How do we know what we need: differentiating evidence based treatments for the public

I am interested in making a website to help direct people at the right kind of sources of support when they are hitting a block or feeling unhappy with their lives. So I started to look at what was out there. I found lots of small silos full of professional jargon that would help people to identify a counsellor, psychotherapist or psychologist if they knew that was what they needed. But I also found lots of sites that point people at all kinds of snake oil that has no evidence of efficacy at all. For example, Findatherapy.org lists the following categories as “therapies”:

Abdominal-Sacral Massage
Acupressure
Acupuncture
Alexander Technique
Allergy Therapy
Aromatherapy
Arts Therapy
Autogenic Training
Ayurveda
Biofeedback
Bioresonance Therapy
Body Stress Release
Bowen Technique
Chiropody
Chiropractic Treatment
Clinical Pilates
Cognitive Behavioural Therapy
Colon Hydrotherapy
Colour Therapy
Counselling
Craniosacral Therapy
Crystal Therapy
EMDR
Emmett Technique
Emotional Freedom Technique
Energy Medicine
Flower Essences Therapy
Foot Health
Havening Techniques
Healing
Herbal Medicine
Homeopathy
Homotoxicology
Hydrotherapy
Hydrotherm Massage
Hypnotherapy
Indian Head Massage
Kinesiology
Life Coaching
Manual Lymphatic Drainage
Massage Therapy
Matrix Reimprinting
Maya Abdominal Therapy
Meditation
Microsuction
Mindfulness
Myofascial Release
Naturopathy
NLP
Nutritional Therapy
Osteopathy
Physiotherapy
Pilates
Psych-K
Psychotherapy
Reflexology
Regression Therapy
Reiki
Relationship Therapy
Rolfing
Sex Therapy
Shiatsu
Speech Therapy
Sports Therapy
Structural Integration
Tension and Trauma Releasing
Thai Massage
Thought Field Therapy
Yoga Therapy
Zero Balancing

That’s a list of 70 “therapies” of which at least 40 are obvious quackery, and very few could be said to have any form of persuasive evidence base for efficacy*. But the practitioners of each are persuasive, and the websites use pseudoscientific rationales that might fool those who are not as cynical or conversant with the scientific method as we are. So how do the public know what kind of help to seek out? How does someone who is feeling miserable, has a job they hate, financial difficulties and problems in their relationship know whether to get financial advice, careers advice, life coaching or therapy? And if they pick “therapy” how do they know whether to get CBT, psychoanalysis, art-therapy or non-directive counselling? And how do they know whether to get it from a therapist or a psychologist or a counsellor or a mental health specialist or any of a hundred other job titles? And within psychology, how do they know when to seek a clinical psychologist, a health psychologist, a counselling psychologist or any of the job titles that the HCPC don’t register?

I think apart from word of mouth and google, they don’t. Most people ask their GP or their friends for recommendations, and then go with something available locally within their price range. They don’t read the NICE guidance or understand the various professional bodies or regulatory systems. They trust that they’ll get a gut feeling as to whether it is going to help or not from the first session, and most of that “gut feel” is probably based on personality and charisma, and whether or not they feel listened to. The decision then rests on whether the therapist wants to work with them and has the capacity to take them on, and the price they ask for (assuming the service is in the private domain rather than the NHS).

Even the NHS itself isn’t very consistent about evidence based practise. For example, the NHS still funds some homeopathy – possibly wasting up to £5million per year on this placebo treatment that is entirely without evidence or credible rationale. Likewise I’ve seen NHS therapists who have done training in models of therapy that are implausible and without evidence (eg ‘energy therapies’ like EFT). Perhaps this is why the majority of clients doubt the efficacy of talking therapies. Yet, despite this scepticism, most would prefer to try therapy than medication yet the use of psychotropic medications has risen much more rapidly than the use of psychological therapies.

So where do we draw the line? If we only deliver fully evaluated treatments and those where we understand exactly how they work, then the amount the NHS can do when it comes to therapy will be much more limited. Lots of therapeutic interventions in practise are derived from other models or by combining aspects of various models. This allows individualisation of care. Similarly, there are many therapies which are being developed that have promising methodologies and are tightly rooted in scientific knowledge, but have not themselves been subjected to RCTs that prove efficacy yet (eg DDP). And many RCTs seem far removed from actual clinical practise where clients have a variety of overlapping conditions and clinicians deviate substantially from the treatment manuals.

