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 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). 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.

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 just wanted to get on with the doing without that slow process of validation, 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.

 

Holding the buck: Some thoughts about accountability in the modern marketplace

A couple of weeks ago, I gave a talk to the Institute for Recovery from Childhood Trauma at the House of Lords. I decided it would be too stressful to travel down that morning, so about three weeks in advance I booked an apartment through booking.com. I’ve stayed in apartments and rooms through online sites quite a few times before without incident. Normally they send a code for the door by text or email, or instructions to open a key safe. However, this booking was confirmed with instructions to collect the key from a nearby address by 9pm (I was told if I arrived later there would be a £20 late collection fee). So I caught an earlier train and got a taxi to the pick-up address, which transpired to be an office building, locked up for the night. The security guard on site who came out to see why I was loitering had never heard of this being a collection point for apartment keys. So I spent 45 minutes waiting at the pick-up address and checking the apartment address just down the road, with no ability to check my email or find the phone number of the owner due to the o2 outage. I then found a restaurant which let me use its wifi to contact the apartment owner. He answers the phone as Booking.com and says the pickup address sent to me by email was never given (despite me having it in writing on my screen as I spoke to him) and that I had not confirmed the time. He says he will send a man to meet me with a key. But he isn’t willing to send the man to the restaurant in which I am sitting, I have to go wait across the road outside Patisserie Valerie (which is also closed) for a man in a red jacket.

In about 15 minutes that man arrives. He greets me by name, but does not offer me any apologies or identification. I can’t tell if he is the man I spoke to on the phone or not. He does not provide a key to the apartment, but tells me to follow him and walks off in the opposite direction to the apartment. I ask him where we are going, he says “to the apartment”. I say that it isn’t the right way, and I don’t feel comfortable following a strange man to an unknown address. He is short with me and tells me that he is taking me to an alternative apartment, because a cleaner snapped the key in the apartment door 20 minutes previously. I find this suspicious as a) I’ve been waiting at the apartment and just up the road for 90 minutes and nobody has come or gone from it in this time, and b) why would a cleaner be in an apartment at 10pm that is supposed to have check-in from 3pm to 9pm, and c) why did the man on the phone not notify me of a change of address or email me with a change of booking through the site on which I had booked?

He leads me down less busy streets and alleys across Soho. I start to get anxious that I’m in a part of London that is unfamiliar to me, and have no idea where I am going. I will not be at the address I have booked and nobody will know where I am, its past 11pm and dark, and I’m being led by a total stranger who has shown me no ID. So I call my husband, explain the situation and start reading out street names so he knows where I am. He says that I sound nervous, and that if my gut doesn’t feel like this is safe I should trust it and go somewhere that does.

My mind goes into overdrive. I start worrying I’m being taken to an unknown address, where I might be robbed or attacked or anything. I’m thinking perhaps they gave the fake address as a means to be harder to trace, or perhaps they use the photos of one apartment in a good location to put people in cheaper accommodation in less favourable locations. Perhaps he is nothing to do with Booking.com and is just a confidence trickster. Did he definitely use my name? Was he the man on the phone? I have no way of knowing. I can’t just follow a stranger to an unknown address in the middle of the night with no explanation. I find an open wine bar to run into and hide.

Suddenly, all those feelings are right at the surface and I’m sobbing with fear and hiding behind the counter of the wine bar until the man has gone. Then the man who claims to be from Booking.com (I still can’t tell if he is also the man in the red jacket, or someone different) calls me and asks where I am, and I say “I don’t feel safe dealing with you and being taken to an unknown address, I’m going to find somewhere that feels safe to sleep”. It seems like something I should be able to take for granted, that now seems out of reach.

