Runway: A blog about whether being self-employed or starting a business is a viable option financially

If an aircraft runs out of runway before becoming airborne then it will have to stop or it will potentially crash horribly. For this reason, runway is used as a metaphor for the relationship between the money available in a business and its running costs. If the business does not generate enough income to keep the cashflow up to cover costs, then it will either come to a stop or come to a horrible end. But unlike an airport, where sufficient runway already exists for the purposes of launching planes, with a new business you have to find or create the money that will hopefully let the business become self-sustaining. And unlike an airport, at which planes get up into the air uneventfully every few minutes every day for many years, most businesses fail within the first three years, often because of not being able to generate enough income to sustain the business in the longer term.

I think a lot of people in employment have fantasies about being self-employed or starting their own business. For clinicians, the fantasy is often about offering therapy in private practise to insured or well-heeled clients with milder problems. Whilst the hourly rates for private practise might seem attractive compared to a salary divided down into an hourly rate, the figures represent something really different. Salary is paid on leave days, bank holidays and when you are sick. It covers maternity/paternity leave and redundancy if you are no longer needed. You get supervision, CPD, equipment to use and premises to work in. You also have a team of other professionals supporting you in the background from admin to HR, finance, operational management, procurement and maintenance. You don’t have to think beyond providing the clinical and associated psychological services. Salary packages, particularly from the NHS, also contribute to very favourable life insurance and pension schemes. When you are self-employed you need to think about premises, insurance, supervision, CPD costs, DBS checks, accountancy, advertising, tax and how you will generate income if you don’t or can’t work. You may also need equipment from computers and stationary to psychometric tests (which are enormously expensive both to purchase and for record forms).

Remember that the bills need to be paid immediately, but clients may not pay you as promptly – and some may not pay at all. This is particularly true for me when doing expert witness work where the timelines from accepting the work to receiving payment for it are amazingly extended. If I accepted an instruction in principle on 1st January, I would typically receive instructions for it 1-3 weeks later. My appointments would take place 4-8 weeks after that, and my report would be submitted a fortnight later, perhaps in late March. There might then be further instructions or clarifying questions, before the case is heard at the end of May. Any invoices will only be processed when the case closes in June, and then sent to the Legal Aid Authority for scrutiny in July. If there are no queries the LAA then send payment to the solicitors, who eventually send it on to the expert in the August or September, though some will drag their heels for several more months. So I have to wait six to twelve more months to receive payment. And about 8% of the work is never paid, because the solicitors closes after the Legal Aid claim is made, or because the LAA determined that some of the work wasn’t “reasonable” or because there was a problem somewhere in the line of communication and one of the parties doesn’t claim a share of your invoice. Meanwhile the work is taxable in the financial year in which it is completed, and the VAT is payable at the point the invoice is issued. I also have to pay any staff who contributed at the end of the month in which we did the work.

Even as a sole trader working from home in a service industry with relatively low set-up costs, most of us need to earn some money to cover our living expenses, and can’t go for months or years unpaid. That means that unless you have a massive inheritance or lottery win to draw on, it might not be possible to give up salaried work to take the gamble of trying something independent. My rule of thumb is to have a minimum of three months living expenses saved before you consider leaving salaried employment. You might get this from a redundancy or mutually agreed resignation scheme, or by putting money aside whilst you are planning. You should also compare your current and projected earnings. My way of calculating this to calculate your annual salary plus 25% (the approximate value of the pension and protections) divided by 210 (the actual number of days an average NHS employee turns up to work). You can then compare this to what you think you could earn in a day if you had private clients, a contract with a large company to deliver training or services, a calendar full of supervision or consultancy, or whatever you imagine doing. You really need a multiple of three between the first number and the second to make being self-employed pay equivalently after costs, though if you really hate your job or are prepared to take a reduction in income (at least in the short-term) you might consider a multiple of two. I don’t believe it is viable to go below this because in my experience people never properly account for the amount of expenses involved, or the for the amount of non-income generating time required. As well as the fact that not all of your available slots will be filled until you are well established, it is worth bearing in mind that most full-time clinicians spend about 15-18 hours per week on direct clinical work, and the rest on work tasks that would be non-income generating in the private sector, such as screening referrals, setting up appointments, phone calls, email, supervision, meetings/indirect work, writing letters/reports, other admin and CPD.