The other confounding factor is that when it comes to talk therapy, it turns out that the modality or adherence to the manual matters very little compared to the relationship between the therapist and client. It seems the key ingredients are listening to the client, genuinely caring about them, giving them hope that things could be different, and giving them the confidence to try doing things slightly differently. Whether we have years of training and follow the manual diligently or whether we are newly qualified and muddling through seems to make much less difference than we think. In fact, therapist variables are much more powerful in influencing outcomes than modality, and even than the difference between treatment and placebo. That is no surprise to me as I’ve personally benefited from physiotherapy that included acupuncture – despite having read studies that show it to be no more effective than ‘sham acupuncture’ where random locations are pricked with a cocktail stick!

In the paper I’ve linked above, Scott Miller argues persuasively that we don’t need to focus on understanding how therapy works, or in using the medical model to work out what works for whom with endless RCTs. He shows evidence that experts are defined by having deep domain-specific knowledge, earned by a process of gathering feedback and focusing on improvement. So he argues that in the same way, expert therapists are those who collect and learn from client feedback. So his answer to the issue of evidence-based practise is for us each to collect our own outcome data to show whether our work is effective according to our clients (and by comparison to other options), and to see if we can improve this by using simple ratings within each session that check we are working on the right stuff and that the client feels we understand them, and that the working relationship is good.

So what does this mean for the proliferation of made up therapies? Does it mean that we should leave the public to buy a placebo treatment if they so wish? Or does it mean we need to focus on the modality and evidence base after all? The ideal would obviously be better regulation of anyone purporting to provide therapy of any form, but given the HCPC remit doesn’t even include counselling and psychotherapy, I think we are far from this being the case. To my mind it throws down a gauntlet to those of us providing what we believe are effective and evidence based treatments to collect the outcome measures that demonstrate this is the case. If we are sure that what we offer is better than someone having an imaginary conversation with an imaginary ‘inner physician’ by feeling imaginary differences in the imaginary rhythm of an imaginary fluid on our scalps then surely we ought to be able to prove that?

And what does that mean for my idea of making a website to point people at helpful places to start a self-improvement journey? To me, it shows there is a clear need for simple and accessible ways to identify what might be useful and to allow the public to differentiate between sources of support that have evidence of efficacy, professional regulation, a credible rationale for what they do, reputable professional bodies and/or personal recommendations. Maybe such a website can be one contribution to the conversation, although I’ll need both allies and funding to get it to happen.

 

 

*I’d say EMDR, physiotherapy, speech therapy, CBT and some types of psychotherapy and counselling probably reach that bar. Mindfulness is probably getting there. Art therapy probably suits some people with some issues. Yoga, sports massage, pilates, osteopathy, meditation, life coaching and (controversially) even acupuncture probably have their place even though the evidence for them as therapy modalities is limited. Most of the rest are quackery.

How to recruit (and what to do with my therapy company)

My working life has been increasingly focused on improving outcomes for Looked After Children. I deliver training and consultancy to care providers such as residential care companies and fostering agencies, as well as to health, social care, education and legal sector professionals. I have also developed a suite of online tools to help commissioners and providers to assess needs, track progress and evaluate outcomes for Looked After Children, including www.BERRI.org.uk  I think the introduction of clinical governance processes to the social care sector is long overdue, and I’m hoping that I can contribute to a culture change that drives up standards for Looked After Children. Signs are good, in that Jonathan Stanley chair of the Independent Children’s Homes Association (ICHA) said “you have set the gold standard for care providers” and Sir Martin Narey said “this is the missing link” when it comes to residential care. So I am trying to make this my business.

I’d like to find someone to help me take that forward, who has the kind of financial/business/admin skills that will complement my clinical skills and ensure we run efficiently as a company. Perhaps a business graduate with lots of energy, or an experienced admin who wants a new challenge. Ideally able to come to meetings in Derbyshire at least once a week. I’ve been inundated with demand, which is great, but it means I need help to keep organised and on top of all the competing demands in my new line of work. And that means that I need to give up, hand over or sell on other things I have been involved in.

With that in mind, I am wanting to make a plan for what to do with my existing therapy and court work business in Milton Keynes when I move out of area in a month from now. It’s a profitable business, and meets the needs of a client group who fall between health and social care. We offer edge of care assessments, psychological therapy and support to prevent kids coming into care, to support placements, enable rehabilitation to family, or for children and families who want help with parenting or a mental health issue. We also do court expert witness work for the family courts, and provide consultation into two sets of children’s homes.  However, the only other qualified CP involved is going on maternity leave soon and there is nobody else to provide cover. If I was staying in the area and/or had the time and mental capacity to continue running it myself, I would. But given I can’t, I want to make a good landing for it. And that means either recruiting a temporary or permanent clinical psychologist, or selling the business on to somebody who has the capacity to build on it.

