Professional practice

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 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 ‘secret diaries’

Secret diaries. The preserve of people who can’t tell you the truth, despite desperately wanting to. Sometimes they’re interesting because, if we’re honest, most of us are nosy and voyeuristic. Some are boring. I will never care what a financial analyst does all day (#sorrynotsorry). But the point of a secret diary is that it’s meant to reveal a mystery in some way. I am trying to think of one which was about someone in a mysterious profession but I can only think of ‘Girl with a one-track mind’ which is going to give you totally the wrong idea about me. Evidently I don’t read enough secret diaries.

BUT. The Guardian has a mental health series on at the moment, and it has featured a few secret-diary-expose-type-things. Yesterday (or maybe on Tuesday – I don’t know and it doesn’t really matter) there was this: ‘The secret clinical psychologist’s diary‘. I commented on Twitter (obvs) that I thought more could have been made of it. Now, I don’t know who wrote it, but I know someone wrote it. As I generally try not to be a douche (no, really, I try quite hard to be a non-douche) I am going to say why I thought more could have been made of it without being cruel.

I think psychologists do a lot. Really. I have been qualified a year and I do a LOT of work. That goes for every health worker I know. But to the outside world what we do is a mystery. Diaries like this are the way – anonymously – to explain it; to make people see that we do more than ‘talk to people’ and drink tea and hug it out. I don’t think the piece says enough about the consultation we do; the teaching; the supervision; the meetings; the paperwork; the demands of the clinical work. Only one clinical case is referred to. This might be because of confidentiality but I obviously don’t know. The final paragraph refers to inpatient work but no mention of this is made in the earlier part. Now obviously I don’t think this psychologist only saw one person in their working week, but the articles doesn’t make much mention of the sheer variety of the work. I am sure, also, that the time constraints are enormous and the pressures immense. In my view, it’s no bad thing to say that in the public domain. In fact, in the current climate, I think it’s essential. We are under siege but no one is listening. People in power think they can slash our resources without any impact on our wellbeing or the care we can provide our patients with. Well we can’t. Public sector staff are beyond stressed at the moment. The stats are freely-available. We need to publicise what we do so that the public at large gets a better understanding of it and of unsustainable it is.

You will see why I was frustrated, I hope.

I think it’s great when people want to do this stuff; I just don’t think we should be afraid of saying ‘we work damn hard in a job that can be difficult and stressful and exhausting and in which we see and hear appalling things’. Really, that’s all my frustration is: don’t play down what it is you do. We have a history of playing down what it is we do and I don’t think it benefits anyone.

I toyed with the idea of writing my own diary but there are issues. I can’t write it under my own name because I am easily Googleable and my patients might be traceable. I can’t write it anonymously because I have a very particular writing style and it would be patently obvious that it was my work. And I’m too lazy to make it up and invent patients (also I should be writing other things at this very moment in time so, you know, PRIORITIES.

So there we are. Sadly I can do nothing about the points I raise above but it’s really not for want of motivation. If you want to know the nuts and bolts of what I do, ask me. But, in case you’re interested in the more general stuff, here you go.

I work in an Older People’s Community Mental Health Team. Primarily I see people over the age of 75 but sometimes they’re younger. Many have dementia; some are low in mood or anxious. Some are in poor physical health; some are at risk of falling or vulnerable to abuse or exploitation. Most live at home but some are in residential care. I do some inpatient work, but that’s not the bulk of my clinical work. I have no consulting rooms so see everyone off-site. I cover an entire borough of London so I travel a lot.

I work with patients and their carers. Dementia can wreck entire families and often carers need support. They may be watching a loved one disappear before their very eyes and the strain is often enormous. Typically, I will try to help the person with dementia to manage their memory loss and I might also do some family therapy to think about the impact of dementia on relationships. Often I do assessments of challenging behaviour – not uncommon in dementia – and try to implement strategies to reduce the risk of harm to both the patient and their carers. Sometimes I talk to carers about the grief they are experiencing; about the difficulties of looking after someone who may no longer recognise them when they are still trying to maintain jobs and families and lives of their own.

Sometimes it is heartbreaking.

