Professional practice

On the commodification of ideas and the Great Knowledge Swindle

Sometimes academia really is very trying.

I have the great privilege of having had a clinical training as well as a research training. Unlike a lot of people in my line of work, I enjoy both elements tremendously. I’m interested in people and the things that can lead to life taking unexpected turns, but I also love science. I love having an idea or thinking of a question and trying to find a way to make that idea happen, or have that question answered. It has always been a mystery to me that so few clinical psychologists enjoy research; that so many endure it only because they have to in order to be able to qualify as psychologists with the express intention to abandon the whole thing as soon as they possibly can. Be under no illusion – research is frustrating and time-consuming and SLOW: recently, I sent a paper based on my MSc research to my co-authors. This paper had been ‘in preparation’ for three and a half years. Granted, I was trying to write it whilst engaged in a doctoral degree; my supervisor was trying to finish her own thesis. But now we have the comments of the co-authors and then the six-month wait for comments from reviews once we submit and then if we’re lucky another few months until publication. Contrast this to writing for the press – three-hour deadlines and boom! – instant gratification. It won’t take great leaps of imagination to understand why journalism is so refreshing.

All that palaver notwithstanding, I really do enjoy research. I like thinking about methodology and number-crunching; I love writing and, obviously, I rather enjoy seeing my name in print; testament to the months of work and thought put into a 5000-word piece. And research is important – it guides our clinical work but it also represents the genesis and evolution of ideas, and there is little that is as important as ideas. All progress is rooted in ideas; all knowledge ultimately emanates from creativity.

So why is knowledge so wretchedly difficult to access?

This is how research works, in general: I have an idea. Think of a way to research that idea. I need money to fund it. I apply to a grant-making council, which is almost certainly funded by taxpayers’ money. They give me money, I do the research, I write it up and send it off to a journal who then publishes it. But here’s the sting: no one can read it. At least, not without paying the most enormous charges. Universities and NHS Trusts 9and industry, sometimes) pay fortunes (not small fortunes – just fortunes) to private publishers, who get this work for free, for the right to read research paid for the public at large. Institutions easily pay hundreds of thousands per year for access to these papers and the publishers, knowing they have a captive market, can virtually name their fee and their terms. So the public pays twice; once to fund it and once so that a few academics and students can read it. But the rest of you? Forget it. You’re only allowed to read it if you a) pay per paper (often about £30) or b) find someone with access who will give you a PDF. Amongst people in my line of work it’s common to find people begging for articles. I’m lucky in that I have access to an extensive repository of papers, though that access won’t last forever. But even so, I can’t always get what I need.

Presently I am revising a paper on neurological disorders; a paper I wrote ‘for fun’ (stop laughing) when working in stroke last year. I need a paper which, by hook or by crook, I have been resoundingly unable to access. This is an important paper and my own will have a bit of a hole in it if I can’t read it. So I tried everything from the British Library to online repositories, but to no avail.

Ordinarily I would huff and puff for a bit and then get over it. But this comes on the back of my seeing several conferences I would dearly love to go to, only to balk at the costs. A conference on neurology (hugely related to the paper I am writing): £400. A conference on psychotrauma: £300. A conference on forensic psychology: £250. Forget transport, accommodation and eating – this is how much it costs to sit in a big room and watch someone read some slides. But, actually, my professional registration is dependent to some degree on me spending vast sums on sitting in big rooms watching someone read some slides. And it is my privilege to have to pay for it.

These conference organisers are no different to publishers. Academics generally build reputations on public funding and they rarely get paid fabulous sums to speak for an hour to delegates. It’s the organisations which make a fortune. And actually, they don’t have to. I went to a Public Health England conference yesterday. Fifteen workshops and several plenaries; people who have real expertise in their fields. It was excellent and it was free. I’m part of a team organising a conference this summer in London. Nine terrific speakers and lunch thrown in; all for twenty quid. You know what the difference is? We’re not out to profiteer from ideas and eminence. True democracy is the democratisation of knowledge. But we don’t have that kind of democratisation. What we have, dear reader, is nothing more than a swizz of the most scandalous proportions. And, because we value learning and scientific progress, we hold the system up. We pay the fees and, in consequence, we remain a captive market.

On love and fragility

A few days a go I came across this: an essay titled, essentially, ‘how to fall in love‘. It’s not the sort of title which I find particularly appealing, associating it, as I did, with a certain kind of magazine. But people kept linking to it so I decided to have a look. I confess I was expecting a load of nonsense about what to wear, how to compliment the other party and how to follow a date up to ensure a long-term relationship. I was pleasantly surprised, then, to discover that this was a little more substantial. The piece was based on a study which attempted to build intimacy between strangers by each asking the other 36 increasingly personal questions.