I also need to recruit to provide cover for the services that I supervise within Keys group whilst various staff are on maternity leave, as well as to new vacancies within Keys. But despite the enormous importance of the work, and the fact it is highly valued, and as part of a well-equipped team without many of the niggles of the NHS (for example, we provide tea and coffee, you get your own desk and computer, and the caseload is manageable) recruitment pathways are not as easy when you are outside of the NHS and the first point people look at when seeking work is NHS jobs. We’ve tried BPS appointments memorandum and various recruitment agencies and websites, but so far nobody suitable has applied. So what now?

If anyone has any ideas, the company information is below:

1) My company in Milton Keynes

Lifepsychol/Evolving Families offer therapy to about 10 families, some court expert witness work, and consultation at a day rate into Keys in south Bucks and Peterborough. The qualified CP is going on maternity leave and I am moving out of area. We therefore either need to:
a) sell the business as a going concern to somebody or a company who can pick up the clinical provision (this could potentially include the evolving families business name, bank account, social media, website and email address, with ongoing referrals and enquiries – to run either as a traditional company or as a social enterprise)
b) recruit a member of staff to pick up this work and be an ongoing employee
c) recruit sessional cover of 2 days per week for 6 months to cover the maternity leave

2) To help run my BERRI project

A business graduate or experienced admin who can turn their hands to all kinds of tasks to make a small business work effectively, from responding to email and telephone messages, to keeping on top of the finances, client account management, customer support and converting enquiries into subscribers. Basic salary, plus bonus related to success of company, and the chance to grow with us and earn ‘sweat equity’ in year three. We are flexible and family-friendly. May be able to work some hours from home, but must be able to meet in Derbyshire at least once per week. It may be possible to start part-time and build up, if you are returning to work after a career break.

I would welcome enquiries about any of the above options to lifepsychol@gmail.com

2) Within Keys we have several vacancies to deliver consultation as part of our psychology pathway, and to supervise the APs doing assessments. There may also be scope for some direct therapy. We would either be able to offer permanent contracts for full or part time work, or sessional work which would be contracted for six months initially and then potentially extended.

Vacancies include:
– Full time or part-time posts to cover Warrington/Manchester
– Full or part-time post to cover Shrewsbury area
– Full or part-time post based at Sheffield/Chesterfield/Peterborough
– Full or part-time post to cover Taunton and/or South Wales (we have about 2 days work in each location, but can top this up to full-time with input into another project)

With all of the above, hours, location and salary are negotiable dependent on experience. Email lifepsychol@gmail.com and/or juliehamilton@bettercare.co.uk

Also, if anyone has any contacts to circulate the same around the clinical courses, we would be interested in prospective applications for trainees due to qualify this year.

Wisdom, sycophants and advice that won’t work

I have been watching and reading a lot of Brene Brown stuff recently, and for the most part I feel like she has been able to identify and tap into some important concepts that chime true with my own understanding of attachment, shame, perfectionism and self-compassion, but there is a part of me that is a bit uncomfortable. When I’ve watched recent interviews, such as this one with Oprah I find myself responding to the comments like “that is so powerful”, “right, right, right” and “there are so many things I love about you” with a bit of a cringe. I think it is partly that it feels like a sycophantic mutual love-in amongst a particular group who have formed their own self-improvement echo chamber, and partly that the whole American over-the-top-ness of it makes it come across as less than sincere.

Obviously Oprah is in herself an incredibly impressive person: She is self-made despite horrible early life experiences and someone who adds welcome diversity to the line-up of bland white males and slim, magazine-beautiful young women that populate American TV, she has popularised acceptance of LGBT people and been empathic about a wide variety of life experiences and mental health problems. Plus she is a significant philanthropist (albeit that her charitable activity in itself is not entirely without criticism). However, Oprah and her ilk are so non-critical of patent nonsense from self-help books about spirituality and positive vibrations to dodgy hormone treatments that it feels like a huge missed opportunity to have not put a threshold of scientific scrutiny (or at least critical thinking) to claims when she has such an enormously influential platform.

Likewise it is hard for me to reconcile why a credible researcher like Brene Brown would be prepared to be thrown in that mix and start marketing self-help courses for Oprah watchers. It doesn’t seem to make sense without attributing a financial motivation for accessing the wider audience that is more powerful than professional ethics.