I use an eclectic therapeutic approach. Different approaches work for different people. I spend a day a week in a family therapy clinic and I am also training in family therapy. In addition to traditional therapy I also do neuropsychological assessments for dementia. These assessments can take up to eight hours to complete, plus time to score and write a report – possibly up to six pages of dense text. Sometimes I have the difficult task of telling someone they have dementia. I try to do this in the kindest way I can but it is never, ever easy.

A couple of times a month I am ‘on call’, which means I deal with all referrals to the team. I might have to deal with GPs or Social Services or do an emergency assessment. I am on the phone to Social Services a LOT. They all know my voice now. Sometimes patients or their families call because they are worried about something. Often, we can sort it out by telephone. Sometimes we spring into action immediately. Flexibility is the name of the game. It has to be.

Each day I have a team meeting to check how everyone’s diary is looking and to see if they are worried about any patients, or to see if they need a second person to accompany them on a visit. When you work in the community you need to make sure your colleagues are safe at all times, so there are multiple processes in place to make sure our whereabouts is logged.

On average, every week I will do two initial assessments with a colleague to see if the person has been referred to the team best able to help them. There is a lot of paperwork attached to these assessments, and more generally. Risk management is a big part of the job. In teams like mine, we see people who are often actively suicidal, or whose use of alcohol might place them or others at risk. Emergency meetings with Social Services are not infrequent. We will do whatever we can to keep people safe – we will arrange for smoke alarms to be fitted; for kitchens and bathrooms to be adapted so that people can stay at home for as long as possible.

I go to meetings. I have a weekly business meeting and referral meeting; I have regular supervision and I also supervise some of the work done by a couple of other people who are new to the team. This means that we have to prepare for all their clinical work, that we have to discuss it afterwards and that I have to go through all their reports with them. I enjoy it, and they are bright and keen to learn. I do some informal consultation with other members of the team if either of us needs some input around our clinical work. I am clinical lead for my team so I go to additional meetings to talk about non-clinical issues. Now and then I write reports to do with service development. If my colleagues are away I might visit their patients to make sure all is well.

I eat lunch at my desk, in a hurry, most days. Every day I take a book to work. Almost every day I end up discussing clinical issues or dealing with admin over lunch. Often I feel like I’m chasing my tail. Sometimes I realise I’m up do date with all my paperwork and I feel smug, but it never lasts very long.

That’s an average week, I think. I might have forgotten something, but you get the gist. And you will see, I hope, why I get frustrated when people undersell themselves, and us.

On clinical psychology as part of the problem

It feels a bit trite writing this now.

Last week, (and believe me, I have never said these words before) I wanted to go to Birmingham. There was a conference I fancied going to, on the topic of ‘Power, Interest and Psychology’. The conference sprang from the ideas of David Smail, a deeply influential psychologist who died last year. I never met him but he wrote prolifically on ideas related to the causes of distress – not faulty genes or a lack of moral fibre, but a society in which power is distributed unfairly and in which humans suffer as a consequence. I love that stuff – the chance to think about the unequal structures we have created and the ways in which they can be dismantled; the chance to be (legitimately) angry; the chance to thrash the ideas out with friends and colleagues who are sympathetic to them. I didn’t make it because it was priced well out of my reach which, if anything, shows at least that the organisers, my professional body, retain some sense of irony. But I was going to write a blog, regardless. Then Paris happened and my thoughts were consumed with that. I have toyed with writing something on that – on being Muslim in Europe; on having spent my entire adult life being part of a group widely feared as potential terrorists; on the fact I am now more acutely aware of my Muslimness than ever before – but I don’t know what the point is. I wrote things after the London bombings and after Lee Rigby and after Charlie Hebdo and I don’t know what more there is to say aside from the fact that I am weary of it and I am increasingly feeling less safe as a Muslim woman and that I see no sign of any improvement.

