Nature versus nurture revisited

This week I have been reading the Power Threat Meaning Framework published by Lucy Johnstone and colleagues. This document is an attempt to challenge the dominant medical model in adult mental health with a more functional framework for formulation, based on the person’s experiences and circumstances. It is an interesting and challenging read, because it tries to cover the political and philosophical context of challenging the medical model, and input from service recipients about the benefits and challenges of different ways of conceptualising their difficulties. But at the core it rests on a pretty simple and (I’d like to think by now) well-established concept – that the adverse childhood experiences a person has prime them to use survival strategies that make them vulnerable to difficulties later in their life. Those early templates for dysfunctional relationships and the sense of self created by inconsistency and maltreatment also mean that people are more likely than others without those experiences to go on to have other relationships and experiences that are traumatic/harmful as they grow older, which compound the strategies and narratives with which they navigate adult life. The survival strategies which made perfect sense in response to their experiences at the time, have a lasting impact on the brain, body and behaviour. They change the way the person perceives themselves, understands the world and relates to others, and go on to have detrimental effects long after the initial trigger is gone.

As I have mentioned in previous blogs, a person exposed to high levels of trauma or adversity, especially if lacking protective relationships, will become more vigilant to signs of threat, less able to focus on the tasks that help us attain educationally and in the workplace. Where their early relationships have been dysfunctional, they are likely to struggle with forming healthy later relationships, and are more likely to express needs indirectly and in ways that cannot be ignored – including in ways that lead to negative societal responses, such as rejection and/or pejorative judgements by others, involvement with mental health services (and being given diagnostic labels), involvement of criminal justice systems. This leads to an increased risk of socioeconomic adversity, lower social connectedness and a greater chance of a range of adverse outcomes.

In short, thinking about adversity in both the person’s childhood experiences and current context, not only gives us insight into the biggest variable in personality disorder, attachment disorder and other specific conditions. It also explains a lot of the risk factors for wider issues with physical and mental health, challenging behaviour, addiction, violence, crime, homelessness, harmful relationship patterns and helps determine our sense of self and our ability to make healthy social connections. Adverse childhood experiences increase the risk of a very wide range of  physical and mental health problems, for a range of reasons including lower self-care and poor lifestyle choices, a lack of self-monitoring and seeking of appropriate care in the early stages of problems, and what seems to be increased propensity for ill-health mediated by the stress messengers in the body.

I’d go so far as to say that getting child protection and parenting right is the biggest task facing humanity, and the area where I believe we can make most difference for the future – hence dedicating my career to working with the kids who have experienced the most adversity and trying to improve their outcomes. But as I have explained above, it doesn’t just stop there, because the ripples of that early adversity continue to spread out into the lifespan for many people, forming a barrier to the protective factors of education and employment, establishing social networks the means to access pleasurable activities. This can then be compounded by financial hardship, hostile systems (such as benefits sanctions and fitness for work tests) and lack of access to resources (including finding it hard to identify and navigate access to social care and health services, to know and assert their rights, or appeal against decisions made by organisations). So the same people who experienced chronic developmental trauma and have unresolved psychological consequences from that are often struggling with their personal relationships, as well as practical issues like debt, homelessness and crime. In that context, dysfunctional coping strategies like substance abuse or presenting with challenging behaviour or mental health symptoms make more sense as attempts to obtain escape or safety.

There are also vulnerability factors such as being in a disempowered/minority population group, that also bring compounding adversity such as sexism, racism/xenophobia, homophobia, transphobia, ableism, ageism, religious intolerance, etc. These can impact at all life stages. For example, a child with physical or intellectual disabilities is more likely to be the victim of abuse, to experience bullying, and (perhaps increasingly as they grow up) to struggle to access community resources, financial independence or a supportive social network. For people from cultures outside of the majority in the country where they live, there can be language and cultural barriers, prejudice and political/economic challenges, as well as exposure to poverty, war, terrorism and other threats to survival that are outside the experience of the majority of lifetime residents of developed nations. Certain population groups such as asylum seekers find things particularly challenging in terms of finding safety, housing, financial security, after already experiencing multiple traumas in the country they have left and during their journey to find safety. Each individual is unique and their story, current situation and past experiences are a huge influence on the way that they experience and interact with the world.

