On psychology getting its priorities right

Well, it’s been a year since I last blogged, and frankly that’s probably a good thing. I had anticipated a reduction in productivity and so it came to pass. 2017 turned out to be a year in which I changed job several times, moved house and watched two people die, so it’s fair to say it was eventful. Oh and I got a kitten, who is sweet and funny and of whom I am very fond, despite the fact that she constantly gets in the way and that I now get absolutely no peace in my own house. So all in all, keeping my head down – relatively speaking – was probably necessary.

I write this as I journey to Cardiff. My only blog of 2017 was written shortly after a trip to Liverpool, technically because I was speaking at the UK’s main clinical psychology conference, but mainly because I and some friends had organised our own (not exactly rival but not exactly not rival) events: a fringe festival bringing mental health and the arts together, and then a one-day conference looking at psychology going ‘beyond therapy’. Cardiff is the venue for this year’s events, both the main conference, which I’m not going to, and the fringe events, which I am proud to be a small part of.

I think it’s important to be proud of your contribution to your profession. Not in the way that many of us are – considering ourselves experts; getting caught up in the arrogance that can pervade; judging people based upon their academic output – but of the important stuff. Of going to work and doing what needs to be done to help people. Of using the knowledge and skills you have to try to bring psychological ideas to new audiences. Of doing it all in a way that tries make things better. The small things that are really the big things. Often unsung, but vitally important.

I am privileged to do what I do for a living, and I am privileged to know so many people who go above and beyond to try to fly the flag for better health and social care services, and who critique the policies that cause so much damage. Almost all of these people do huge amounts of work – usually for no money and very little in the way of glory – to do these things. Our profession is stronger for them, and lucky to have them.

So I am very dedicated to the profession of clinical psychology. But sometimes I have real concerns about other psychologists. And this past week has brought that to the fore.

A week ago a new document was launched looking at an alternative to psychiatric diagnosis. This blog is not a review of that document, because it’s 400 pages long and I haven’t had a chance to read it properly yet. The principle tenets of this framework are as follows:

And when I’ve finally read it I might write something on it, but there are plenty of people cleverer and better-read than me who will likely do a better job. And 400 pages is no small task. It was actually my planned train reading but I only got to page 18.

I have no major problem with the framework, though I don’t believe diagnosis is going to fall overnight, and I don’t know how health, social care or welfare systems would operate if it did, so I’m not getting too excited just yet. And it does strike me as interesting that a team of white professionals has written a 400-page document talking about power – and, whilst there was a consultancy group, consultancy is not the same as authorship and as a brown Muslim woman I absolutely own my response to that defence – but in the main I’m interested in seeing what impact this framework has on policy, because that’s where it needs to take root.

I do have a problem with the reaction of my fellow professionals to the same document. People who dislike or disagree with the framework have pulled it to pieces and questioned why it was ever written. Now, sure, pull it apart – we need to critique ourselves and our practice – but to denounce it as heresy is unhelpful, particularly if you don’t have the courage to write your own alternative framework. Being catty on Twitter is undignified. It does all of us a disservice. We should be better than that. It’s not that I can’t see why people might be sceptical – when my patients need the be signed off work their employer needs a diagnosis. So does their insurer. If they have OCD or a specific phobia it’s probably helpful to be able to give it a name, because talking about intrusive thoughts and compulsions is all a bit psych-speak for most of us. Labels and names and categories have their uses and we can’t lose sight of that. But there are diagnoses which are very harmful – I speak here of ‘personality disorder’ – and we do need to think very carefully about how we move away from decades of iatrogenic harm based upon a label that tells you that you are defective to the very core. Perhaps, then, trying to look at the whole spectrum of human distress within one framework – even one that’s 400 pages long – isn’t the ideal place to start. But there are ways of saying it, and a substantial number of people haven’t demonstrated much understanding of that.

People I would consider to be quite eminent – by which I mean long in the tooth – have been hostile to the point of vitriol. The authors have been attacked in a most unpleasant way. Clinical psychologists (thankfully very few of them, though) have used Twitter as a platform to call those who disagree with them – including people who use mental health services – stupid or unenlightened. The word ‘stupid’ has actually been used. It’s gone so far that I and some similarly perturbed colleagues had a look at the social media guidance provided by our professional and regulatory bodies. Someone else has grumbled about it being our new professional ‘policy’. It’s nothing of the sort. It’s a model; a construct; not an ultimate truth. You’d think people trained as social scientists would understand that notion. Instead, we’ve had people saying things like ‘Not in my name!’, as though the the document was tantamount to the dodgy dossier which led to the Iraq invasion. It’s ridiculous, and its unprofessional, and it makes me ashamed.