I’m going to read all her books and then I’ll be in a better place to comment, but I’d like to think I’m not being naive or rigidly judgemental here. I’m sure if I felt that I had an important message to share and Oprah offered access to her audience of millions, and I felt that would help to change the world I would make compromises too, both to get the message out and to get the book sales, raised profile and funds that would enable further work. And I fully accept that there have to be coffee table books that are accessible to wider segments of the population than the referenced texts of scientists and clinicians that are more closely tied to the evidence base from which they are drawn. But something still feels uncomfortable.

So, is it just a cultural divide or my own hatred of insincere praise, or is it something deeper that is rotten about the self-help culture?

I’ve started to think that the self-help world, like the diet industry, is rotten at the core because it is invested in failure. I don’t mean the books often recommended by mental health services as ‘bibliotherapy’ that address mental health problems based on well-evidenced psychological techniques like CBT here, which are predominantly helpful. I mean the 2000+ books per year of home-brew wisdom about how to be happier, grasp control of your destiny, be more successful, fix your marriage in a week, get more energy, unlock your chains! Most of these have no evidence base whatsoever, and the authors often have no scientific or mental health credentials. A cynic might say they are selling false hope. Yet the same unhappy people try again and again to change their lives by reading the next book, spending more and more money to make changes presented as easy that are actually unsuccessful for the vast majority of those that try them out.

Just like the diet industry, self help is an industry that has had meteoric growth. Yet little of that is based on any evidence of either the underlying principles or the efficacy of outcomes. There is minimal evaluation, and what there is isn’t promising. In fact, recent research (albeit on a very small sample) has shown that reading self-help literature actually makes people more depressed and anxious!

“The sale of self-help books generated over $10 billion in profits in 2009 in the US, which is a good reason to find out if they have a real impact on readers,” said Sonia Lupien, Director of the Centre of Studies on Human Stress (CSHS). The results of the study showed that consumers of problem-focused self-help books presented greater depressive symptoms and that growth oriented self-help books consumers presented increased stress reactivity compared to non-consumers. No difference was found in any variable according to whether people had read self-help books or not, suggesting they have little impact on functioning. In fact “the best predictor of purchasing a self-help book is having bought one in the past year” suggesting that the same group of people repeatedly buy self-help books but aren’t actually changed by reading them.

In the same way, every new year consumers with weight-loss resolutions in the UK spend £335 million, yet a month later for more than half of them there is no measurable impact on their weight or fitness. Overall the diet industry has an incredible failure rate: 95% of people re-gain the weight they lose. Yet the consumers keep on spending. In the USA consumers spend more on diet-related purchases than the combined value of the government’s budget for health, education and social care. And yet a little basic knowledge of the subject could inform them that most of the things they try won’t work, and that there are very well established links between diet and health.

It seems I am not alone in this discomfort, and Brene Brown herself has felt it and responded. I still think she is one of the good guys, and clearly there are gender politics and marketing influences she struggles to counter, but it remains a fact that there is little to distinguish the good from the bad in the self-help field. I wonder if it is time for those of us who write from an evidence base to respond to that and to start a website to evaluate claims from self-help literature?

Giving psychology away – the positive ripples of training

When I left the NHS I wondered whether I would have enough work to keep me busy, and felt like the expert witness work I do the family court would probably be the main strand of my income for the foreseeable future. However, perhaps because of my book, I have increasingly been asked to speak at conferences, provide training to various groups of professionals, and consult to organisations – particularly on the topic of working with attachment, trauma and the impact of maltreatment on children. This has become an enjoyable sideline where I can cascade psychological thinking to a wider audience, meet lots of new people, learn from others, and earn a good daily rate without the same emotional weight as doing court work.

I also like any work that involves improving the quality of services, particularly for complex or marginalised client groups. It was therefore very interesting to me when I was asked to meet up with some of the directors of a children’s home company, Keys Childcare, about offering training and consultation to a 20 placement project they were running about an hour away from my base. After some initial meetings, we decided that I would offer some staff training sessions (on attachment, trauma and the impact of maltreatment on children’s development) to all the staff, and then help them to implement a more systematic program of care planning and outcome measurement. The aim was to make decisions about which young people needed therapy and what form of therapy they received more evidence-based, as well as to ensure that all of the staff were involved in making the care for each young person as therapeutic as possible.