That said, money isn’t everything. I know some amazing selfless people who have earned less than minimum wage for many years, but followed their heart because they cared passionately about what they were doing, and the impact it could make in the world. I’m not quite that altruistic, perhaps because I am the main earner for our family unit and feel an obligation to sustain our quality of life, but I’ve had to learn to live on a much less regular income. I pay myself minimum wage then supplement this with lump sums when the business is profitable. To make this even more unpredictable, I have often had to loan money into the business in order to pay salaries when others have been slow to pay us for work we’ve done. Overall I’d say my income is lower than when I worked in the NHS and did some court expert witness work on top, but nowadays on balance it probably matches my consultant grade salary. The amount I earn feels sufficient for our needs – and probably stretches a little further as some expenses have been absorbed (eg my mobile phone bill is paid by the company, as is the cost of any CPD I want, the costs of my accountant, and some little things like a sandwich and soft drink when I’m away from the office on business).

There are also some things that money can’t buy. I’ve loved the freedom and flexibility of being self-employed, even though there have been times that have been quite tough financially. Whilst it initially increased my workaholic tendencies to quite alarming proportions (peaking at working 9.30am to 6.30pm in the office and then 10pm until 2am at home most weekdays, and fitting in 5-10 hours of work per weekend), more recently I’ve been able to achieve more of a work-life balance. I’ve stopped doing as much consultancy and training that involved staying away over night, and reduced the court work that created so many high-pressure deadlines. I’ve started to cluster meetings in London once a month, arranging other meetings over videoconferencing where possible. I’ve withdrawn from the committee and policy work that was taking up a big chunk of my time. I’ve also recognised the wise advice of a past supervisor that said I needed to fill up life outside work with commitments that would compete with work, rather than expecting to ever be the kind of person who can ring-fence free time. So I’ve started putting social appointments in my calendar, made a commitment to swimming regularly, I’m doing more adventurous things with the children, and I’ve even been able to sneak out for the afternoon with my husband from time to time. Running my own business has also given me a chance to relocate to an area that I love, where my qualify of life and working environment is much nicer.

When weighing up the options, bear in mind that working as a sole trader can be quite isolating. In the NHS or other organisations we usually work within teams, often with the benefit of colleagues to bounce ideas off, or who can contribute to formulations from other perspectives. Working with others also allows you to collaborate or to delegate work to people with complementary skills or interests. It shares the risk of complex cases, and means you don’t feel solely responsible for the waiting list or the stuck cases. It can allow you to prioritise work and manage your workload. When you are the only one doing the work this becomes much more difficult, and the pressures and sense of responsibility for clients can increase substantially. Even though the waiting list might be shorter, you might feel more guilty if there is a delay in starting work with a new referral, or more responsible for ensuring a good outcome for everyone. When your income literally depends on how much work you do it can be hard not to end up over-working to the detriment of everything else in your life. However, on the flip side you can feel pride in positive outcomes, and a waiting list becomes a marker of success (that people are willing to wait for you) rather than a mark of failure like it is construed in the NHS (where there is pressure to meet targets, and services don’t have enough resources to keep pace with need, and are the only available option for most people).

You also need to realistically appraise your business plan. Most people go into business in the belief that they have found a niche in which they can earn a profit, and hope that demand for their services or product will arrive as soon as potential customers know it is available. However, that can lead people to be overly optimistic about how fast they can gain traction in the market, or the level of profit they can make. Unless the plan is to seek external investment, most small business owners need for the business to become profitable fairly quickly, and few would be willing to pour their life savings into a new business in the hope of a return further down the line. When trying to start up a company or expand a sole trader enterprise into a business that employs others it can often feel like a Catch 22 situation, that you can’t afford the things you need to generate the income that will fund the things you need. But unlike on Dragon’s Den or in Silicon Valley, few people have access to capital investment and most professionals (in the health and social care field at least) are wary about taking on loans before the business has the means to repay them, even if they can access lending.