Psychologists – particularly of the clinical variety, it seems – have really got to up their game. We lord about declaring ourselves to be reflective and able to consider a range of perspectives and then we act like this. It’s a disgrace. But it’s also the wrong battle to be fighting.

Today some data was published showing that in poorer parts of the UK life expectancy is decreasing for the first time since 1945. This appears closely linked to cuts to health and social care, as well as welfare changes. The decrease has only been observed since 2011. It’s not hard to make the link. But has there been a social media furore from my colleagues over this? Was it mentioned once in any presentation today? Was it ‘eck. But this is what we need to be talking about. These are the battles we need to fight. Not squawking about changes that might or might not affect policy over the next decade; shouting and stamping about the people who are dying now.

I simply don’t understand why more of my colleagues aren’t beating the same drum. Sure, my perspective is heavily coloured by my demographics and the experiences that have come with them, but surely even the most privileged person must understand that the basics of food and shelter and dignity keep people level. Not entirely level, but they make a good start.

Really what I’m saying is that I have been profoundly disappointed by some of my colleagues recently. And if I’ve been disappointed goodness knows what the public has made of it. And we have got to change. Not just for the sake of clinical psychology but for the rest of society. If we don’t wake up to that we’re going to perish. And that really would be a shame.


On clinical psychology and stagnation

January is always a struggle. It’s freezing, it’s wet, and any festive joy you may have been channelling has evaporated, leaving only your expanded waistline as evidence that it ever existed. Even if you hate Christmas, I don’t know anyone who loves January. Its only redeeming feature is that the days finally begin to get longer. 

My January was notable because I started two new jobs. What that meant in reality was that, in addition to all my actual clinical work, I also had to spend huge amounts of time trying to get ID badges and security passes and printing tokens (since when do you need a SWIPE CARD to print a letter, by the way?) and IT access and clinical notes access and remembering the names of five thousand different colleagues. 

Tiring, reader, does not even begin to cover it. Though I suppose world events *may* have something to do with that. But anyway. I’ll have no shortage of opportunities to write about the nightmare of global politics over the coming months, more’s the pity, so I am going to write something less dystopia-focused. 

My new-job-excitement was subject to an interlude because I went to Liverpool. Basically, the main clinical psychology conference was occurring there and a motley crew of colleagues  and co-conspirators had thought it might be good craic to simultaneously have a fringe festival bringing together mental health and the arts, as well as reprising Beyond the Therapy Room, which was first held in London in 2015, and which is very close to my heart. So I was always going to spend a few days in Liverpool, but I wasn’t too fussed about the big conference. 

I then got a very kind offer from the inestimable Anne Cooke, who was organising a panel debate on the future of the profession. Many of the biggest names in U.K. clinical psychology were on the panel, and I agreed, though I confess I wondered from the beginning what I could say that would be useful or interesting. I have no pretensions about my contribution to my profession – it is, as you would imagine, tiny. But anyway, I said yes. 

The week of the conference rolled around and several of the panellists emailed synopses of their points. I had no idea what I was going to say so kept quiet. The day before the conference rolled around. I hared off for a half-day at work before trotting to Euston for a train and spent the journey stuffing my face and looking out of the window, still unsure what I was going to say. 

That night I met up with some friends who were also involved in the Fringe and we spent the evening escorting acts to venues and so on. I had by this time some half-formed ideas for what I was going to say, but no more. 

On the day of the conference I still wasn’t sure what was going to come out of my mouth (not unusual, given that I rarely plan a talk thoroughly, but this was vague, even for me) but I knew it would have something to do with the privilege of clinal psychology training and the passport it gives you to a better kind of existence (the debate was recorded and once I’ve a link I’ll post it here). But as I got onto the stage (a stage so flimsy that I genuinely thought my right foot was going to go through it at one point) and took my seat I suddenly realised something. 

I was at the flagship clinical psychology event in the U.K., at a debate on the future of the profession. And all I could see around me were white faces, mainly – and I do hope they’ll forgive me for saying so – of a certain age. Now there were exceptions, of course. A few ethnics, some younger folk. But there were a lot of old people in suits. And even though I had been around these people – all decent people, I’m sure; some of whom I know, and none of whom I wish to denigrate – all day, it wasn’t until I saw them as a group that I realised how homogenous they appeared to be. And so I began to wonder why this might be. 