Now I found this more intriguing than I had initially anticipated. I am a psychologist, after all, and that means that I am interested in relationships. I am also fascinated by fragility. Many of the people I see clinically end up in my consulting room because life has become too much from them – too cruel, too lonely, too tough. I ask them to expose their vulnerability to me – to tell me what frightens them; what demons haunt them. I am always struck by the privileged position I have – trust is earned, not given, and many people have trusted me with their pain and fear.

But I am a human as well as a psychologist and I know that it is not just my patients who are fragile. We all are – perhaps that is the essence of our humanity. Life can be dreadfully painful. To my mind, therapy is one of the ways of understanding that pain and learning to live with it. I can’t eradicate your experiences, nor do I wish to, but if we can find a way to allow you to exist without those experiences sapping the joy from existence perhaps we have done enough. It is, of course, easier said than done.

But then I began to think about professionals and whose job it is to expose our fragility. We are no different from our patients, really. A lot of people I have seen clinically seem to have a notion that we who work in mental health don’t understand what pain is. That is often, in my experience, incorrect. Many of us don’t talk about it as a general rule, but that doesn’t mean that loss and despair haven’t touched us. Perhaps, when it comes down to it, loss is what it’s all about – loss of identity, safety, love, self.

One of the interesting things about clinical psychology training, as opposed to psychotherapy or counselling training, is that we are not required to have our own therapy. I have always been deeply unsure about this. I think it suggests some fundamental difference between professionals and patients, which, as I said, I think is trumped by our shared humanity. I think it deprives us of a chance to reflect on ourselves and the reasons we do what we do for a living, for, to be sure, it is an odd way to spend your days. We might talk about being interested in people, but there are plenty of ways to indulge that interest without exposing yourself to tales of horror; without sharing someone’s else pain so acutely. I think there’s much more to it than that. Therapy is a means by which you can get to know yourself better. In my line of work, self-awareness is of paramount importance – knowing why you respond to Patient A differently from Patient B; understanding why you can’t work with Disorder X; why you’re so desperate to help someone with Problem Y. I don’t think we all have a Messiah complex but I do think our career choices are often deep-rooted and under-analysed.

But not being compelled to have therapy of our own also stops us experiencing what it is like to be a patient. It’s not necessarily easy being the therapist, but I reckon it’s a good deal harder being on the receiving end. It is difficult to tell someone the things that you are ashamed of. It is hard to talk about the abuse and neglect you have experienced and to cry about the abandonment you have felt. It is not easy to build a relationship like this. It takes the most enormous courage and it deserves huge amounts of respect. And whilst no one’s journey is the same as anyone else’s, it is experiences such as these which can attune us more sensitively to the pain and longing of others, which allow us to build those connections so integral to therapeutic work. And that is why I believe that every psychologist should understand the process of exposing their vulnerability, their fragility and their pain and that they should be compelled to do so as part of their training.

On the psychologist as ‘collateral damage’

As I creep towards qualification as a clinical psychologist (a week away!), my mind is drifting, understandably, towards life-post-training. As a trainee, most of what you do is guided by your supervisors; although that doesn’t stop entirely once you’re qualified, you do get more liberty to practice as you see fit. Most of us practice in fairly idiosyncratic ways, even if we use specific models or theories as our basis. To my mind, people are different and their problems are never the same, so it makes perfect sense to provide a broad church of interventions.
But there is more to being a clinical psychologist than providing therapy, as any of us will tell you, and, for me, there is more to being a clinical psychologist than my job. We don’t walk out of our offices and cease to be clinicians; nor do we suddenly stop being the people we are during work hours. For it takes something to choose to do work like this: we tend to be interested in others; we are often acutely aware of the impact of emotional distress on people and those around them; we likely have a strong sense of social justice. These things may be more finely-tuned over the course of training but they probably exist in spades before that. It’s hard to turn it off, but, increasingly, I’m wondering how that knocks on to my non-work-work – the work I do that is psychology-related but which is not in my job description. There are obvious things – I would like an academic career; with the result that I spend some of my non-work time writing academic papers for publication. I blog a bit, though that has taken a dip recently. I occasionally write a bit for the press and I’ve started lecturing. In recent months, I’ve spent more time working with other psychology types, working on projects related to the impact of inequality on mental health and the role of my profession in doing more to effect social change. It’s busy, but it’s exciting. Crucially, I am also maintaining a life that is truly ‘non-work’.
I’m brutally aware, however, of how easy it can be to slip into ‘overworking’ mode. I suspect that the sort of person who is happy to go into academia is also the sort of person who might find themselves working sixty-hour weeks. I have spent the past four years being a postgraduate student, which often involves working unconventional hours. Prior to that, I worked shifts, which is about as chaotic as it gets. The truth is that it’s been about six years since I had a ‘normal’ working week. Pleasingly, I have a lot of energy and I work reasonably efficiently. Nevertheless, it’s something I have been thinking about a great deal.
Throughout clinical training, we are encouraged to maintain the ‘work-life’ balance; encouraged to say no to things we can’t do; encouraged to take care of ourselves so that we can take care of others. It doesn’t sound all that easy; it’s even harder to do in practice. It’s easy to slip into working more than necessary to get something done purely because you will feel guilty if you don’t. It’s easy to go to work when you’re unwell because you don’t want your colleagues to have to pick up your work when they’re probably already stretched to the limit. It’s easy to beat yourself up for not doing enough when you are acutely aware of how much there is to be done (the social inequalities stuff I’m doing at the moment, for example, seems directed towards an enormous dragon; one that may well not be slain for quite some time).
One of the therapies offered by some in my profession is schema therapy. I don’t use it myself, since I’m not trained to do so, but the principles of it interest me. Essentially, it suggests that we each have specific ideas about ourselves and our relationships (schemas) that repeat throughout our lives. There are 18 basic schemata, and some evidence suggests that, amongst people in my profession, the self-sacrificing schema is the most common. As you might expect, people with this way of relating to the world tend to focus on meeting the needs of others at their own expense. It makes sense – we tend to work with people whose needs have often not been met by others, whether that be the need for love or acceptance or safety. As a consequence, it’s all too easy to go above and beyond the call of duty. It’s hard to say ‘no’ when colleagues ask if you can take on extra tasks. It’s gratifying when your expertise is recognised and you’re invited to contribute to policy or guidance. And, equally, making this into a career is hard. Some people want to be clinicians who work five days a week and no more. Some have different aspirations and, like all worthwhile things, achieving those aspirations takes work. We’re no strangers to hard work – I have spent ten years working towards qualification and that’s certainly not out of the ordinary.
So what do you have? Well, you might have a profession in which people believe in what they do and want to do it well. You have people who want to do good. You have people who probably have s strong ethical code and who perhaps want to leave some kind of legacy (we’re not immune from liking our egos to be gratified; we’re not superhuman). How easy it is, then, to burn out. That’s not something unique to health professionals, of course, but it’s something we are at significant risk of.