The staff at the bar are super-nice and patch me up, give me some water and use of their wifi. They offer me wine and fancy olives. I take the latter (and they are the best olives ever, as well as thoroughly nice people, so do check out Antidote if you are ever in Soho). When I calm down a bit, I start searching all the usual websites to find a hotel room. I then find out there is nowhere else to stay. And I mean that literally. Even when I increase my parameters to travel up to an hour from my location, nothing is coming up on any hotel booking site that isn’t fully booked. So I’m sat there in a random wine bar in Soho, 200 miles from home, and there are no longer trains to get back there even if I didn’t have to be in London by 9am the next morning to speak at the House of Lords.

At nearly 11pm I find one, very expensive, hotel with a single room available through LastMinute.com. I book it, pay and then pay £20 to get a taxi there only to find it is overbooked and they’ve already turned away 4 other customers. It is a converted Georgian townhouse with a small number of rooms, so I’m sat in the only chair in a tiny lobby. I’m repeatedly calling LastMinute, and it has gone past midnight so there is no longer even a means to find another hotel (as you can’t search for availability for the previous night), and they tell me they don’t have a room. It takes me four calls and 47 minutes on the line to speak to Last Minute’s customer services, who conclude they can’t find an alternative room for me, and don’t see that as their responsibility. At 1.25am they suggest a room is available at the Taj St James Court hotel and they have reserved it for me. I call them, they have no rooms and have never heard of me. It is now 1.30am, and I am making plans to sleep in the bucket chair I am sitting in, in the hotel lobby, as I have nowhere else to go* and it is raining heavily. Eventually at 2am the hotel say that one guest has not checked in yet, and agree to take the gamble and let me use the room. I get less than four hours sleep for twice-the-price-I’d-normally-set-as-my-upper-limit-for-a-room, before having to head out to speak at the House of Lords.

Having given the talk** I decided to complain to both Booking.com and LastMinute.com. The response from the former was “You got a refund for the apartment, so it’s all settled” and the latter offered “€20 as a goodwill gesture due to the 2 hour delay checking in”. No recognition of the fact the experience was traumatic, wasted 5 hours of my evening, cost me 3 extra taxis, and left me 200 miles from home without somewhere safe to sleep. I am faced with the realisation that trauma is subjective, and to many men hearing the tale I might have taken fright for no reason and brought the events that followed upon myself. I am forced to say “imagine if your Mum were in this situation” when explaining it to try to trigger sympathy. But nobody really cares. The apartment owner feels he has done his bit by refunding (and the website has conveniently blocked me from leaving a review). The men in the call centres were in another country, abstracted away from the problem. The customer service teams are seeing the facts in retrospect, not the feelings the experience generated, and are motivated to protect their brand rather than genuinely caring about me as a customer. The night manager of the hotel cared, because he met me in person, and saw I was upset. As a result he tried his best, but he wasn’t in a position that could resolve the problem.

And that’s where I finally reach the point. In a system where you book with a middleman who doesn’t actually provide the product you are paying for, nobody really feels accountable for the service you receive. And, to bring this round to being relevant to a wider point for health and social care, this model is being increasingly replicated in public services, where the NHS or local authority commission the service from another provider, who is assumed to be responsible. That split between online broker and real life provider, or the public sector split between purchaser and provider seems like a good model for each of those parties, as the purchaser delegates responsibility whilst fulfilling their obligations (or making a profit, in the case of online brokerage sites) with much reduced staffing and without having to invest in any tangible assets. The provider gains access to a wider market, rather than becoming obsolete. But somehow inevitably, as in my experience, the recipient of the service misses out in the middle, and finds out there is minimal quality control and an absence of clear lines of accountability when things go wrong or aren’t delivered as planned.