There are 12 000 clinical psychologists in the U.K., but only around 2-300 attend the conference. And, from the few I have attended, it’s often the great and the good who come; those who are established and respected and whatever else. I went because I was speaking, but otherwise I wouldn’t have (I’m not a huge fan of 3-day conferences, for many reasons and in any case, the sheer cost of it was prohibitive). But many of the clinical psychologists I know couldn’t give two hoots about it and that, I think, is concerning. 

Put bluntly, we had a debate about the future of the profession attended primarily by people who may well not even be practising in ten years’ time. Those people may know their stuff; they may have built careers and won awards and got tenure and have a publication list as long as your arm, but they are not the future. People who are barely-qualified are the future. People struggling to get onto training are the future. And the people who use our services are the future, because they know what our profession needs to do differently. And whilst there were one or two explicitly ‘service user’ voices, they were drowned out by the rest of us with our doctorates and our academic posts and our reputations and our egos. 

And as the panel stopped talking and the audience began to contribute I knew that nothing that anyone had said would make any difference in the real world and that many of the conceptual debates will go on for years to come and that although we might have clapped and patted each other on the back we need to start having radically different conversations with radically different people if we are ever to make any progress. 

So, conference duties over, my attention returned to the Fringe. I attended events on both the Thursday and Friday nights, scampering across the city to try to cram in as many acts as possible. Inevitably, there were too many late nights and too many detours to the nearest fried chicken shop.  But it was joyful and energising in a way that most conferences, I think, fail to be. And on the Friday – the last night that most of us were in the city – we once again trundled off somewhere for crisps and conviviality. And I looked around the table and I saw perhaps 18 or 20 people – performers, their friends and partners; psychologists and their friends and partners – many of whom barely knew each other; some of whom were good friends, discussing mental health and art and politics and something and nothing and it was joyous. And that is my psychology – a psychology in which I can have a drink and share some crisps with someone and get to know them. And that, I think, is the psychology that many people – qualified or otherwise, because our shared humanity is what’s important here – believe in. 

I don’t think the current model can survive, not if we want a profession that is going continue to be relevant in the decades to come. Academic publishing is in crisis – hell, academia is in crisis. The NHS is in crisis. Mental health services have never not been in crisis. Taking three days off and paying the better part of £500 to stay in the cheapest hotel you can find and go to a conference which obviously isn’t attracting the people who will be ‘doing psychology’ for the next thirty or forty years? It’s not sustainable. It can’t be. 

What I want is to go to a clinical psychology event that actually represents people. At the moment, we don’t. We know that clinical psychologists are too white, too cisgendered, too rich, too able-bodied, too straight. Apparently we’re also too female, though it’s still men who get the most senior jobs so my sympathy is limited, frankly. But also we have this absurd division between ourselves and the people who use our services and although we might talk about ‘no us and them’ I don’t get that sense of democracy in action. There’s always a service user stream at conferences, of course, but it does feel rather like crumbs from the rich man’s table. 

I suppose my vision is of events which bring people together – irrespective of your background or training – and which allow them to think of ways to make our systems and practices better. That’s not radical – better people than me have been saying it since forever. We talk about making services accessible to all, but we haven’t managed it with our training pathway and we certainly don’t manage it with our professional events. It’s hardly surprising, then, that so many of us have such complex feelings about the way we earn our livings. 

I don’t know how this magically happens. There are obviously people doing this work all over the place, and maybe those people aren’t attracted to fancy conferences and that’s fair. But there is very evidently a real problem if huge swathes of people feel disconnected from and unrepresented by their professional body. And of course you have to be part of something to be able to change it. But you also – as many of us know – have to be given the opportunity to actually create real change. And maybe that’s something we need to work on. 

On the end of a year

It’s a funny thing. Despite the catastrophe that was 2016, I’ve not written a lot this year. I used to blog more often, and one thing I’ve learned is that the more acutely I feel something the better I usually write about it. But there’s probably such a thing as feeling something too acutely, and 2016 has been overloaded with emotion, for good and ill. I have something – based on a blog post – with an editor, awaiting publication, but this post is the last thing I will type this year. I mean that quite literally – I leave my job tomorrow and I really don’t intend to do much in the way of writing in the next 24 hours.

I’m not sure how much writing I will do next year, really. I enjoy doing it but sometimes it’s hard to feel that it isn’t just adding to the white noise which permanently surrounds most of us. And I have never pretended that my thoughts are especially original – perhaps I write more for myself than for anyone else, and perhaps there’s nothing wrong with that.