So, in that context, you will see why it feels trite to write this now. But life does not stop because of atrocities and I am still a psychologist and I still think there is much to be done in the world of psychology. Those who know something of me will know that I struggle enormously with my profession. I think it is worthwhile, which is why I do it, and  I often enjoy it, but it is far from perfect and  I would be lying if I said we always got things right. I suppose my attempts to do things slightly differently – to organise conferences looking at social context and to be part of a group which contributed evidence for a DWP report on Workplace Capability Assessments – stem from this; from some sense that there is so much more to be done than spending the next forty years tackling only the resulting distress, rather than the root causes. I don’t believe in cure without some attention to the causes and I certainly don’t see myself as some kind of healer. I think there is value in the work I do with people but to be perfectly frank by the time I see them there is often so much damage that has been done that it cannot be undone. I may be many things but I am not a magician. I can do nothing about the fact some of my patients were brutalised by their parents; about the fact many were raped; about the children they have had removed; about the violence they have endured; about the bullying they have experienced. I can do nothing about the fact that they have grown up in a deeply unequal society in which being gay or black or poor or an immigrant is often stigmatised. I know that experiences such as these lead to distress – I mean, I have data to back it up, because apparently we can’t just think in terms of common sense anymore – but I see virtually no efforts to do anything about it. Instead, we only see people when their own resources have been entirely used up and they are in desperate pain and we might try to help but the blunt truth is that our systems can brutalize and damage people further. It’s an unpleasant thing to think and to write but it is sometimes true.

A simple example is children who are sexually abused. We know that these children are much more likely to: develop an eating disorder, self-harm, drop out of school, use alcohol and drugs, have violent relationships, end up in the psychiatric system and get a diagnosis of borderline personality disorder, which, until fairly recently, was seen as ‘untreatable’. Now, if you get a BPD diagnosis, you might get some form of help, though the cuts are wreaking havoc, frankly. But the thing is, for some people BPD is a really bloody awful diagnosis to have – think of it, a label slapped on you which tells you your very personality is deficient. I can’t say I’d be thrilled. But if you are a person who has been sexually abused and who has had lots of bad things happen to them as a result because your attachments are ruptured and you find relationships hard and you feel ashamed and guilty and worthless and you take drugs to numb those very painful feelings, you may well not get the help you need, no matter how much you ask for it, because, unless you have a BPD label, you might not be seen as ‘ill’ enough. So what’s the message mental health professionals give people? ‘Get worse, if you want any help. Show us how desperate you are for help.’

Our system, dear reader, is flawed.

But of course it’s more fundamental than that. As psychologists, my colleagues and I are highly trained. Many of us have three degrees; some four or five. We are trained researchers and clinicians. We understand health but we could probably hold our own in some areas of sociology as well. I lecture trainee clinical psychologists on the topics of social context and race and class and sexuality. We are highly skilled people, often with vast amounts of knowledge at our fingertips. We know the causes of inequality and emotional distress; we know that intervening early is more useful than doing so later on and we tend to have the networks and the credibility to use that knowledge for social good.

Unfortunately, for most of the past 100 years, we haven’t. It wasn’t psychology which campaigned for the civil rights movement; it wasn’t psychology which rioted at Stonewall. On the contrary; we were too busy being involved in the eugenics movement and ‘treating’ people for being gay, which was classified as a mental disorder. More recently, we have had the dishonour of being complicit in torture. My profession does not have a good record when it comes to fighting for the rights of the oppressed, the marginalised and the dispossessed. And even now, knowing the crimes that were committed by our predecessors, many of us are content to sit in our consulting rooms and our ivory towers, working with the tiny proportion of people who come through our doors. I don’t know if you have ever tried to access NHS psychology but it is not easy. There are too many people in pain and too few of us to be able to provide them with what they need. I have the luxury of being able to see people for six months at a time if they need it; maybe more. Many people I know have nothing like that flexibility because their resources are so stretched but ultimately it’s our patients who draw the short straw.

My job is full of ethical dilemmas. Do I see the lonely old person because seeing me is the only social contact they have and because it lifts their mood slightly? Or do I discharge them because I am not ‘doing psychology’ with them? I’m not sure what ‘doing psychology’ is, really – as far as I’m concerned, most of my job is simply talking to people and trying to understand their situation and how they came to be in it and trying to fathom a way we can help them change it. Sometimes we can’t change it but that doesn’t mean there is no value to my input. I can’t just discharge someone sad and lonely without any follow-up but other agencies are drowning in referrals and their waiting lists would make your toes curl. But I can’t see people unless I can justify my involvement and sometimes it is hard to do that when you are the only psychologist covering a massive borough and sometimes I have to, with regret, discharge them and hope I have done enough.