My point is that even if you have a great business idea and an established reputation getting enough money to start and sustain a business is tough. Cashflow is a make or break issue. Generating sufficient working capital is one of several elements that challenge new start-ups. In fact, of small businesses that fail (based on figures from the USA), 82% attribute this to cashflow issues and 29% say that they ran out of cash, whilst 42% said that the issue was a lack of market need for their products or services, 23% don’t have the right team to deliver the business, and 19% can’t match a competitor.

I guess that makes me a survivor. I launched my small business seven years ago this month, and it is gratifying that we’ve managed to weather the politics of adversity to still be trading. However, making money is still something I find quite challenging. I’ve come out of a career in the NHS in which the financial transactions involved were far removed from my daily life, and the idea of making a profit was quite aversive. But I’ve had to learn to make my business financially viable. Whilst there have been times that have tested me almost to my limits, the business is still functioning and financially we are still on the runway. I view that as a success. However, I feel like we have never quite reached the position of being airborne, where the business is self-sustaining without me personally doing income generating work as a substantial proportion of my time – and that would be an enormous issue if I ever needed time off sick.

My penultimate piece of advice is to speak to people who understand business and finance before you embark upon your journey, and regularly as you go along. I’ve had the benefit of great guidance as I’ve travelled outside of the NHS and into the world of business. As well as my fantastic ongoing mentoring from Impact Hub, which has included some work on the financial elements of the business plan, I recently won a place on a scheme sponsored by Barclays bank to help social purpose businesses to scale up. I’ve been attending Judge Business School at Cambridge University with several other small businesses, where we have had a series of days to explore our options and make a growth plan for the business. Having identified gaps, I’ve then taken actions to rectify them. For example, we’ve built a website for BERRI so that prospective subscribers can see what our tools have to offer, and that has brought in a flurry of new subscribers. I’ve also explored the options to help me scale up more rapidly and increase the impact of what we can deliver. Thankfully we have a strong business case, and I’ve been increasingly able to articulate that as a result of the work I’ve been doing. Over the last month I have spoken to two potential sources of investment. That would give me more runway to play with, but I need to work out whether we are fully aligned in terms of the destination and route to get there before I can be sure that is the right move to make compared to continued slow organic growth.

My final advice is to recognise your own limitations, and to find ways to delegate the tasks you are not good at or not enthused about, and spend time with people who share your passions or the skills you want to grow. For me that means having an administrator who makes up and chases up my invoices, accountants who can deal with payroll, tax, NI, pensions etc and advisors who guide me to apply for the right grants, tax rebates and training schemes. I also meet up regularly with other social entrepreneurs to share our progress and plan collaborative projects. I just appointed an experienced Business Development Lead for the company, who I hope will help me to weigh up the options for investment, and help us to grow quickly but in a way that feels right and prioritises making an positive impact on the lives of vulnerable children over maximising profit. I’m hoping we’ll reach sustainability by the end of the year, but there are still hurdles to overcome, and even when we get into the air I can’t imagine it will be a journey without occasional turbulence.

I am not a therapist

I’ve always been someone that likes to keep busy, and has a lot of ideas about places where psychological thinking can make a positive impact. The aspect of my character that I now identify as entrepreneurial and put to good use in my business has always led me to want to try new things and create innovative solutions to problems. I like a lot of things about being a clinical psychologist, and particularly our ability to turn our hand to multiple types and levels of work. However, unlike many other clinical psychologists, I don’t really see myself as a therapist. In fact, I haven’t seen more than a handful of clients for individual therapy over the last decade, and even before that it was a pretty small proportion of my qualified jobs. I’ve always had more of a focus on the other facets of being a clinical psychologist. I think the picture of a clinical psychologist as a therapist is so strong that a lot of people will now be wondering how I fill my time!