For ages, I have dreamt of having more time to write. I have always written in my ‘free’ time, but the nature of the jobs I have had over the past ten years has meant I haven’t actually had that much free time, particularly as I do some fairly regular stuff on a voluntary basis as well. Essentially, I have worked a LOT over the past few years. But, from January, I drop my working hours and, ostensibly, that will give me more time to write. But I’m not sure if I’ll use it to write, or to read, or to think, or to exercise, or to just sit.

It’s easy, as a psychologist – or, probably, anything, but I can only speak as a psychologist – to get pulled in a lot of different directions, for all sorts of reasons. It’s especially easy, I think, if it’s really important to you to be a ‘good’ psychologist. I don’t know how I conceptualise that, necessarily, but I suppose part of it is trying very hard not to cause people more harm. And that’s a really hard thing to do, because mental health services and the people who work in them have been doing harm for a very long time. So it becomes very easy to have incredibly high standards, or to look to other people’s standards, which you then perhaps can’t meet, and it’s probably not the most helpful pattern to fall into. It’s obviously even easier when you’re a heavy social media user, and I’ve noticed in recent months that I’ve spent much less time interacting with people on Twitter – and certainly less time discussing mental health in any particularly in-depth way. I enjoy Twitter a lot, and I’ve met many people I like and respect through it, but it does seem like a constant fight, sometimes, to be all things to all people, and often it’s rather more stressful than I would like it to be. You can’t vanquish your own pain by funnelling it all into someone else, and it’s not nice watching it happen, or having it happen to you. But, of course, if you’re going to use a tool you have to be prepared to take the good with the bad, and maybe I’m a bit tired of the anger and the pain and the overt hostility. So while I won’t quite be flouncing off into the sunset, I’ll probably be around a bit less.

In the immediate future, I will be in a kind of purdah – it’s time for a well-deserved, and distinctly overdue, holiday, and I shall be incommunicado from tomorrow. I might, after my return, feel differently, but I don’t think so. I suspect that a couple of weeks away from the chatter will be very good for me and I’ll realise, as I always do when on a self-enforced hiatus, that it can sometimes take away from my life, as well as adding to it. And, of course, I’ll be busy having a new job and and that will probably give me plenty to be getting on with.

I hope that next year will bring less of a malaise, politically, but I won’t hold my breath.  And maybe I will come to a point where I can offer a perspective on things which is more original, more nuanced and more useful in creating positive change. But, as I have said before, perhaps the biggest resistance in these unpleasant and damaging times is simply treating those around us with kindness and gentleness and humanity. And so, in that spirit, a Merry Christmas to you all, and may you be buoyed up for the challenges of 2017.

On Voting

It’s the time of year when editors start to commission those ‘year in review’ pieces. I’m not going to write one of those, for all sorts of reasons. But it would be absurd if 2016 had failed to leave a mark on me. 

Regular readers may recall the blog I posted after the 2015 General Election. I was shocked by the Tory majority; horrified by what it meant. ‘But’, as always, I said ‘we have to regroup and fight the good fight’. I was resigned to swingeing cuts until 2020 but I had hope that Labour would be an effective opposition. I’ve yet to see much evidence of that, but I digress. 

Along came the announcement of the EU referendum. I was disturbed by much of the rhetoric around it and appalled by the murder of an MP, but, despite the polls, I thought the Remain camp would edge it. I didn’t stay up to watch the results – I never do, because I can’t bear the patronising tone of the commentary and I have no interest in Jeremy Vine’s crap graphics – but I checked them as soon as I awoke and I was staggered. But this came at a time when I was still reeling from the shootings at Pulse and I simply couldn’t process it. It was clear to me that the Leave campaign was fuelled by hate and that it spat out lies and I simply couldn’t believe that people – people I knew; people who had been refugees; people who were themselves migrants – could buy into the ‘foreigners go home’ rhetoric. 

Despite my best efforts, I am still angry at those people. Because however I try to rationalise it, deep in my heart I am angry at people who have benefitted so much from the EU over the past forty years but decided that my generation should not benefit. Interestingly, I am not as angry at the people who are working-class or poor or who have few opportunities and believed that Farage et al. were their  saviours. I’m angry at the migrants who sided with a bunch of racists and fell for their lies. I expect migrants to see through those lies because they have likely been lied about themselves. Every time I think of it I am filled with a fury which is alien to me. I am not, by nature, rage-filled. I am angered by injustice and bigotry and cruelty, but we should all be angered by those things. But to be consumed by a rage so great that it threatens to overwhelm all rational thought is new to me. But beneath the anger, of course, is fear and disbelief. 