But there are the bigger dilemmas. Make no mistake – I earn my living because other people are in emotional distress; because life has battered them and they cannot cope. You may say that I am doing a ‘good thing’ by doing what I do and that I must be a ‘good person’ but, believe me, there is very little about me that is noble. I care about my work and about my patients but the fact is that the day we manage to eradicate inequality, oppression and societal violence is that day many of us will be out of a job. Of course, given our current policies, that day isn’t coming anytime soon, but that in itself is a concern.

I see my job in the way I see a charity. It exists to fill a gap. If a charity is effective, at some point it should cease to be necessary because the gap has been filled by advances in policy and practice and it should close down. If I and my fellow psychologists were doing what we should be doing – focusing on preventing sexual violence, war, substance use problems, torture, racial and gender inequality, homophobia – we would, hopefully, run ourselves out of jobs at some point. That would be a good outcome, societally. A world in which you don’t need mental health professionals is a world I would like to live in. But we don’t do it. We don’t fight the causes; we firefight the dreadful consequences. And the effects on us are terrible. Health professionals are prone to all sorts of mental health problems. And why wouldn’t we be? Imagine spending forty hours a week hearing of others’ pain and distress. Imagine doing that for forty years. Imagine what that does to your view of humanity. Imagine what that does to your relationships. Make no mistake: our jobs can destroy us.

So, in fact, our lack of action when it comes to dealing with the root causes of emotional distress serves no one. It doesn’t serve those who continue to be marginalised, oppressed and victimized. It doesn’t serve the people around them. It doesn’t serve us as professionals. It doesn’t serve society. It simply perpetuates the damage and the despair; it keeps rotten systems alive and it maintains a steady flow of people through our doors for decades to come.

It is an outrage and we should be ashamed.

On working versus living

It is, I believe, National Work Life Week, which means that talking about work-life balance is currently in vogue. I am unfortunately not in vogue, because I have been thinking about writing this since August but, you know, BUSY. Anyway, I decided that I should probably get myself in gear and Write Something because it’s been an age.

Psychologists often talk of the work-life balance as something they aspire to but often fail to achieve. When I began clinical training, a reasonable chunk of the induction was spent talking about the demands the course would place upon us and the effort we would have to expend to retain life outside our jobs. Interestingly, it was noted that it was usually the trainees who had children – only one person in my cohort did – who made time for their real life, mainly because they didn’t have much choice.

Over the next three years, I watched my colleagues work during the evenings, at weekends, and on annual leave. This last one horrified me. I liked training because it meant I had huge flexibility – I could work on my thesis and case reports whenever I wanted, which meant I could also go to the cinema whenever I wanted. I can’t write or think at pre-appointed times, so when it was all useless and I could barely string a sentence together I’d wander off and try again when I was ‘in the zone’. It was marvellous. During my doctorate I went away more and saw more films and plays than I ever had before. I discovered opera. I read voraciously. I did, in some ways, have the time of my life, although my thesis did go ‘bang’ at one point so don’t think it was all plain sailing. But the point was that I knew it was just a job – a job I love and that I am good at, but just a job. I saw my patients and wrote my assignments and so on, so there was no way I was going to take annual leave to write a thesis. When my data analysis wasn’t working and I had to rewrite my entire Introduction I despised my research; having to forfeit leave to rework it would have made me impossibly angry and bitter. It was precisely because doctoral training was tough that I needed – not wanted; NEEDED – that leave. NHS annual leave entitlement is reasonably generous, but so it should be, frankly. I need those holidays to recover from the intensity of the work; to ensure that when I am working I am a good clinician, not a fed up, burnt out one.

