of international psychologists, which I will no doubt blog about another time). In these areas it has not only failed to promote the profession, but also to protect the public.

Unlike other professional bodies, the BPS does not offer much by way of professional advice and representation for its members (eg about workforce and pay issues, disputes with employers). It doesn’t act like a union to defend individual members or the interests of the profession, or provide us with insurance or collective bargaining. It doesn’t show our value to the public or those in power through media statements, responses to news and current events and policies, representation on government and policy bodies. It is ineffective in building the status and public awareness of the profession. I believe our professional body should constantly articulate the need for proper mental health services and highlight the useful role the profession can play in meeting those needs. Likewise it should constantly express opinions about government policy and other issues that may be harmful to the psychological health of the population, and highlight what we think would help and the role we as a profession can play in systemic changes and in planning strategies at the population level that prevent or reduce distress.

So I think radical change is needed. If that isn’t possible as a program of reform from within, and Jamie Hacker Hughes’ Presidency suggests it wasn’t, then we need to split the DCP away from the BPS and/or build something new that is fit for purpose.

If you also have an opinion about the BPS and/or DCP, whether or not you are a member, please answer their survey here. Feel free to cut and paste any part of this blog into your response if you wish to do so. Likewise feel free to share a link to this page, and if you are an aspiring or practising clinical psychologist you are welcome to join in the discussion about the BPS on the clinpsy forum.