So I will answer that question: I have done loads of highly specialist assessments (of neurodevelopmental concerns, attachment, parenting capacity, mental health, life skills, self-esteem, wellbeing etc) and lots of formulating and report-writing – some in collaboration with psychiatric or medical colleagues or within a wider MDT, but more as an external expert or second opinion. I have advised the family courts as an expert in care proceedings and complex custody disputes, and completed numerous pre-court assessments for local authorities to help inform their care planning. I’ve managed teams and services, and supervised from 2-20 other staff at a time, along with sitting in various organisational/management structures. I have designed and delivered training to parents, carers and professionals, and I have done lots of consultancy to various organisations and professionals (mainly those providing health and social care services, or involved in the family courts), and help placement providers to improve their services. I design and deliver group programs (eg Managing behaviour with attachment in mind), but then rapidly cascade train other staff to continue to deliver them. I wrote a book about attachment/developmental trauma, and lots of papers and policy documents about Looked After children, and acting as an expert witness to the family court. I sat on a BPS committee and I contributed to NICE and SCIE guidelines. I’ve designed, managed and evaluated therapy services (but employed others at lower bands to deliver the therapy). I’ve been an expert advisor to the HCPC in a fitness to practice case and to the team investigating a death in public care. I’ve done loads of practice-led research about each client group I’ve worked with, from looking at the psychological and health economic impacts of offering brief therapy to hospital users with diabetes, to commissioned evaluations of other services. So I have plenty to fill my days despite not having a therapy caseload!

I have reflected on why it is that I don’t feel drawn to therapy, and reached the conclusion that, whilst I see it as a very worthwhile endeavour, I don’t really have the patience for resolving difficulties one person at a time over sessions spanning many months. I’m always more interested in grappling with the bigger questions of why people are in distress, and what we can do to most effectively prevent or ameliorate those difficulties. When I’ve solved the riddle (or at least, reached a plan that improves upon existing solutions) I like to evaluate its efficacy, modify it if necessary and then disseminate the learning and/or train others to replicate the solution. I try to step outwards from the individual issue to the broader themes and ways that we can intervene on a wider scale. To use a visual metaphor, if dealing with mental health problems is like bailing out a ship, then rather than scooping out water one cup at a time, I am trying to work out how to plug the leaks, and to design boats that won’t have the same vulnerabilities to leakage in the future. It also helps me to avoid feeling hopeless about factors outside my control and demand exceeding supply, or burned out by an accumulation of traumatic stories.

Jenny Taylor, a past chair of the Division of Clinical Psychology, once described our profession as the structural engineers of the therapy world. Unlike a therapist trained in a single modality of therapy, we can survey the landscape and assess the need, then design the intervention that best meets that need – even if we are not always best placed to deliver it. We can base that recommendation on our knowledge of the current evidence base, which can change as new information comes to light.  If we consider the challenges people face as a river they need to cross, a therapist trained in a single model of therapy might be a bridge-maker. A psychodynamic therapist might be a mason who can build traditional stone bridges and claims that this design best stands the test of time. A CBT therapist might be a carpenter with a set of designs for wooden arched bridges that he claims are cheaper and quicker to erect. Each sees their own skill as either suitable to solve the challenge or not, but also has some incentive to sustain their own livelihood by continuing their tradition. A clinical psychologist can survey the land either side of the river, the span length required to cross it, and the materials available in the locality. They can then advise on the various options, including the relative costs and the evidence of how they fare in different conditions. They may or may not feel that bridge required is within their own skill-set to erect, but have a reasonable overview of other bridgebuilders in the area to recommend. If new designs of metal suspension bridges are developed, this is not threatening to the structural engineer, who can adjust their recommendations to incorporate the emerging evidence base.