The upshot is that when I go away, I REALLY go away. On annual leave, I am totally incommunicado. I don’t want to talk to anyone (after all, if I wanted to talk to people, I wouldn’t go somewhere they weren’t). I work a lot so I am entitled to some downtime. It is for these reasons that I frequently disappear from social media and ignore my emails for days on end. In the spirit of this, I went away over the August Bank Holiday to take in some country air. I rumbled back to London on the Monday and turned my phone on at some point that evening. What struck me was the number of people – mainly psychologists, because this is technically a psychology-related account, though you could sometimes be forgiven for thinking otherwise – were talking about actual psychology. Research and stats and theories and clinical practice and other stuff that made me want to ask why the hell they had nothing better to do with their time. And then I remembered that, in the not too distant past, I could have similar conversations that went on until 11pm, midnight – in fact, it sometimes seems as though the psychologists of Twitter only come out to play (or think, or disagree) in the witching hour. Not necessarily surprising – I do most of my thinking at night, and it is often then I have fewer distractions, but, really, do we not have better things to do with our free time than talk about work-related stuff? Every time I check Twitter I feel as though every other psychologist IN THE WORLD is more engaged with their profession than I am, but the fact is sometimes I don’t care enough to talk about it or write about it – as I said at the beginning, I’ve written nothing psychology-related in months; I have five papers languishing, awaiting revisions, because I can think of about five hundred things I’d rather do than write an academic paper that no one will read. Sometimes I just want to read a novel or go for a walk or have a social media conversation that’s casual and easy and doesn’t need fifteen tweets to demonstrate the inevitable necessary nuance. Sometimes, I don’t want to be a psychologist; I just want to be a person. Sometimes, and hold on to your hats here because this will come as a shock to you – nuance can go whistle. I want to make sweeping statements and chortle at gifs and comment on films I have seen.

Basically, my job is serious and I am worried it will turn me into a serious person who finds it impossible to disengage from it. I have an unusual approach to my job, a passion for it combined with impatience and a somewhat irreverent style, but it’s one that fits me and seems to suit many of the people I see. I hear painful things in my clinical work and I need to shut off from it sometimes. The last thing I want to do is discuss therapeutic models at a quarter to midnight; what I want to be doing is lolling about looking to be entertained fabulously.

Obviously I have no vested interest in telling other people how and when they should be using social media. Whatever. I don’t understand why anyone reads news on holiday, for example (or ever, actually); nor can I fathom why you need to relentlessly livetweet your free time. I’m not enough of a psychologist to make inferences – by which I mean, I’m a forty-hour-a-week psychologist, not an always-on-psychologist. I sound as though I lack commitment to the psychology cause, but I don’t. I simply have a resounding commitment to my own mental health, which, frankly, too few of us do. Life is about more than work and there is much joy to be had, if you simply care to look for it. So I am slowly accepting the fact that my psychology-related Twitter account is becoming ever-less psychological and I am revelling in the fact I don’t have the slightest desire to reverse the trend.

On judging your patients

The thing about working in mental health is that it can be appallingly easy to turn into an insufferable know-it-all. This is partly because the second you tell someone what you do for a living (and I write this as a psychologist, rather than a nurse or an occupational therapist, for example) they ask you lots of questions. This means that you get to feel very clever and wise as you discourse on the ’causes’ of mental illness, or as you briefly summarise how one accesses mental health services (no one ever asks how you access physiotherapy – they just trundle off to the GP. But mental health seems hidden in the shadows and no one ever seems to know that you usually need to trundle off to your GP if you’re worried). But very quickly, this can feed your ego. The fact is that many of us in health do have very specialist training and that we have worked damned hard to ‘make it’. I think people who ask about our work usually do so because of a genuine interest and often they expect some sense of expertise (though perhaps not pomposity). The problem, I think, is not so much in how we relate to the public at large, but how we relate to our patients.

To be perfectly frank, it’s really easy to end up with a mindset which informs you that you are, fundamentally, better than your patients. Often, we work with people with offending histories, with significant relationship problems, with addictions, with thoughts of suicide, with financial problems or with less education than we have. Think about how most of us get our sense of self; what make us feel good about ourselves – our physique, our job, our car, our hobbies, our salary, our partner, our house. If your lifestyle meets a certain set of social conventions it’s really easy to become superior, to see every patient as another set of problems You will almost certainly have seen a health professional who made you feel like that at some point – who made you feel small and stupid and insignificant. I’ve seen at least three like that. I hated them all. I never went back to see any of them. I had that luxury. Many don’t. Many get stuck with professionals like that; professionals they ultimately despise.