So far so obvious. But then the question we ask less often: is it worth it? If I spend fifteen years working more than I should and in that time I contribute significantly to research, policy implementation and service development, does that mean that the potentially negative effects on my health are offset by the good I have done? Everything has a cost; no benefit comes without a price. In war we talk of ‘collateral damage’ and we seem to have an unspoken agreement that destruction is sometimes necessary and often tolerated. We work towards the ‘greater good’. Surely that logic needs to extend to individuals if we are to avoid being hypocritical? We have killed tens of thousands in wars over the past decade for the sake of some ‘greater good’. Surely, then, the health of a couple of dozen psychologists can be sacrificed in the pursuit of better public health. For that is our business – improving public health, in any way we can.

Now the conundrum comes when we talk about abstract sacrifice and try to apply the principles to personal sacrifice. So, in the abstract, none of us is indispensable, however displeasing that is. We are all mortal; we will all die. Given that, the idea of some of us sacrificing our health or dying as a consequence of putting as much into our work as we can seems like a small price to pay. The greater good, eh?

But. One of the other things psychologists do is take the abstract and bring it down to the personal. Emotions, individual experience, all that stuff. So while in the abstract we can think of self-sacrifice as something which is a means to an end, the truth is that very few of us is comfortable with being the one that burns out, the one who has a stroke in their 40s, the one who dies in what should be their prime. We don’t mind collateral damage as long as we’re not the people who make up the collateral (just like the collateral in war, of course).

The scientist in me (for I do consider myself a scientist)  has a bit of a problem with this, as does the ethical human. Given that I believe in what I do, given that I believe that much of your value as a person is based upon the good you do for others, given that I am fully aware of my mortality and the extremely limited time we all have to do anything of worth, why on earth is it fine for you do work yourself into the ground to achieve something extraordinary but unacceptable for me to do so? Many will take exception to that and state that it is never acceptable for anyone to work themselves into the ground for the sake of psychology or public health; if you’ve read this far, you’ll gather that I question that rather. Or is that just my maladaptive schema talking?

I’m not quite sure what the answer is to all this. I don’t think there’s any great nobility in wrecking your body and mind for the sake of your job, but, then, this isn’t about a job, per se – it’s about helping to make a society which views and treats people with mental health problems differently. Nevertheless, my suspicion is that working to a degree which damages you is likely to result in your colleagues pitying you and wondering why you can’t do yourself that which we try to help our patients to do – to avoid trying to be superhuman. Many of the people who come to see me end up there because they simply tried to do too much and, eventually, they reached their limit. The comparison is not lost upon me. But then, I’ve always said it – there is little that differentiates me from my patients, aside from the fact that we sit on different sides of the consulting room. Essentially, we’re all the same – humans, with our flaws and our egos and our need to do or be something or someone out of the ordinary, though our reasons may be different. Ultimately, whether as professional or patient, we are, as I am so fond of saying, all in mental health services.