This fitted in really well with an outcome measurement system I had been developing for several years, using my ‘BERRI’ checklist of Behaviour, Emotional well-being, Relationships, Risk and Indicators of something requiring further assessment (such as markers of neuro-developmental conditions, or more usual behaviours, perception or thinking which would merit more specialised interventions). I had already developed a system whereby data could be entered into the BERRI online and produce a feedback report, and scores could be compared to track progress over time. This could produce a visual representation of a young person’s needs across the five dimensions, and allow us to be more holistic in our thinking about how to support them to make optimum progress.

radar

After discussion with my friend and colleague on the BPS CYPF Faculty, Dr Andy Rogers, who had used the system in units he was consulting to, I had started to develop a system for targeting particular concerns to address in the care plan. This involves identifying around three specific concerns from the BERRI and tracking them with greater frequency, typically daily, whilst giving the staff various strategies to try to address them. The target behaviours can be entered into the online system, which can then produce graphs to show progress and to identify any triggers. For example, in the chart below I’d hope that staff would instantly wonder what triggered the big green spike of aggressive behaviour.

tracking

I spent a couple of days each month with Keys, completing the staff training and improving the online system so that it would meet their needs. We also developed a pathway in which there would be a psychological screening assessment when young people arrive in placement, and their paperwork would be properly digested to ensure we had all relevant information from their history as well as an initial BERRI checklist, and we would bring this together in a meeting where the professionals around the child, their care team, the therapist linked to the home and myself would put together a therapeutic care plan document and identify the targets to work on over the coming months. The care plan could contain a summary of the history, a formulation section giving insight into the meaning of the behaviours and concerns the child was showing, then the targets we had agreed to track, and the strategies we had identified to help work on those concerns.

This was seen as a refinement to the existing therapeutic plan the homes in the project were already using, and embraced very positively. We called the approach Psychologically Informed Care-planning and Intervention, with the acronym PICI (which Jonathan Stanley, Chair of ICHA, said was an acronym that led naturally to a marketing slogan: “if you want the best for your child, get PICI”).

After a few months of seeing the changes within the local project, and gathering feedback from staff, social workers and commissioners, Keys decided to expand my remit. They asked me to do training for staff outside of my local project, and then to do some consulting to the wider organisation. They subsequently offered me a job as Clinical Director of Keys, with a remit to train all of their staff and implement the pathway across the whole organisation. This will take me three days per week for the next two years! They have also agreed to employ a psychology team to implement the project in each region, and this week we appointed the first qualified clinical psychologists. In time this team will grow to cover all of Keys services across the UK. We will also be taking on 3.5 assistant psychologists and more therapist time, so that we have a consistent level of consultation to each home in the company (with additional therapy time in the attachment homes where every child placed gets direct therapeutic input). This is super exciting, and I hope that we are able to evaluate the impact on both staff and the young people we look after.

Keys have embraced the new pathway and outcome measurement system as part of a wider push to improve staff training (which now also includes a modular training program that every staff member will work through) and to be able to evidence the effectiveness of their care. This includes a desire to be more evidence-based in how they make decisions about placements and interventions. The changes also coincided with the tenth anniversary of the company moving into childcare and buying the initial ten Keys homes from their previous owners, and also with a rebranding exercise. When they revealed the new branding a few weeks ago in Belfast I was delighted to see that Keys now describe themselves as providing “psychologically informed care for children and young people” and see this as a way to improve the quality of their placements (and through this to gain better Ofsted inspection grades, and become the placement of choice when commissioners seek to place complex young people).

It seems like a natural progression from the kind of consultation I was doing in a CAMHS LAC team, but on an organisation wide scale. My small amount of time has the power to influence more children by working indirectly. By “giving psychology away” I hope I am giving increased insight to those doing the day to day care, and slightly changing their way of working with the young people. Instead of a child getting one hour per week with me, they are getting 38 hours per week with a slightly more psychologically minded caregiver, and my influence can reach 320+ children and nearly 1000 staff.

The staff within Keys have been really enthusiastic about the new pathway and have given me positive feedback for the training days, so the although there is a lot of travelling and a very ambitious timetable for implementation I am really enjoying the work so far. I also get surprisingly positive feedback from training elsewhere, which is so lovely to receive. I think it really stands out for me given how few positive feedback loops there are in most clinical roles nowadays (beyond the occasional client or colleague sending a thank you card). I get a real buzz from positive tweets about my training or keynotes, gaining high scores on conference feedback forms, positive reviews of my book, or complimentary endorsements on LinkedIn.

