taking about psychology

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of it was hard to navigate, and key documents were hard to find, the documents and information on the site were often out of date and much of the content was hidden behind walls for members and separated into silos by the Society structure that were impenetrable by topic.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.

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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.

Gaining Influence

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

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

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

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

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

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

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

 

 

Talking about depression and seeking help

Someone I know emailed me this week, saying he was feeling depressed. He was very self-critical about it because objectively his life was the best it had ever been (after a lot of difficult experiences in his childhood and early adult life he is now employed, in a relationship, with a nice home) and therefore it felt ungrateful to complain about anything (like social anxiety, work stress, sleep disturbance, niggles in the relationship, having to care for a dependent parent) as he should be happy. He felt perpetually exhausted and like therapy and medication was for people with ‘real problems’ and talked about wishing he didn’t exist. This was my answer:

There is no ‘should’ with feelings. They just are what they are. We can learn to challenge our thoughts or change our behaviours, which can have a positive knock on effect, but feelings we have little control over. So just be mindful of them, and try to deal with the stuff that underlies them when you are feeling well-resourced and supported.

I read a rather naff explanation on facebook today, but it has a germ of wisdom in it:

I held up an orange and asked a boy in the audience “If I were to squeeze this orange as hard as I could, what would come out?”

He looked at me like I was a little crazy and said, “Juice, of course.”

“Do you think apple juice could come out of it?”

“No!” he laughed.

“What about grapefruit juice?”

“No!”

“What would come out of it?”

“Orange juice, of course.”

“Why? Why when you squeeze an orange does orange juice come out?”

He may have been getting a little exasperated with me at this point.

“Well, it’s an orange and that’s what’s inside.”

I nodded. “Let’s assume that this orange isn’t an orange, but it’s you. And someone squeezes you, puts pressure on you, says something you don’t like, offends you. And out of you comes anger, hatred, bitterness, fear. Why? The answer, as our young friend has told us, is because that’s what’s inside.”

It’s one of the great lessons of life. What comes out when life squeezes you? When someone hurts or offends you? If anger, pain and fear come out of you, it’s because that’s what’s inside. It doesn’t matter who does the squeezing—your mother, your brother, your children, your boss, the government. If someone says something about you that you don’t like, what comes out of you is what’s inside. And what’s inside is up to you, it’s your choice.

When someone puts the pressure on you and out of you comes anything other than love, it’s because that’s what you’ve allowed to be inside. Once you take away all those negative things you don’t want in your life and replace them with love, you’ll find yourself living a highly functioning life.

Now, I’m not totally on board with filling yourself exclusively with love and light (because I think negative feelings are pretty normal and have their value too), and I’m not sure that anyone can ever respond only positively to life’s pressures, but he is right with one thing – your response under stress reflects what you have learnt and experienced in your life up to that point. If you are filled with the poison of being bullied at school or denigrated by your parents, with the wounds of failed relationships, with traumas and losses, then that becomes your norm. It will tarnish your view of yourself, the world and others, and it has the potential to leak out in unhelpful ways. When you carry that baggage and aren’t buoyed up by positive experiences and relationships it becomes much harder to be resilient to the day to day stressors of life. It becomes harder to feel you deserve a better life and to seek out positive experiences for yourself, and you can instead end up avoiding or sabotaging them.

Therapy is there to help you recognise that skew, and to separate the result of negative experiences from your innate worth as an individual. It can help you to challenge your thinking, to change your behaviour, to give yourself opportunities to test and refine your beliefs about yourself, the world and others. It can help you reflect on the patterns in your relationships, why you keep replaying the ones that are not helpful and how you can begin to change this. And sometimes when you are feeling so hopeless and worn out that even the idea of therapy is too much to manage, medication can help to give you the energy and optimism back to allow change to be possible.

The biggest problem of depression is that people can see it compassionately in others, but we are very critical of ourselves for feeling that way, and unable to recognise that the stuckness and self criticism is part of the depression and – importantly – eminently treatable. If you read back your email to me and imagine someone else made it, I think you’d be a lot more compassionate to that person than you are being to yourself. The problem is that you are trying to measure the objective situation with a subjective (and in fact distorted) tool – yourself. And that distortion increases when you are depressed. So be kind to yourself, and allow others to help you. You don’t have to be stuck with feeling sad just because you can’t pin a reason for it on something specific or because there are other people who have bigger problems in their lives.

You said that you sometimes wish you didn’t exist, but I am very glad you do, and I am sure that there are lots of other people who value you and would miss you if you weren’t around. When you are depressed it is hard (if not impossible) to imagine that life can get better. But it can get better. Not only that, but it does get better for most people with depression. Most people who are depressed or even suicidal go on to happier times and to be glad they didn’t act on those thoughts. So please, seek help and don’t give up. Call the Samaritans if you feel like you might harm yourself, and speak to your GP about medication and/or a referral for psychological therapy. After all, 90% of people who turn up to therapy start to feel better, and you can too.

A shallow look at fat

In her usual abrasive style, Katie Hopkins’ latest click-bait project is ‘to fat and back’ – she is putting on 3.5 stone in weight and will then lose it again, to show us how easy weight loss is and how there is no excuse for being fat. Some journalists appear to think there is something in it whilst others are a little more sceptical.

To me it seems obesity isn’t a simple matter of will power. You can’t will yourself thin any more than you can will yourself out of depression or addiction. The evidence shows diets don’t work, and once obese it is very hard to revert to lower weights again and sustain it. It is much better to aim for a healthier diet and lifestyle than a smaller body. And despite widespread understanding that fatness is associated with poor health outcomes, it is very hard to change, and often reinforced by stigma and shame. Your ability to change the pattern will depend on how long it has been around, your biology and what caused it to start in the first place, as well as your commitment to change, support network and what else is going on in your life. In Clinical Psychology we look at the biological, psychological and social contributors to particular behaviours or symptoms and make a formulation of how these interplay, so it is frustrating when people with no expertise pronounce easy solutions which ignore these factors.