Much of this attitude is reflected in the ‘should’ attitude. ‘He should stop drinking’. ‘She should stop self-harming’. ‘He should lose weight’. Never mind that lots of health professionals drink too much, that many of us are overweight, that lots harm their bodies (and perhaps minds) through drug use – our patients ‘should’ do what we think they ought. One of the more vigorous campaigns of recent years has been the anti-smoking one – aside from the ban on smoking in public places, most hospitals are now smoke-free, which means that if you want to smoke you either have to walk miles to the nearest exit (hospital sites are often enormous) or you have to find a corner and hope no one sees you, much like a schoolchild, except you’re probably thirty years too old for school. And that’s just for the staff – there has been enormous emphasis on stopping mental health patients from smoking. This seems well-founded – people in MH services are more likely to smoke, to have poor physical health and to die earlier. But one thing that’s always struck me is that if I was often highly-stressed and if I didn’t have the things that keep me pretty solid – my job and my interests and regular holidays – I’d need something which took the edge off the worry. Most people who smoke say it takes the edge off – people who drink too much often say something similar – so would I smoke? Possibly. Would I drink? We know that one of the main reasons people drink is to deal with unpleasant emotions, so again, perhaps I would. On top of that, if I was an inpatient in a psychiatric ward I may well smoke just to pass the time. They are often not, it must be said, the most stimulating of environments.

So I am, evidently, sympathetic to alcohol and tobacco use because in my experience it is usually symptomatic of something deeper. I was thinking about this today because today I told several of my patients that smoking probably helped their mental state and that trying to reduce their tobacco use was probably unwise (as an aside, most people I see are in their 80s and a small part of me thinks that if you’ve been smoking for sixty years maybe I should just let you get on with it, especially if you also happen to – and brace yourselves here – enjoy it). I was muttering about this on Twitter earlier when the esteemed Alex Langford (@psychiatrySHO) asked what I thought of crack use as a coping mechanism. I told him that, fundamentally, I believe people cope in the best way they know how. I don’t think taking crack is how I would choose to cope with the things that make my life more difficult, but then, I have a lot of other coping strategies – I have friends and I write and i have the luxury of being able to pay for cinema or theatre tickets to escape my worries. Not everyone has those things and not everyone knows they exist. I grew up in a family in which alcohol was a no-no, so I never learned that it could make you forget your worries. That’s a relatively unusual experience, but the fact I don’t drink to forget doesn’t mean I’m better than someone who does drink to forget – maybe they have more to forget than I do. Or maybe I was just lucky enough to have a bigger bag of tricks than they.

But this goes for many things – self-harm is a coping mechanism for many people. So is eating. So is getting angry. So is telling people you’re considering killing yourself. One of the most awful phrases in mental health is ‘maladaptive coping strategies’ – a phrase I am ashamed to say I used to use before I really thought about what it meant. These days I try to be a little less sanctimonious. Most people do what they need to do to survive. If they’re hungry they steal. If they’re lonely they’ll try to find a way to be looked after. If they’re in pain they’ll find a way to express it. And if life has been so ghastly that you can’t express it through words or by asking for help, you need to be more creative, even if that has some negative consequences. A&E staff can sometimes be dismissive of people who attend following self-harm, but at the very least they will patch you up and provide you with something approaching care. Getting drunk might lead to a terrible hangover but at least you were free of your demons for eight hours. If you’re isolated and lonely casual sex can be a really good way of feeling loved, even for a short time – and, just for reference never, ever underestimate the importance of being touched by another living, breathing person, even if it does occur in less-than-ideal circumstances. Getting angry and assaulting someone might land you in court, but at least you weren’t small and frightened and vulnerable to harm from another. The trouble is that not all professionals see it like that – for many, it’s a case of ‘do as I do’, or, perhaps, ‘do as I say’ (as I said, we’re not immune to coping in many and varied ways ourselves). What this frequently means is that we judge our patients; that we look down on them for not being good enough or trying hard enough – perhaps feeding right into their own fears about not being good enough and not trying hard enough. But more than that, we implicitly tell those patients that the mechanisms thy have learnt are incorrect, are unworthy. You know what? In my experience, many patients already think that, at some level. I don’t think it’s unreasonable for mental health professionals to provide something a little more sophisticated, a little more constructive and a little more compassionate.