As Johann Hari rightly points out in his recent article to promote his new book, everybody knows that our experiences, relationships and living conditions impact on our state of mind. If a loved one such as a partner or child dies, you are likely to be sad (and perhaps angry, or relieved if they were suffering, or many other complex feelings). Likewise, if you are given a warning of impending missile attack most people would feel anxious, and become hypervigilant for signs of threat. Therefore, most people would not think of grief after a bereavement or loss, or anxiety when in an acutely threatening situation as pathological. Which makes it somewhat curious that the medical model has been applied to mental health in the way that it has. Why has it become that depression or anxiety or even addiction is seen as a disease, a neurochemical imbalance that needs to be treated with medication?

Perhaps the advances of modern science studying genes and neurochemicals made us think of ourselves as complex biological machines that could be understood at a physical level. Perhaps there is wishful thinking about biological models leading to potential cures. Perhaps the fact that brain injuries, tumours, dementias and neurodevelopmental conditions can make an impact on our feelings and behaviours made it seem that all feelings and behaviours could be attributed to brain changes. Perhaps the idea of massive numbers of people suffering is too distressing to think about and it is a common defence to depersonalise that, and to other the person suffering. Perhaps the narrative of mental illness has sustained the power and income of the medical profession as experts and gatekeepers to such treatments. Perhaps it was clever marketing propaganda by the pharmaceutical companies to sell more of their products. Perhaps it was so persuasive because it fits with the neoconservative narrative to think of individual failure rather than individuals showing the symptoms of societal problems (and therefore our collective responsibility to solve these problems and look after each other, rather than just thinking of ourselves). Or, more likely, it was a combination of these and many other factors.

Of course, we don’t want to throw the baby out with the bath water. There are certainly people for whom psychiatric medication has made a massive positive difference. People who feel more able to concentrate and gain attainments when on stimulant medication, or who feel less hopeless, anxious or angry when on antidepressants, or people whose distress, confusion or aggression is reduced by neuroleptics. But we can’t work backwards from positive impact to considering that proof of a neurochemical deficit or imbalance. After all, the evidence for analgesics is very strong, but I doubt anybody thinks a headache is a symptom of lack of aspirin! We need good unbiased data to understand what is going on, not the cherry-picked examples that currently make it into the public domain. Alltrials is a good step in the right direction in this regard, but there is still bias in what research gets funded and what gets published, with bias towards the sexier topics of new technology, genetics, scans and hard science, and less towards the sociopolitical aspects affecting individual and population wellbeing.

I’m not saying that nature isn’t important. It seems likely that various medical/biological factors do mediate the impact of experience. For example, some conditions like autism, intellectual disability, and dementia do appear to have predominantly biological causes, whilst having impact on thoughts and feelings. Brain injuries and diseases can affect personality, mood and behaviour, and various hormonal and physical conditions can affect brain function and impact on mental health. There seem to be genetic differences (eg to telomeres) that make some individuals more resilient to adverse experiences than others. And some twin studies show genetic factors influence the incidence of conditions like schizophrenia and bipolar disorder, although again the epigenetic factors seem important, it is not clear whether the biological differences are a cause or a symptom of the condition, and the role of biology is not large enough on its own to explain who gets these conditions without also considering experience. Like most of these debates, the answer isn’t going to be one extreme or the other. I am glad that the pendulum has swung back towards considering nurture and experience more, and not exclusively the high tech science of genes, psychopharmacology and brain scans. It seems likely that who we are and how we feel and function in the world is affected by both our biology, our experiences, our circumstances and our relationships both now and in the past.

So, whilst Christine Courtois and Bessel van der Kolk’s efforts in the adult and child spheres respectively to get the impact of complex and multiple traumas and damaged attachment relationships recognised as a better way to understand attachment disorder and personality disorder than a neurobiological disease model (and their challenges to the DSM) have not yet been successful, I am heartened if this way of understanding the impact of experience is gaining more credibility in the field. I think the power-threat-meaning framework might be helpful for some clients, and the questions that they advise asking are certainly good way of starting a clinical assessment.