If a thin person with very negative ideas about obesity puts on weight for three months, they will find it unpleasant, find losing weight rewarding, and have all the previous factors that made them thin before to revert to. If she is being filmed and paid then she has financial and performance pressures to succeed also, her reputation and career to maintain, as well as a wardrobe to return to. She has the metabolism, muscle tone, neurochemistry and lifestyle of a slimmer person. Will three months change that? She has people around her who expect her to be active and slim, and will support her returning to that familiar mould. And when losing weight she has the money for personal trainers, gym memberships and healthy food (if not diet systems and products) and the sense of herself as a thin person who is capable of exercise.

It’s a million miles away from being a chronically obese person and trying to lose the same amount of weight. To pretend this is a serious experiment that will tell us something about how to lose weight is playing at a serious issue. It reminds me of Pulp’s Common People.

A real obese person has a lifetime of thoughts and feelings about their body, and the perceptions others have of them. They carry internalised shame and self-criticism that associates fat with laziness, gluttony, lack of willpower, and lack of self-respect. They probably avoid eating in public, or showing their body shape. They might not feel comfortable going to places where attention is drawn to their size, or they would stand out compared to thinner, fitter people – like gyms, swimming pools, or exercise classes (because statistically the people who you see there most are the fittest people, and not other new starters or people who find it hard, because these attend less and are more likely to drop out over time, whilst health/success is self-sustaining).

And the weight may have many origin stories that are tied in to uncomfortable issues they wish to avoid thinking about or haven’t yet resolved. They may have put on weight after a trauma or loss, during a pregnancy, or to insulate themselves from the world, or because food is the only pleasure in their life. They might comfort eat because feeding is tied in to their experiences of nurture. The origins of the ACEs study show that morbid obesity is associated with severe early trauma, with 55% of patients in a bariatric surgery clinic disclosing childhood sexual abuse (usually incest). It can be a form of slow suicide, or a daily process of numbing out the pain and yet unwittingly reinforcing the body shame that they experience.

Or it can have less extreme causes. The individual might be ignorant about healthy eating, or have other lifestyle constraints that make healthy eating harder, like poverty or chronic sleep deprivation, or a family/peer group that consume huge amounts of calories (whether the 20 pint weekend, the endless cake in the office, massive portions or regular takeaways being delivered). They might have health conditions or disabilities that make exercise or even activity difficult. They may have developed psychological and neurochemical reward pathways for their eating pattern. They may feel shamed by the societal pressures to conform to what is considered attractive in the airbrushed models on glossy magazines and find thinking about losing weight a painful and ever-present topic (see this paper by Ratcliffe and Ellison last year). On the other hand, they may be ambivalent about weight loss. Their partners, parents, friends or kids may be used to their shape and habits, or even like it. They may have had many experiences of previous attempts at weight-loss that have been unsuccessful or were quickly regained. Change in many circumstances is really hard to make, and harder to sustain.

Every obesity story is different. I know people who feel they need to be heavier than a past abuser or dominating partner, so they can’t be pushed around again. I know people who want a layer of protection against a dangerous world. I know people who want fat deeper than a knife blade is long, in case they are attacked again. I know people who want to deter any sexual attention. I know people too anxious to leave their house to shop or exercise, or too poor to afford fruit and veg or to pay for fuel to cook with. I know serotonin junkies where food is their drug of choice. I know exhausted people who fend off tiredness with sugar. I know of people who eat because they are under stress. I know a lot of unhappy people who don’t think they deserve better, or could ever be attractive or physically fit. I know people who are hopeless about ever losing weight (often within a wider sense of hopelessness about their lives). I know people who have spent their whole lives being fat and living a lifestyle constrained by that fat – tired, big, heavy and excluded from physical activities. Mocked at every turn. Excluded from aspects of society. Disempowered. Weight loss is categorically different from that starting point, and it is not just naive but wilfully ignorant to pretend otherwise.

Of course, I also know people who like being fat, have come to accept themselves as they are, or who see their weight as a very low priority in life. There are women who enjoy defying what they see as body fascism or sexist expectations about women’s appearance, or who simply see their curves as sexy. I can see the appeal in filtering away the shallow people who care about how people look more than who they are and what they do. And I’m aware that BMI is a blunt tool for measuring obesity, as it ignores body composition and scores people with high levels of muscle as equivalently “unhealthy” to those with little muscle, despite the positive differences in health that resistance exercise is known to make.

Katie won’t be happy being fat, and maybe it will give her some perspective about how judged and self conscious people feel when they are overweight. Maybe she’ll show some hitherto hidden empathy or concern for others apart from herself, but I doubt it. The promotional spots so far suggest the usual dose of hubris and ignorance, carefully engineered to provide publicity. I see this program as part of our obsession with celebrity and appearance, and the tendency to discuss serious issues (especially those affecting women primarily) with no depth. Hopkins has become the mouthpiece of internalised sexism; the pervasive belief that women need to be decorative rather than functional to be of value, and therefore shouldn’t think about issues beyond their own appearance and judging the appearance of others. She is also a caricature “baddy” that earns her living by being controversial, and by saying things that are not socially acceptable but that reinforce the wider narratives of the organisations that give her air or column space, who like to blame the individual and turn attention away from the real underlying socio-political causes.

Finally, I am reminded of a line that is helpful to think to yourself when experiencing playground bullies: I’d rather have my weight than your attitude. For all the challenges involved in losing weight, it’s still easier than changing personality or gaining empathy after years as a callous, judgemental, self-serving, attention seeking provocateur.