I really like this metaphor and strongly identify with the role of structural engineer rather than bridgebuilder. I had always thought that this was instilled in me by my first graduate job, where I was an assistant psychologist on a research project about improving quality of life in residential care homes for older people, and I could see how the research and clinical work were closely tied together and built on each other reciprocally. But now I think my love of data and the scientific method runs deeper than that and I can see it infused throughout my whole approach to life since childhood. When it comes to my work I am a scientist practitioner down to my bones, as I always collect data as I go along. Where I don’t feel like I understand the situation well enough, I first look to the literature and then to gathering data and doing my own analysis to try to gain insight. When I develop something new to try, wherever possible I try to evaluate what we are doing, and refine it through an iterative process until we can prove maximum efficacy. I see that process as being part of the USP of a clinical psychologist – that we think like scientists and gather data to inform our interventions.

But I’m not sure that we communicate this mindset well enough, or that it is universal amongst the profession. It certainly isn’t what draws people into the profession in my experience. Too many clinical course application forms I review could be paraphrased as “I want to learn to be a good therapist” with an afterthought of “and do/use research” because they think that is what selectors want to hear – but in my view therapy can be done by lots of cheaper professionals, who might do an equally if not better job of it. I believe that clinical psychologists should be more than well paid therapists. We should know the evidence base and be able to take on the most complex assessments and formulations (even if others then deliver part or all of the treatment) but also to be able to develop, refine and evaluate novel therapeutic interventions, supervise other staff, improve services, consult, train and manage – things that extend beyond the skillset of most therapists. I’m sure it is clear by now that this is where my own interests lie. And I think it shows through in everything I do.

For example, when I was asked to lead the CAMHS service providing neurodevelopmental assessments I started with a literature review and current policy and best practice guidance. I then conducted an audit of the existing pathways, then tried to make things better. We set up a new clinic system with more rapid throughput and more thorough assessments, and then re-audited showing a reduction from an average of 18 months of input to five, with increased clinician confidence in the service and higher client satisfaction. I also wrote a booklet to help provide the information to parents whose child received a diagnosis of an Autistic Spectrum Condition. Although it required dedicated clinician time for the multi-disciplinary clinic and for the psychometric assessments generated, overall the new pathway freed up capacity because less cases were being held open by other clinicians whilst waiting for assessment, or kept open for prolonged periods afterwards to help the family understand the diagnosis and connect up to local sources of support.  I also sat on a multiagency strategy group to look at establishing best practice standards for the county.

I had the same approach when I was asked to support the adoption and permanence service. I initially set up a consultancy clinic, where social workers could bring cases to discuss or book in families to see jointly. I found that I was explaining similar information about attachment, trauma and neuroscience to multiple professionals, parents and carers in the consultations. So I designed a group to share this content. I called it “Managing Behaviour with Attachment in Mind”, and developed some “doodles” I would draw on flipchart paper to explain the concepts more accessibly. I evaluated the impact and showed it to be an effective format for supporting parents in this situation. The groups were popular and over-subscribed, so I trained others to deliver the group to keep up with demand, first in my service and then more widely. Many people in the groups liked to photograph the doodles to remind them of the topic, so I decided to write a book to share them and Attachment: In Common Sense and Doodles was born.

But I also wanted to know about how we could achieve permanence for more children. I started by looking at the literature about what makes effective adoptive matches. Very little information was available, so I systematically audited the paperwork from 116 adoptive matches and followed them up over 7 years to see what factors influenced the placement outcomes. I was able to look at whether the innovative adoption project to place children with more complex needs had better or worse outcomes, and was able to explore the impact of different motivations for adopting. Whilst to me this was just a natural process of answering the question as an evidence based practitioner, it transpired that these studies of adoption risk and resilience factors were amongst the largest ever done, and I have discovered unique findings that I really should publish*.

