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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 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:

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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.

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 language, power and the psychologist’s ego

Psychologists are always banging on about power. Our profession has a history of engaging in coercion and abuse. Some, shamefully, have been involved in torture in more recent times. We have been involved in terrible treatments for ‘mental disorder’ and ‘crimes’ such as having children out of wedlock. Most of us are aware of this and try not to act in ways which could be perceived as abusive. It sounds easy, but actually it’s very difficult. In mental health, we still detain people against their will. We tell them they have to take medication to be discharged. We still restrain. We detain them again if they don’t abide by the conditions of their discharge. Psychologists are rarely involved in the process of detention and lots of us seem to find this a relief. If I had to detain someone against their will I would probably find it a real ethical dilemma.

 

So in that sense, psychology is separated from the power typically granted to those who work in the psychiatric system. In recent years, we have questioned ourselves and our profession more closely. We now conduct research following the acquisition of ethical approval. We ask people what they want from therapy and try not to force it upon them. We encourage (there’s another blog to be written on this) ‘service user’ involvement, which essentially means that the people who use our services get to have a say in who is recruited to work in them and how those services operate. Increasingly, we as a profession treat the folk who come and see us as ‘experts’ – we generally know nothing of the reality of their lives unless they tell us, and we try to get into their worlds rather than simply applying our own notions of what we think their reality is. All these things are good, as long as they remain genuine and don’t end up being tokenistic and mechanistic. But there is one area in which we continue to uphold the power vested in us by our education and qualifications and that is in the language we use.

 

Most professions use their own lingo. Engineers have theirs, web designers have theirs, and, god knows, lawyers have theirs. Languages, in my opinion, have two functions: to create an identity and to exclude others. This is the case for all languages – the bilingual family may choose to speak their native language at home in order to keep it alive and to retain a connection with their culture. They may also use that language when they are out and wish to pass comment on someone without that person understanding them. In psychology, we have our own language; ‘psychspeak’, as I term it. Here are some examples of psychspeak, along with some handy definitions, and, where appropriate, a small explanation of why they wind me up so much. Incidentally, I didn’t know many of these until i began clinical psychology training. I am still terrible at knowing the lingo. I get the concepts and I can apply them, but I don’t talk the talk. Partly this is because I put no effort into learning it, and that probably tells you much about how much I value it. In any case, for your enjoyment:

 

Anxiety-provoking: something which makes you worried. But why? No-one says ‘joy-inducing’. There’s no need to say an exam is anxiety-provoking (what an inefficient use of syllables). Exams worry you. That’s fine. It’s normal.

Authentic: genuine. Often applied to therapists. As in, you should be authentic with the people you see clinically. What this means is ‘be yourself’. Why we need a term for this I don’t quite know. I mean, we do work with people. We generally have quite good people skills. We’re not actors. We rarely have to pretend to be something we’re not. There’s no reason to turn it into a honed skill when it’s actually about confidence and accepting yourself.

Anxiety: worried. Nervous. Frightened. In the real world, people use words like ‘worried’. ‘Anxiety’ is a clinical word. It exists in our clinical categories. The people who see us don’t generally have a good knowledge of our jargon. Why not use terms they use? I AM in psychology and I never say I’m anxious. I’m worried, I’m nervous, I’m apprehensive, I’m uncomfortable. Don’t dress it up just because you can. It’s not the mark of being a better therapist.

Affirmation: agreeing. I mean, REALLY.

Validating: accepting. As in ‘I validated her anger that her husband had had an affair’.

Overwhelming: too much. Now this is a word used in everyday life, obviously. But we apply this to EVERYTHING.

Flow: things you enjoy doing. Normal things, like reading and running and knitting.

Safety behaviour: Something you do to avoid an unpleasant feeling. A bit like avoiding having a row when you hate having rows.

Hypothesis: an idea I, as a therapist, have for the reasons behind your behaviour. Hypothesis. Is there a more appalling way to say ‘an idea’? How do you think that makes the person in the other chair feel? Do you realise how patronising it sounds? If a psychologist used that term with me I’d give them short shrift.

Shared understanding: telling someone else what you think.

Narrative: story

Affect: mood.

Thickening: adding detail. Thus, ‘thickening the narrative’ means ‘making the story more detailed’.

Family system: family, oddly.

Restructure: change

Reframe: thinking about it differently. Therefore, ‘My friend didn’t talk to me in the shop because they find me boring’ becomes ‘they didn’t talk to me because they didn’t see me’.