I cannot believe that we have got to a point in British history where those fleeing for their lives are referred to as ‘cockroaches’; where people who look different are told they’d be better off drowning than reaching these shores. I cannot believe the hate I see and hear around me. This is not the Britain I grew up in. This is not how we do things in the country I have always considered my home. My family came here as refugees and we did everything ‘right’ – they worked and paid their taxes. They raised children who were polite and upstanding and those children were fortunate enough to get a good education and now they – I amongst them – work and contribute to society. We don’t commit crimes. We don’t incite violence. We respect the land that gave us sanctuary when our own lands wouldn’t. 

But despite all that, our demographics count against us. The thing about demographics, of course, is that you can’t do a lot about them. I will always be Asian. I will always, for as long as I live here, be a second-generation immigrant. I do, of course, have rather more control over my faith, but if you think you’re going to bully me out of that you’re very much mistaken. 

I understand that indigenous populations might fear ‘the other’. That makes sense to me, as a psychologist and a person. But what is beyond me is the divisions that have been exposed between people who have similar experiences. How can someone who sought asylum forty years ago vote against the interests of those seeking asylum now? Where on earth has your humanity gone?

So this is how the EU referendum left me feeling: sick at the success of a campaign which was designed to fragment our society. But it also meant that I became virtually reconciled to the idea of a Trump victory in the US. Not pleased by it, but not naive enough to think that our cousins across the pond would be any better at recognising lies and hate for what they were. So when I awoke last Wednesday, I could barely raise an eyebrow at the result. I can still barely raise an eyebrow. It’s not that I don’t care – it’s just that I feel numb. I suspect that beneath that numbness lurks rage and terror and hurt. Because it does hurt, as someone whose demographics are so vilified, to know that 25 million people voted for a man who may cause you and people like you harm, and that almost 50 million didn’t care enough to vote against him. And again, it’s the minorities who voted for him that I am angriest at. It’s the Mexicans who voted for him, despite him calling them ‘rapists’. It’s the women who voted for a misogynist. It’s the people who have thrown their brothers and sisters – and maybe even themselves – under the bus in the name of freedom. 

You may tell me that there’s no need to be terrified; that Trump won’t do half of what he said he would. And you may be right; but there’s no guarantee of that. And if you’re not frightened I suspect you’ve no need to be. The rest of us – the ones who stand out; who wear our difference openly – know that to be frightened is the only realistic response to such a calamitous result. 

Not that I’m a fan of Hillary Clinton, mind. And, of course, America has huge problems with bigotry and war-mongering and prejudice. A Trump presidency just lifts the veil on it. But veils are important. Whilst hate is veiled you know it is something mainstream society shuns. When the veil is lifted you know the hate has become mainstream. 

This is what I – and maybe others with minority identities – truly fear: the normalising of hate and bigotry. And the problem for me is that I’m not sure how to process that as a person, so I have no idea how I do it as a psychologist. Yes, we engage in small acts of resistance. Yes, we maintain our individual humanity even as society loses its collective humanity. Yes, we continue to fight for those who will be most damaged by this terrible new world we are creating. But the problem is that the hate peddled by these people is pernicious: if we’re not careful, we all become tainted by it. And I am in danger of doing what so many have done and of tarring all those who voted for Trump with one brush. I am in danger, in short, of doing exactly what these people want: of falling for their spin and their lies and of hating people I have never met but who I have constructed in my mind’s eye. 

So I don’t know what I do with this, as a psychologist. But as a person, I suspect my first and greatest task is simply this: do not hate. Do not become that which seeks to divide and to destroy. 

And that, I suspect, will be much, much easier said than done. 

On Islam, homophobia, and hate crimes

That the Orlando shooting was a homophobic hate crime is incontrovertible. The massacre of people at a gay club is obviously different from the massacre of people at a football stadium or an office or a shopping mall. I have no interest in arguing this point.

The news which has since emerged – that Omar Mateen went to Pulse on a reasonably frequent basis; that he used a gay dating app – puts a slightly different spin on it. No longer are we simply dealing with a man who may or may not have been an ISIS sympathizer; we’re possibly dealing with a man who was closeted; full of fear and shame and self-loathing. It’s obviously an extreme response for that ghastly mix of emotions to manifest themselves as mass murder, but, if that is the case, all of us need to take a long hard look at ourselves and the society we have created.