For example, there is a level of risk aversion that has made local authorities anxious about providing residential care placements, because of the prevalence of historic institutional abuse and the increasing awareness of child sexual exploitation and involvement in county lines (and the accompanying risk of compensation lawsuits). The result is a marketplace where private providers (many of them owned by international venture capital groups who pay minimal UK taxes) use unqualified, low-paid staff to care for some of the most complex and vulnerable young people in the UK, and it is hard for recipients or commissioners to distinguish them from provision that has different financial or delivery models. Likewise in health (and public transport) private providers cherry pick off the profitable services, whilst the public purse is left holding the can when they don’t deliver. There is a move to entrench this even further with the push towards Integrated Care Providers, where private organisations can manage the entire health and social care services for a particular region of the UK, in a way that is potentially unaccountable for its decisions and not subject to the rules for public sector organisations (like Freedom of Information requests, public consultation, or being subject to Judicial Enquiries if things go wrong, or even their statutory obligations). I think that might be a recipe for disaster, but then, I’m not a fan of corporations and the super-rich profiting from the suffering of the rest of us.

Update: Booking.com have agreed to reimburse my costs in relation to the apartment (but have not yet done so), whilst LastMinute.com have not yet replied, telling me they take 28 working days to respond to customer complaints that don’t accept the initial boilerplate response. I suspect that just like in health and social care, the (explicit or implicit) policy is to respond to those who kick up a fuss and have the potential to create negative publicity if things are not resolved, meaning that those who are devalued most by society have the least redress when things go wrong.

*call me a wuss, but I declined the option of having one bed in a bunk room in a hostel shared with 8-12 strangers
** which I will give again and video as soon as I shake the cold that’s currently making me croak

The attraction of small rewards

I went to the Y Not Festival last month. It was a bit of a mixed bag because of the weather, and the terrible app that was supposed to function as a map and timetable was a daft idea on a site with limited mobile in the first place and totally useless in practice as it wasn’t updated when things changed. But we saw some good bands, and ate some good food, and it was only half an hour from home so we also slept in our own beds! But the reason I mention it was because of a trivial but unexpected thing: They had an incentive to recycle the plastic pint glasses that were being used and dropped on the floor. They offered 10p per glass to take them to a recycling point in sets of five. For the most part that wasn’t enough for people drinking to bother keeping and pooling their glasses to cash in. But a small economy developed amongst people who found it worthwhile to go around collecting the dropped cups. There were some sets of kids excitedly supplementing their pocket money by collecting piles of cups during the day, and also a few adults who increased in numbers in the evenings.

At £5 per pint the beer was not cheap, and I joked with my husband that I’d see if I could collect 10 cups to offset the cost each time he drank one. But as soon as we started collecting cups, we realised that there were loads of them, and it was easy to make quite good money from them. In three hour-long collecting binges, and whilst listening to bands I enjoyed, I stacked and recycled well over 500 cups. That was enough to pay for all our food over the weekend, and the couple of drinks my husband had. Of course my legs ached like crazy the next day, after all that walking around punctuated by 500 bodyweight squats. But I felt good about being part of the efforts to clear up the site and recycle the cups.

Of course I’d much rather they used reusable cups as they did at Timber festival, or ones that are biodegradable as they did at Woodside. And it doesn’t really make much sense to pay random people more per hour than they pay their bar staff or rubbish pickers, let alone to pay the people who were simply emptying out the plastic recycling bins, stacking up the plastic cups and taking them to the recycling point like their own little black market scheme. And I wasn’t persuaded that they were actually going to recycle the cups at the end of the weekend. But I was interested in the fact that I somehow found it fun to do a dirty, smelly, physically demanding job earning way less than I can earn from work. Apart from the novelty and fact it filled in the gaps between artists, the reason was as obvious as those demonstrated in Pavlov and Skinner’s seminal experiments: The small but proximal rewards were enough to reinforce the behaviour, and make me want to repeat it over and over again. In fact it became quite addictive. The small payments made it feel like a game in which I was succeeding and earning five to ten pounds per trip to the recycling point made it really tangible that I was being rewarded. I could have spent the entire weekend picking up those crushed and broken plastic cups and straightening them out into stacks to cash in, and my kids were jealous that they’d missed out on the opportunity to earn cash because they had chosen to go to their grandparents rather than the festival.