Appraisal: judgement. interestingly, ‘negative’ appraisals are generally spoken about more than ‘positive’ ones, though of course psychology is often based on the assumption that something is ‘wrong’.

Cognitive biases: errors in thinking. I’m never quite sure who decides what makes something an ‘error’, though.

Maladaptive cognitions: incorrect thoughts. There is an implied judgement here which makes me uncomfortable.

Maladaptive behaviours: behaving n ways I think you shouldn’t. See above.

Insight: often, seeing things the way I see them. So someone might believe they see angels. and that these angels are real. This might be termed a ‘lack of insight’. If they later agree that the angels were imagined, that might be considered ‘insightful’. This always assumes that the professional, who presumably doesn’t believe in angels, is correct. But what if you do believe in angels? How then do you think about the person who sees them?

Psychologically-minded: thinking the same way we do. Psychologists are terrible for this. Often we demand psychological-mindedness before we see someone. How, pray, will they develop it if we don’t try to help them?

Behavioural activation: doing things. Not special things, just the things that you’ve stopped doing. Getting out of bed, for example. Going for walks. Washing up.

Schema: your way of thinking.  So a self-sacrificing schema might mean you act like a bit of a martyr.

Externalise: express. As in, ‘externalise your anger’.

Rupture: damaged. Often used in the context of relationships. Thus a ‘therapeutic rupture’ means ‘I’m not getting on well with my psychologist’ (although of course, it’s almost always the psychologist who will speak of a therapeutic rupture.

Attachments: relationships. Good, bad, often complex. But, nevertheless, relationships, plain and simple.

 

This isn’t grousing for no good reason. As I said, language holds much power and in psychiatric systems, the people who come and see us rarely have much power. It is ethically wrong to use complex words needlessly. More than that, it might severely limit the extent to which they can work with you. Many of the people we see will have found school difficult or might have had learning difficulties. They might have been humiliated and belittled by parents or teachers. If we use these words, words they quite possibly won’t understand, what are we doing? In some case, we’re probably reminding them of times they didn’t understand something and were made to feel stupid for it. I would hate it if I ever did something which made someone who had come to see me for help stupid. Is it necessary to use complex language? Rarely. Does it make therapy more effective? Probably not.  Having a therapist who is on your side and who tries to understand is what helps. I would suggest that having one who uses words you understand aids that process.

 

So why do we continue to use jargon? Perhaps to give ourselves a professional identity, though I reckon it’s more the latter. If we speak a language only we understand, we can claim an expertise. I’m not saying we don’t have any expertise – I haven’t spent ten years getting to this stage to claim I don’t know anything – but it’s one thing to have knowledge and another to make it unnecessarily apparent. I came into psychology to try to do a good job; not to massage my own ego. But it’s seductive. Being Dr? Getting published? Being a senior member of a mental health team? Knowing something about how you might be able to help damaged people? All enormously gratifying. But that kind of gratification is dangerous: once you get sucked into it it can be terribly hard to escape. And once you are working to gratify yourself, what happens to your previously noble intentions? Nobility and egotism can rarely coexist. Sadly, I’m not as noble as I’d like to be and I’m not immune to feelings of gratification. But really, if there is a way to truly enter the world of the person who comes to see you in despair and desperation and to leave your own need to be applauded at the door, we, as therapists, have a duty to find it. And for me, that begins with language.

In which I set this blog only moderately high standards

Mental health has long been a topic shrouded in mystery, known only to those who have experience of it, whether as professionals or service users (or, indeed, as both). I’ve always thought that those of us who do have experience of the area have an obligation to remove that shroud; to make it more accessible and less ethereal.

Over the past few years, I’ve noticed that the portrayal of mental health and, in particular, the public dissemination of research into mental illness, has often been problematic. Research ‘findings’ are published in newspapers and on the radio but most of us have little understanding of the scientific method and this limits our ability to digest and critique that research. In my view, anything that contributes to the general public’s understanding of science is good. Unfortunately, I haven’t got the qualifications (or the time) to debunk all the dodgy claims that are made, but I do know a thing or two about mental health, and I’m no stranger to conducting research. This, then, is my humble attempt to contribute to the public understanding of psychology and psychiatry. I hope to discuss stories and research presented in the media, and perhaps some of my own musings too. Debate is most welcome and I look forward to your contributions.