Anyone who thinks homo, bi and transphobia went out of fashion the day LGBT people got the right to marry and adopt is living in a dream world; just as anyone who thinks the end of segregation was the end of racism needs a reality check. We live in a world of deeply-rooted prejudice; a world in which coming out can, quite literally, cost you your family and your home. In some cases it can cost you your life.

We can blame Islam for making Mateen homophobic – though there’s no evidence he was particularly religious, and as a Muslim who has read reasonably widely around this subject I contest the claim that Islam is intrinsically homophobic – or we can take a more mature approach; one that doesn’t involve ‘othering’. Because it’s not only people of faith who are homophobic, is it? We live in a homophobic society; it’s a miracle for anyone to grow up without being tainted by some of that hatred and fear. None of us is immune from it. The important thing is how and when you extricate yourself from it. Mateen, evidently, never managed it. But lots of LGBT people don’t. And that’s the same for many other minorities – we all know women who can be sexist; ethnic minorities who can be racist.

Yes, mosques and the people who run them need to make statements to the effect that there is no room for such violence in Islam or the wider world; that all people, regardless of gender or sexuality are worthy of love and acceptance. But it’s not just down to mosques, because it’s not just in mosques where LGBT people continue to feel excluded. It’s also in schools and offices and football teams and in government. And by failing to acknowledge that you buy into the myth that we are ‘post-homophobia’. Like hell we are. If we were post-homophobia we wouldn’t still need LGBT clubs; we wouldn’t have to have ‘safe spaces’, where you can hold hands with your partner without fear of reprisal; we wouldn’t need legislation declaring people’s right to live and exist as equals.

But we do have all those. And we don’t have them because ‘Muslims’; we have them because we have failed to create a world in which all of us accept and love all others, regardless of who they love.

It’s not Muslims, or people of faith. It’s homophobes, whoever and wherever they are.

It’s all of us.

On wanting to die

It’s an avalanche of blogging at the moment, rather. First I wrote this on the assumption that people with mental health problems have no right to choose to die and then my colleague and Twitter chum Huw (@Huwtube) collected some of his thoughts on the topic. Between this and discovering, in the past ten days, that three of my former patients have died recently, it’s all been rather death-heavy.

Lots of the people I work with want to die. Most of them are old; many have dementia. Some are housebound, or bedbound. They may no longer be continent. Lots have carers who wash and dress and feed them. Some are going blind. Good physical health can be a thing of the past. Frailty and infirmity are what they see coming towards them. Many are terrified.

I often ask the question ‘do you ever think about harming yourself?’ It’s rare my patients say ‘yes’, but many say ‘I want to die but I don’t know how to do it’. I’ve heard that statement more times than I can count but it’s always been something that’s puzzled me – so many of the people I have worked with have known exactly how to kill themselves that the naivety of not knowing almost brings me back to another reality; one which is not so skewed by the desire to not be alive anymore.

When I heard about my patients having died – all from natural causes – I was sad, but that was primarily because I knew their families and I knew that watching their loved one suffer had sometimes been a torment, particularly towards the end. A part of me also felt that at least the patient was no longer in a state they didn’t want to be in. I didn’t wish them dead but I certainly felt a sense of something – I can’t name it – that it was over. ‘It’. I don’t even know what I mean when I say ‘it’. ‘Illness’ seems a silly word; ‘life’ seems cruel’; ‘suffering’ seems pompous.

Perhaps this is why it is so hard to talk about this stuff. No matter how articulate you think you are, how verbose – and I am certainly verbose – the language can elude you. I can’t always describe what I think or how I feel, and that means I might be clumsy or say something ill-judged and then I worry dreadfully that I’ll be misconstrued. As I acknowledged in the post for Discursive, I worried a great deal how people would construe what I was trying to say. 1100 words is nothing on a topic of this magnitude and there is plenty to think about and plenty that needs to change (I freely admit that the comments on that piece are far superior to my original post and they are very much worth your time). What I said, essentially, was that people who find life to be unendurable have a right to an opinion on whether they should continue to live or die and that mental health professionals cannot simply tell them they have no right to die. Conversely, people in distress who express a wish to die should be given the emotional and practical help they need. Ideally, they’d get it long before it gets to that point, but that’s a blog for another day.

Life can be unendurable for many reasons. Classically, we see it through the ’emotional pain’ perspective, but, thinking sociopolitically, there is more to it. The assault on welfare and social housing and the cuts to services have served to make life unendurable for people who may well have been coping before 2010. People are dying and the State is responsible for their deaths. I understand that people who are in a desperate state and who see no way out might want to end their lives. I don’t consider that ‘insane’ in any way; I can see perfectly well that it may be a rational solution to a problem which appears to have few alternative solutions. The difficulty – or one of them, I suppose – is that surely a health professional who supports that wish to die becomes unwittingly part of some kind of social cleansing? But equally, unless you can actually change that person’s circumstances and improve their quality of life, is it not unethical to consign them to an indeterminate period of despair?