You could argue that I was using a sledgehammer to crack a nut by doing all this research and trying to change process when organisations are notoriously slow to change, and that I could have spent my time more productively working with more individual adoptive families. But that’s not how I’d see it. The research I did helped me to understand what the key variables are when considering whether a child can achieve permanence, what kind of family we need to look for to place them successfully, and what kinds of support might ensure that the placement succeeds. I hope that I have fed that knowledge back through my court work, and into various organisational and policy work over the last decade. I have also disseminated it at conferences. However, I would still like to spread it further, because it is my belief that such knowledge can have positive impact at multiple levels – it can help to inform individual placement decisions, service-wide strategies for helping optimal numbers of children to access permanence, and national policy about adoption.

That work led naturally on to developing our services for Looked After Children when I left the NHS and set up my own company, LifePsychol Ltd. We provide training and consulting to foster carers and residential care staff, the social care organisations that support them, and the wider professional networks surrounding them, including education and health staff, police, lawyers, magistrates and judges. As I started to get more immersed in working with children in and on the edge of Care, it led me to recognise that there was a lack of validated and reliable tools to identify the needs in these populations, no outcome measurement tools that could reliably measure change over time in a way that was sensitive to the context and type of life events these young people experience, and a dearth of clinical governance in terms of the efficacy of both placements and interventions for this group of children. That seemed shocking to me, given their highly complex needs, and massively elevated incidence of mental health problems, challenging behaviour, risk to self and others, and prevalence of intellectual or neurodevelopmental difficulties.

As well as the human cost of not being able to identify the best choices for people, it seemed unacceptable that huge amounts of money were being spent on placements and specialist services for this group without any evidence of them changing their wellbeing or life course for the better. Placements seemed to struggle to identify what to work on and how, and there was little objective indication of what defined a successful placement, beyond annual visits from Ofsted (who were predominantly focused on process and procedure). The high level of need and the lack of clinical governance in the sector has allowed various specialist therapists and services to spring up that are virtually unregulated, and many placements have adopted terms like “therapeutic” without these having a consistent definition or meaning. So I wanted to see whether I could make any headway in changing that.

Meanwhile there is pressure from the government to improve outcomes for children in public Care, because they are seen to fare badly compared to the general population of children the same age. The difficulty is that this isn’t comparing like for like – children in care have many more adversities to face, both organic and in terms of their life experiences, that mean they often deviate from the norm. For example, I found that there was a 20 point skew downwards in IQ distribution in children in residential care compared to population norms, meaning that 20-25% of children in this setting had a learning disability, compared to 2% in the general population. Likewise the incidence of Autistic Spectrum Conditions and other neurodevelopmental difficulties amongst children in Care is more than triple that in the wider population. The same is true of young offenders. If we don’t acknowledge that, then the sector is being asked to seek impossible goals and will inevitably be seen as failing, even if placements and services are performing optimally and adding a lot of value to the lives of the children they work with.

To state the obvious, children in care are not just randomly drawn from the population – by definition their needs have not been met, and this can mean both the presence of additional challenges and exposure to harm or deficits in care. I believe that to look at the needs of this population and the degree to which these are met by placements or interventions, we need to either compare them to carefully matched controls or ensure that outcomes are always considered relative to baseline. The latter seems more pragmatic. Scores for young people also need to be considered in the context of what is going on in their lives – as changes in placement, daily routine, contact arrangements, or the arrival or departure of other children from the home can make big impacts on the child’s functioning.

So I’ve been beavering away exploring these issues and developing systems to measure needs and make the data meaningful for those providing care and services. The impact might not be as obvious as delivering psychological therapy directly, but I’d like to think that over time it can improve services for thousands (or even tens of thousands) of children, and make a greater net change in the world.

 

*Maybe I’ll write more about this in a future blog. But the short version is that I have been trying to secure some funding to complete the statistical analysis and disseminate this information, and would still like to do so, so if you have any ideas or useful connections to assist with this please let me know. Failing that I hope I’ll find enough time to write a book on making better adoptive matches at some point in the future.

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, and 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.