“What is your story?” Specifically:

1) What has happened to you? (How is Power operating in your life?)

2) How did it affect you? (What kind of Threats does this pose?)

3) What sense did you make of it? (What is the Meaning of these situations and experiences to you?)

4) What did you have to do to survive? (What kinds of Threat Response are you using?) and are you still doing this?

5) What are your strengths? (What access to Power resources do you have?)

It certainly resonates for me, and I wrote about a lot of this stuff in my book, Attachment in Common Sense and Doodles in relation to children who don’t live with their family of origin. I wanted to make information about attachment and the impact of trauma more accessible to carers, legal professionals and social care staff and other profesionals in the child’s network. It isn’t novel content, as it was based on themes that had been researched, written and spoken about by others before me, but I have tried to present it in an accessible and engaging way.

I am heartened that in the last few weeks the idea of experiences and nurture being important in mental health seems to be reaching the public consciousness. It seems to be being promoted more vocally by a lot more clinical psychologists, and to have reached me in various different ways. I’m glad if it is gaining traction and a wider audience, but it might be that’s wishful thinking on my part, and merely a product of my unrepresentative sampling. In light of how horrible a lot of the news is since the Brexit vote, Tory election win and Trump victory, I’m trying to be more selective about what I read and the social media I engage with, so it could be I’m in more of a bubble of like minded thinkers these days, and that is the explanation for hearing more about models that fit my own thinking!

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

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

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

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

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

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

1) My company in Milton Keynes

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

2) To help run my BERRI project

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

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

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

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

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

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

Between a rock and a hard place – when friendship and your professional role overlap

I’ve always tried hard to keep a clear distinction between work and non-work stuff in my life. I expect my friends to be able to offer, on balance, a similar level of support to me than they require from me. If the relationship is too skew then it will be meeting one person’s needs at the cost of the other, and that isn’t a friendship. Friendships are reciprocal, and allow me to trust enough to show facets of myself that I might not want to reveal in the context of work. In the safety of such a relationship I can have my own vulnerabilities. I can worry that I am less than a perfect parent, or talk about my relationships with other members of my family. I can joke, swear, drink wine, express opinions, or laugh at the contestants on The Apprentice without fear that this will tarnish my professional reputation. The rest of the time I feel like I have my professional hat on. I am in a position of responsibility and power, and I am bound by a code of conduct. When I talk or post online as a psychologist, I run the risk that my comments will be brought back against me when I’m in the witness box, or be taken out of context and misinterpreted by a present, past or future client or colleague.

I am friends with some psychologists and other colleagues from work and via the clinpsy forum. That’s a good thing. We share common values and experiences. We have shared stressors, and we spend time together. I am also friends with other professionals that know me as a psychologist, like lawyers, paediatricians, psychiatrists and social workers. Again, our work overlaps and becomes a topic of mutual interest. I also have non psychology friends. That’s a good thing, as they bring different ideas and perspectives. They let me relax, share other interests and remind me of the other parts of me outside of being a psychologist. We can cook, eat, play, exercise, explore, talk. We can play video games, make music or art, debate politics and current affairs. As a prior supervisor would say, we are people, partners, parents and professionals as well as psychologists, and we need to pay attention to each of those roles. What marks it out as a friendship is that there is trust, and that the relationship is enjoyable or nurturing.

The difficulty comes when you feel like you ‘click’ with someone who you are seeing professionally and feel that had you met outside work it could have been a friendship, as that makes it harder to stay within a work role and remain within the more neutral and guarded boundaries that a professional relationship entails. A therapist needs to respect their clients, be curious about them, accept them, hold them in positive regard and see their potential. The relationship may be very important for the client, who may idealise you and want to bring you into their life. But that doesn’t make it a friendship. The power balance is different in a professional relationship. Within therapy the client is expected to disclose a lot about their life whilst the therapist discloses little. It is not a reciprocal relationship, and the relationship is not there to be enjoyable or nurturing for the therapist. Having started from there it is not possible to reach a place of reciprocity (at least not without a lot of time and distance after the end of the therapeutic relationship). So if you find yourself acting too casually, sharing too much information, or wanting to step outside of your normal professional role, this is definitely something to discuss in supervision.