In another example, I’ve been playing a really rubbish game on my iPad called Hidden City. It is a hidden object game, where you have to find items within a picture of a scene before the time limit runs out. For example, there might be a picture of a greenhouse full of caged birds and exotic plants, and you will then be asked to find a pair of binoculars, a fan, an oil lamp, a walking cane, a string of rosary beads, a bunch of chilli peppers, a pair of shoes, a turtle, and various other objects to click on and collect. Each will be visible within the scene, some in plain sight and others tucked away or masked by being in front of similarly coloured items. In certain quests there are also keys to find in the scene that are smaller and better hidden. Whilst this has some inherent mental challenge and novelty, it really is a very simple premise for a game, and quickly becomes repetitive, so you’d think the game would be very boring – in fact it seems boring to have explained it in writing, so I hope I haven’t sent you off to sleep! You would therefore assume that people would drop out of the game very quickly, but that doesn’t appear to be the case. In fact, the makers are so confident that players won’t be bored enough to drop out that they make you search each scene for objects selected from the same list and placed in the same range of places in the scene many times. In fact, to complete some quests you search the same scene over a hundred times. The task becomes more difficult because you are expected to find more objects in a shorter time interval, and the scene becomes more cluttered so it is harder to pick out the specified items, and you have to alternative with searching other scenes to get the tokens required to go back to the main scene. To compound that, there are multiple locations in the game, and each needs to be searched a large number of times, so to complete the whole game you probably have to complete about ten thousand search quests.

It sounds like an enormous and monotonous task, and the game itself is full of bugs, glitches and poor translations, yet it is the most popular hidden object game in the world. More than half a million people have played it, and there are tens or maybe hundreds of thousands of players active at any one time. They are not only signing up to play in huge numbers, they are choosing to pay for the optional purchases to assist their searching, making this game and the multiple other games by the same company, and the multitude of similar games available, highly profitable.  Estimates suggest that over £3 million of in game payments have been made since the game launched four years ago, and tens of millions of pounds are being spent in in-game micro-payments across all the games by this maker each year. It seems illogical, but many players spend way more than they’d need to pay to purchase a really good game to play this glitchy game that is constantly interrupted by advertising for in-game purchases and other games by the same company.

So why do people keep playing, and why do some of them keep paying? I think it is the same idea of reinforcement through small rewards. As a player you experience a lot of small successes. They make the first few searches really easy. Then each time you search and don’t find all the items you are told to try again. If you find them all you are rewarded by a random selection of small icons, and you can collect these items in sets. Completing the set gets you a rarer icon, with some bonus points or magical powers to boost your energy or increase your ability to find other bonus items. In the bigger quests you might also get tokens to unwrap gift boxes containing more icons. You also get overnight bonuses, daily bonuses and components of a magical piece of jewellery each time you play again after more than 8 hours but less than 24 hours. They compound so an unbroken chain of about a month gets you the finished item, and 12% more items to find for a 10 day period. If you break the chain you either have to use or buy in game currency to restore it, or you lose the components you gained. Something about our psyche likes gaining these pseudo possessions and dislikes missing out or losing them, enough that these games are quite addictive. But they are all just small pictures of random things. Why should I care if I have a magical tuning fork in my collection, or whether I get the apple strudel icon that completes the huntsman set that gives me the Austrian clock? There is no intrinsic value in the drawing of the clock, or the strudel or the tuning fork. They bear little relation to the scenes I search, or to the token plot about the magical city trapping people, or the candy-crush style mini-games. My life is not better in any tangible way if I collect 75 keys and open the golden chest to receive 6 bonus items, or if I play the scene 100 times and get a new avatar of the lady of the manor, or the Samuri, or the gardener. Being at a higher level on the game doesn’t convey any greater skill that would garner respect from other players, let alone in the real world, nor does it teach me anything I can generalise outside the game.

