mental health

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 mental health stigma, and working in a ‘nuthouse’

Quite often, I find myself being quizzed on my job by people I barely know. It’s gratifying that people sometimes find what I do interesting, but, in my experience, it’s often secondary to a problem they have had/someone they know has had. It’s indicative, I think, of the indiscriminate way mental health problems are experienced. There is no protection, really; not money or status or education or any of the things we hope will protect us from the torments of life.

And so it was that I spent a quarter of an hour chatting to some ex-colleagues about my work. Some years ago, I worked in another industry entirely, but I still pop in to the office now and again to say ‘hello’ to my ex-boss. Toward the end of my visit, I got talking to three former colleagues and one person who has joined the firm since I left. ‘What are you doing at the moment?’, one of them asked. ‘Writing m’thesis’, I promptly responded. ‘And what will you be then?’, came the question. ‘A doctor of clinical psychology’, I said. I explained that I was working at a hospital, doing whatever it is that I do and that I am due to qualify in the next few months.  My former colleagues knew that I worked in mental health; the unknown colleague obviously did not. And then came the ‘ooh, how INTERESTING!’ comment, expressed in the worst possible way. ‘What’, she said, ‘is it like working in a nuthouse?’

I am rarely flabbergasted but even I was taken aback. To my shame, when I recovered from the question, I stammered out a deeply ineffectual ‘well it’s hardly a nuthouse’ but I felt like I’d done the people who use mental health services a grave disservice. What I WANTED to say (as I squawked to a friend that evening) was something along the lines of ‘have some bloody respect for people who have experienced untold misery and have demons you can’t even begin to imagine’. Now that’s a bit of a crude statement, because not everyone I see has experienced untold misery and not all have demons (any more than we all have demons, that is). But I was furious at the implication that people who have mental health problems are raving lunatics, locked up for the safety of good upstanding citizens. This is nonsense. People with mental health problems – of whatever persuasion – are not the ‘other’. They’re your parents and friends and bosses and dentists and hairdressers. Notions of Victorian asylums persist, but, when you work in mental health, you get so used to being wrapped up in a woolly world, in which we try to be respectful and aware of vulnerability and the things people have experienced, that it can be rather a shock to encounter a question such as the one I was asked. I don’t think this person had any malign intent; she wasn’t the kind to overtly stigmatise someone with a MH problem, but its not really the overt stigma which is the biggest battle. Yes, it matters that people with MH problems can’t get jobs, for example. But it’s the everyday, insidious stuff which erects the biggest barriers. It’s the casual comments about ‘lazy depressives’ or ‘attention-seeking self-harmers’ or ‘fruitcakes’ , the kind of stuff you hear in the pub, which stops people talking about their own experiences. Interestingly, some of the research indicates that anti-stigma campaigns, which highlight how common MH problems are, actually result in an increase in stigma. Really, it’s the everyday disparagement which needs to be tackled but, if I’m honest, I don’t know you do that. I probably failed, frankly, and I’m still a bit embarrassed by it. If MH professionals can’t pull themselves together long enough to respond effectively to something as relatively minor, perhaps we need to rethink how we tackle something which has a huge impact on the likelihood of people seeking help when they need it. In the UK, we have shockingly high rates of self-harm, suicide and substance use, all of which are often related to unspoken difficulties arising from MH problems. If we could crack the stigma issue, maybe we’d begin to see a shift in these related problems. Sadly, ‘if’ is a big word.

On learning in learning disability

As part of the requirements of qualification as a clinical psychologist, you have to do a number of clinical placements. In the UK, one of those must be a six-month stint in learning disability.

I came into clinical training through a fairly unusual route, which meant that I had very different experience from that of many of my colleagues. One of those differences was LD – I had never worked in LD services, although I had worked with people who had some cognitive impairment. The criteria for LD are that you have an IQ (a controversial topic in itself) of 70 or less, that there is some difficulty in functioning, be that in academic settings or otherwise, and that the difficulties are not the result of illness or a head injury; i.e. that they have been present from a very early age. (In the US, the term ‘learning disability’ is often taken to mean something like dyslexia or dyspraxia. In the UK we refer to these as ‘learning difficulties’. It is not an easy distinction to remember, and even clinicians get the two muddled from time to time.) I was, it is fair to say, going in with little prior knowledge or experience.

Four months in, I think I’m starting to get a handle on working with this group of people. I am in a team which works with those with a learning disability and mental health problems. Not until I began to work in this area did I fully start to appreciate how marginalised some of the people I see are. I have long known that being perceived as having mental health problems can result in stigma and barriers and social isolation and I knew that having an LD was likely to do the same, but the interface of the two can sometimes vastly magnify the difficulties. This isn’t because of the LD itself, nor as a result of the mental health problem – it is purely the result of the way society treats those who are different and of the way that some vulnerable people are exploited. I use the term ‘vulnerable’ carefully – not everyone with an LD or an MH problem is vulnerable and many people with neither of those labels are vulnerable. But in the Venn diagram of such things, there is bound to be some overlap.

One of the things I like about my profession is that, despite having spent a good few years working across a range of services, I regularly get angry. Not with the people I see professionally, but with the people around them. The fact I can get angry about the accommodation in which someone lives or the staff with whom they have to deal or the neighbours who make their lives difficult means I still care as much as I did when I chose this as my career and that I still believe that change is possible. To my mind, it’s when you stop getting angry that you should re-think the way you earn your living, because that anger signifies a passion for your work. I think most people come into this kind of work wanting to change things (whatever those things may be). The focus might shift over time, in the way that most revolutionary aims change over the course of years, but as long as the will and the belief is there, you can make a positive impact on the lives of the people who come and see you. Virtually everyone who I have met who works in LD still has a desire to change things for the better. Sometimes that’s change which is recognised: those esteemed colleagues who write reports for the Department of Health and inform policy; more often, it’s the people who do their jobs, day in, day out, trying to help people in distress make their lives better. It can probably feel like you’re constantly pushing for the small victories, but as anyone in mental health will tell you, the small victories are necessary if you’re ever to snatch the big ones.

So what have I taken from this, aside from a better understanding of the impact that disability can have? Well, I’ve learned that even in an environment where NHS services are becoming more protocol-driven, there is still room for flexibility in service provision; indeed, you cannot run an LD service which is not flexible. I have learned that it is possible to get away from the language of psychology and psychiatry (a language I have always avoided, given that, like most specialist languages, it is designed to exclude those who don’t understand it) and make our ideas accessible to everyone. I have learned that writing reports is made far more fun when you use 100 words and fifteen pictures. I have learned that working in LD requires a particular skill set, but that like all skill sets, it can be learned.

And I have been reminded of something too. I have always said that my job is one of great privilege. Strangers come into my consulting room and they tell me about their pain and their distress and their fears. They show me their vulnerability, a vulnerability that is sometimes so raw that you marvel at their resources. I have often been amazed at the strength and grit of the people that I see; speechless at the difficulties that have encountered and which have threatened to overcome them, but which they have not allowed to do so. Factor in the added stress of physical disability and cognitive impairment, as well as the adverse experiences that can result, and I have been reminded of the strength of human spirit, the resilience that many of us have (but which we perhaps don’t know we have). And again, I marvel. And I think that with enough time and will, perhaps we will see the day when those with disabilities, of whichever variety, will cease to be marginalised and will be seen in the way the rest of us like to be seen: as human, with our foibles and neuroses, but with more binding us together than setting us apart.

This post is also due to appear at

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.