Likewise, if someone in your personal life starts to use your professional skills, this needs to be handled very carefully. Parents asking for advice about their child’s anxiety or poor sleep may not differentiate whether you are giving advice as a friend and fellow parent or as a professional. A friend who wants guidance how to access IAPT, or is feeling suicidal and needs to be taken to A&E needs to know you can support them as a friend, but not as their psychologist. We may well know the system and the right things to say, or the right people to approach, but it is important not to end up muddling the role. You can’t ring up someone you know’s treating clinician and say “Hi, this is Dr Silver and I’m wanting to ensure you understand my formulation about my friend Jane”. They are entitled to confidentiality in their therapy and trust within their friendship. But you may also feel a greater obligation to act on concerns about someone’s mental health, or a child protection concern, than a general member of the public.

It is all too easy to get sucked into an uncomfortable place in between. What of someone that approaches you in a way that appeals to both the personal and the professional? They just find you so easy to talk to that they tell half their life story, and next thing you are feeding back a formulation at a dinner party. Where do you go from there? Do you reciprocate and tell the ins and outs of your life, or give them a business card if they want to follow up the conversation with a formal session? Or the friend who just can’t get an assessment for their dyslexia, but is self-critical about how stupid they are, when you have the psychometrics needed in the office and your assistant has a spare hour on Friday. Surely that’s not so personal? Or the friend of a friend that never seems able to access the services they need. Do you step in and advocate for them? Its a very difficult decision to call sometimes. But in my experience it is these situations that are most likely to fall down around your head.

A colleague of mine was concerned that a friend of a friend (lets call her Sarah) was discharged from an inpatient stay without proper risk assessment or follow-up. He spoke to the GP and inpatient team to raise concerns, but nothing was done. Sarah later committed suicide, and my colleague was interviewed in the enquiry that followed. The coroner did not seem able to differentiate between a concerned friend who happened to be a professional, and someone with professional responsibility, and he got given a really hard time. This was on top of the guilt he felt for not having been able to prevent Sarah taking her own life.

Another colleague ended up having to drop everything to collect a friend from various complex situations all over the country as she had psychotic episodes, and would not trust professionals when she was not taking her medication and did not have a good support network.

I ended up writing to the GP of someone I shared an office with early in my career, to report an eating disorder, suicidal ideation and risky behaviour. I felt like there was little else I could do after a supervisor said it wasn’t their problem, because I felt like it was unfair to burden me with the information without allowing me to act on it. I was very clear with the person involved that this was what I was going to do if they continued to confide this type of information, and they had written down the contact details of their GP for me during the conversation. They went on to get appropriate therapy.

When I first met my husband it was evident he was dyslexic. I did some informal assessments so that I was sure my hunch was correct and then pushed him to get formally assessed at university. This confirmed the diagnosis and enabled him to get concessions made about his spelling and handwriting in exams, and I learnt to help by proof-reading his course work. I felt like the assessment needed to be independent to have any authority, and that I could not take on this dual role.

A decade later, I started at a new post and started to become friends with the IT guy who covered CAMHS. It was clear he had a specific deficit with his memory that had never been assessed, and I owned the WAIS and WMS that were current at the time. With the consent of the directorate manager and my supervisor, I did a full psychometric assessment. We have gone on to be lasting friends, and he credits me with helping him to understand that he is a bright guy with a specific deficit, rather than a guy of mediocre intellect who has done well for himself. However he has never wanted to use the assessment formally.

More recently I spent 24 hours taking an acquaintance to A&E after they confided detailed suicide plans in the wake of a relationship breakdown. They asked me to be with them in the room and share some of their abuse history with the assessing clinician, but I had to be very clear to identify as someone from the personal network. I was not a professional to them, but I was also not somebody who could take responsibility for this person on discharge as I lived in a different part of the country.

Each of these has been a learning experience and shown the importance of differentiating the personal from the professional, but it is something I will continue to grapple with both personally and through supervising others. The third role of speaking to other people on the internet is one I will blog about at some future point, and brings with it a plethora of new and challenging ethical issues, not just the way that the informality of the medium makes roles blur more between personal and professional.