I don’t know how you decide if life is worth living or not; not really. And I also don’t know how you can ever come to an conclusion about whether someone else’s life is worth living. I tried having this conversation yesterday with someone and my suspicion is that she was slightly horrified that I – a health professional and a Muslim to boot – could even begin to talk about supporting people’s right to die. I don’t know what impact my being Muslim has on my view of the situation but I’ve always tried to be the kind of clinician whose work is about her patients rather than herself. I try to stick to ethics and my principles and I cannot state where they came from any more categorically than I can state where my desire to do this work came from. The point, dear reader, is that it is not about us as professionals. It is about our patients (the fact I am writing this as a professional has not escaped me). That doesn’t mean we cut our professional selves off from our personal selves, but it does mean we need to get over ourselves and think about what our patients are telling us and what they need more than what we need. Being a psychologist is not about meeting your own needs. It’s about meeting the needs of your patients. It’s obviously easy to type and harder to do, but there it is.

I don’t know how I square that last statement with my earlier statement on being ethical. But then, this post is littered with ‘I don’t know’ statements. And maybe that’s just how it is – we don’t know. We don’t know when someone’s life is worth living and when it is not, and maybe nor does the person who wants to die. And I don’t mean that to patronise; I mean that the future is unknowable and therefore everything we do is based on our best guesswork. In my job there’s a lot I don’t know. I don’t know if my therapeutic approach will work for you. I don’t know if I can help you. I don’t know if I can give you what you need. And sometimes I don’t know whether life or death is the better option. I don’t like to get things wrong, not when it comes to my patients. I want to help you first time round. I want to give you what you need. And so when it comes to life and death I want to get it right. But there are no guarantees. And that’s why, when you ask what I think, I can’t give you an answer. I simply don’t know.

On doing therapy in untherapeutic places

I have been in healthcare for ten years. In that time I have worked in, amongst others, Georgian manor houses, secure wards, prisons, prefab sheds, swanky neurology hospital wings, low-secure units, converted Victorian houses, purpose-built units and the dilapidated dungeon of a Victorian asylum. I won’t lie: none has been ideal. Even purpose-built places have industrial decor and, being a Freudian at heart, as well as being a bit soft, I think therapeutic spaces should be comforting. When I have some say over where I see patients – i.e. when I am slightly more important than I currently am (not very, frankly, however much I like to fool myself) – I will have decent squashy armchairs rather than fire-retardant polysomethingorother, rugs, NICE paintings on the wall rather than a job lot from IKEA and pots and pots of tea on the go. I like my creature comforts and frankly I think patients deserve to be seen in an environment which is pleasant. ‘Functional’ is fine at the dentist. It is not, in my view, when it comes to therapy. Infrastructure is important.

And so, when I saw this, yesterday, I had several responses, and very few of them were positive:


Therapy has always occurred in untherapeutic places. Therapy in prison? We’ve been doing it for years. It’s a challenge, really, because prison is not a nice place and it’s probably not great for your mental health. I have never been on a psychiatric ward and found it comforting. I think it’s a shame – people on wards are often ill and frightened and although they need to be safe they also need to feel safe. I know what makes me feel safe and I don’t think many psychiatric wards would provide it. When I deputy-managed a hostel for women with mental health problems and offending histories I quickly assumed control of all things decor- and DIY-related. I believed that these women deserved to live somewhere that felt like a home. I chose all the furniture when a room was redecorated. I ordered stuff that matched; decent curtains; a nice rug. I made sure the mattress was comfortable and that the bedding was coordinated with the paint. These women had done things which made them outsiders and I wanted them to live somewhere that felt better than hospital or prison; I wanted this hostel to feel like a home, as much as it could. My acid test has always been ‘would it be good enough for my sister?’; lots of the places I have worked have not been, but I tried my best to make this good enough. 

These are all superficial, of course, but the point is the same: how do you do good work in difficult environments? As a rule – in my experience at least – therapy looks at what you can change, because, not to put too fine a point on it, you cannot change what you cannot change. I cannot magically make a ward nice but maybe I can try to make your experience of being there a bit less unpleasant. So my take is always ‘what can we do to get you where you want to be, and how can we try to make it a success?’ But these are interesting times and now psychologists are expected to do therapy in Job Centres and Immigration Removal Centres and I find it deeply unsettling.