So why is a badly made game with such a simple and repetitive premise so popular? I’d suggest that is intentionally designed to be rewarding to play, and to tap into what we know about reinforcement with the number of small rewards it offers. Our brains are set up to love rewards, no matter how meaningless they are, or what the longer-term cost is. Like scratching an itch, or eating something tasty but unhealthy, using drugs or smoking cigarettes, the immediate rewards are often much more effective as an incentive than the longer-term consequences are as a deterrent. The logical decisions we make about changing our behaviour struggle against these proximal sources of gratification. It doesn’t feel like a big effort or commitment, because we are only playing a three-minute mini-game. We are tempted to take the small action to sample the reward, but this then lures us in to take the next step with another small effort, and the result is that we repeat that for far longer than we planned. Even if this means losing out on sleep, or getting things we objectively rate as more beneficial or necessary done.

The same is true of our online behaviour. We chain from one news article to another, or one social media post to another, or one youtube video to another until whole evenings disappear into a black hole. Even when we are going about our daily lives, we constantly check for the small rewards of messages, likes or responses on social media. For many people this becomes something done obsessively, to the detriment of other activities in our lives. As well as hitting our reinforcement pathways, these small social connections also fire up our desire to feel belonging and acceptance in a group, and to gain the approval and/or attention of others. I’ve blogged before about the toxic aspects of social media. Studies have shown that stopping using social media, whether for a couple of hours per day, a day per week, a longer block of time, or permanently, makes people happier (journal articleanecdotes, article citing studies, more anecdotes, even more). Yet for most of us, we are enticed by the sense of connection (albeit often a much more distant and less authentic connection than we make in real life) and the promise of these small rewards.

It makes me think how despite all the progress of technology, we really are quite primitive creatures in some ways, tied to the way our biology has evolved to reward behaviours that had some adaptive function that had evolutionary benefits. So can we make a conscious choice to use these inherent reward systems for more positive purpose? Possibly. For example, we can benefit by building chains of positive behaviours that we don’t want to break – like a colleague who told me he hasn’t drunk alcohol for 92 days after realising he was drinking almost every night. That challenge of having a dry month, or to do without meat, or caffeine, or cigarettes for a set time period seems an effective way to change behavioural habits. It is less final and impossible sounding to have a break from something than to give it up permanently, but it can give you a chance to see what life is like without it, find alternatives that fill that gap and build up some of these rewards for going without. It then becomes easier to continue that pattern, and there can be a reluctance to break the chain, particularly if there have been social or financial or health rewards for the change.

Likewise we can gamify exercise. When I used to weight lift I would share my achievements with a group of other weightlifters online. This gives a sense of a peer group who can reinforce your behaviour and some social pressure to sustain the pattern (though I was never one to post every gym visit on facebook the way that many runners/cyclists use their apps to, or to post lots of philosophy and photos the way that yoga fans seem to – I just posted to a weightlifters group when I made gains, and could compare my progress to others in the group). But even without this online support I had a sense of achievement each time I went to the gym, or completed my routine, or increased the weight I could lift in a specific exercise. I liked to record my weights in a journal and to feel that I was making measurable small gains. I also liked confounding expectations by being an overweight middle-aged woman who had hidden physical strength. I’ve mentioned my joy in having “ninja muscles” before. I’d like to get back to it, and I’m sure my core strength would return. I’ve still got surprisingly muscular legs, though I wouldn’t risk picking up an 18 stone barbell these days!

So I guess the knack is working out how to make our innate reward systems work for us in a modern world. I’m certainly far from achieving that. Change is hard. But maybe I can at least recognise the patterns better now I’ve thought about it more. Maybe I’ll come back to that theme in a future blog.

 

 

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.

Six degrees of separation

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

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

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

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

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

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

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

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

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

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

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

 

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

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

Why is there always a can of worms?

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

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

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

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

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