Now on the one hand, I am always banging on about the need for psychologically-informed thinking in a range of institutions. Policy affects lives and a thorough understanding of the consequences of government decisions on the existence of the electorate is crucial. There is too little psychological thinking around and frankly it’s got us into a bit of a mess. So, on the face of it, perhaps it makes sense to have psychology in JCs and IRCs. But I wrestle with it. And it’s not entirely clear in my own head yet, but these are some of the reasons I wrestle with it:

‘Rapid turnover of detainees’: Guys, therapy is not as simple as prescribing a pill. I’m not a GP; I can’t sort you out in ten minutes. Maybe I can’t sort you out at all, but I’d really rather we both had the luxury of time to discover whether that’s the case or not. Once, I worked on a stroke ward. I liked it. I did assessments and some intervention and some family work. But turnover was so high that sometimes I would be halfway through an assessment only to discover that the person had been discharged. What does this mean? It means my assessment is incomplete. It means I’ve put you through half an assessment and I can’t even write a proper report outlining all the ways you need some help. It’s disappointing for me and unfair on my patient. And in a job like this it would be endless, and disheartening. And it’s one thing to do neuropsych testing and have to leave it halfway; it’s quite another to do a therapy assessment and leave it halfway. Tell me your trauma and your pain and your fear, but only tell me half of it. Let’s open up the can of worms even though we know we won’t be able to stem the flow. Let me hear half your story and build up some kind of connection and then walk out of your life. Let me break rule one of therapy; the one about a safe and secure relationship. Let me retraumatize you. 

You will see my point, I think.

Next: ‘Stepped-care approach’: Stepped care is great, when there is an a actual care pathway. But if you’re about to be shipped off to another part of the world how can I make recommendations for ongoing care? I can’t assume there will be the infrastructure or the clinicians or the money or the skills to provide what you need. You can’t provide stepped care without a staircase. And a staircase with woodworm isn’t a staircase. It’s a disaster waiting to happen.

Next: An Immigration Removal Centre. It will be full of immigrants. Why might they be immigrants? Because I do not read tabloids, I do not think it’s because they want a big telly and a gorgeous partner. I think about poverty and war and torture, because in my line of work I have to think about poverty and war and torture because I come across them all so much. So we might have some complex, traumatized people. ‘Brief intervention’? For traumatized people who may be terrified that they are about to be returned to their tormentors? Shut up. Seriously. If you think that is appropriate I can’t even be bothered to talk to you. You might think that’s unreasonable, and maybe it is, but I’m a psychologist, not an angel. 

Incidentally, and not to be a cynic here – I take Oscar’s definition of a cynic as Gospel and I know the value of many things, thank you very much – several people ‘in the biz’ have suggested that really, this is about managing immediate risk to make sure nothing ‘untoward’ happens whilst frightened and desperate people are held in these centres, and that really therapy is much less of a focus. I couldn’t possibly comment.

But there’s something more fundamental here. I know that the system I work in – the NHS – is flawed. It is deeply imperfect and sometimes it does not support people as well as it could. But I think its intentions are good and I think it retains values I believe in. So I work within it, trying to do my best not to do harm. But the thing is that some environments are so tainted that I don’t know if psychologists should touch them with a bargepole. Surely working in an IRC is akin to saying ‘IRCs are fine, or at least good enough for me to associate myself with them’? You know a person by the company they keep; you judge a person by the institutions they are associated with. There are institutions so disreputable that I would not be associated with them whatever they offered me. It’s about value and ethics and principles. And I know it’s easy for me to say – I have a job, which is more than many can say. But psychologists rarely have to fight for jobs; we are highly employable. I don’t want to legitimise bad practices and bad policy; all we truly have is our integrity and frankly I think it’s worth fighting for. For me, to accept a job like that makes you to vulnerable to corruption. Because good people can work in bad place but it takes an extraordinary person to work in a bad place and not be tainted by the dirt.

We should be fighting inhuman and oppressive practice. We should be standing outside Job Centres and IRCs, waving placards and denouncing current practice. We should be helping policymakers think more psychologically to provide supportive environments. We should not be propping unethical institutions up with the aim of ‘making them better’, because, frankly, it takes more than one psychologist to right a rotten system. Denounce that which is bad; model that which is good. Do not get sucked into bad systems. It rarely ends well, in my experience. After all, dear reader, the road to hell is paved with good intentions and few of us are truly incorruptible.