I went up to Glasgow last week to train some staff to run my group program for parents and carers of maltreated children (Managing Behaviour with Attachment in Mind) and really enjoyed that also. Glaswegians really are the friendliest people in the world, and the group I trained were clearly hugely empathic to the children they work with so they were a delight to train. As I was leaving someone said to me that “training is a way to change the lives of thousands of children”. I think I had made some comment to brush this off (perhaps that it was the clinicians working directly with the families whose relationships were vital, rather than a day from a person like me), but she wasn’t having any of it. She said “no I mean it. I will interact different with the families I see tomorrow and in the future because I spent the day with you, and each person who came to the training will do likewise”. She explained emphatically that she had literally meant that in one day I had done something that would ripple out and change huge numbers of lives. That was pretty humbling to think about.

I’ve also had some exciting discussions about research, service evaluation and different kinds of therapeutic work (for example, working in partnership with collaborative lawyers). So I have decided to have a break from doing expert witness work over the summer and really have a think about what I most want to do. I need to weigh up all the choices in front of me, prioritise the things that make the most impact and/or give me the most satisfaction, and put some energy into finding allies with shared goals (including seeing whether I can recruit another clinical psychologist to LifePsychol in Milton Keynes to pick up some of the therapy and court work). I also want to reclaim my life outside of working hours, and to consider where in the country it makes most sense to be located. But it feels like all the effort I have invested in various projects to date is finally nearing fruition, and there are lots of interesting things on the horizon.

Long ago, I had a task list written on the whiteboard in my office, and Gilly had made me laugh by adding to the bottom of this “build secret volcano base, take over the world”, to reflect my ambitions to change practise on a wide scale. Maybe it isn’t such an unrealistic aim after all.

Between a rock and a hard place – when friendship and your professional role overlap

I’ve always tried hard to keep a clear distinction between work and non-work stuff in my life. I expect my friends to be able to offer, on balance, a similar level of support to me than they require from me. If the relationship is too skew then it will be meeting one person’s needs at the cost of the other, and that isn’t a friendship. Friendships are reciprocal, and allow me to trust enough to show facets of myself that I might not want to reveal in the context of work. In the safety of such a relationship I can have my own vulnerabilities. I can worry that I am less than a perfect parent, or talk about my relationships with other members of my family. I can joke, swear, drink wine, express opinions, or laugh at the contestants on The Apprentice without fear that this will tarnish my professional reputation. The rest of the time I feel like I have my professional hat on. I am in a position of responsibility and power, and I am bound by a code of conduct. When I talk or post online as a psychologist, I run the risk that my comments will be brought back against me when I’m in the witness box, or be taken out of context and misinterpreted by a present, past or future client or colleague.

I am friends with some psychologists and other colleagues from work and via the clinpsy forum. That’s a good thing. We share common values and experiences. We have shared stressors, and we spend time together. I am also friends with other professionals that know me as a psychologist, like lawyers, paediatricians, psychiatrists and social workers. Again, our work overlaps and becomes a topic of mutual interest. I also have non psychology friends. That’s a good thing, as they bring different ideas and perspectives. They let me relax, share other interests and remind me of the other parts of me outside of being a psychologist. We can cook, eat, play, exercise, explore, talk. We can play video games, make music or art, debate politics and current affairs. As a prior supervisor would say, we are people, partners, parents and professionals as well as psychologists, and we need to pay attention to each of those roles. What marks it out as a friendship is that there is trust, and that the relationship is enjoyable or nurturing.

The difficulty comes when you feel like you ‘click’ with someone who you are seeing professionally and feel that had you met outside work it could have been a friendship, as that makes it harder to stay within a work role and remain within the more neutral and guarded boundaries that a professional relationship entails. A therapist needs to respect their clients, be curious about them, accept them, hold them in positive regard and see their potential. The relationship may be very important for the client, who may idealise you and want to bring you into their life. But that doesn’t make it a friendship. The power balance is different in a professional relationship. Within therapy the client is expected to disclose a lot about their life whilst the therapist discloses little. It is not a reciprocal relationship, and the relationship is not there to be enjoyable or nurturing for the therapist. Having started from there it is not possible to reach a place of reciprocity (at least not without a lot of time and distance after the end of the therapeutic relationship). So if you find yourself acting too casually, sharing too much information, or wanting to step outside of your normal professional role, this is definitely something to discuss in supervision.

Likewise, if someone in your personal life starts to use your professional skills, this needs to be handled very carefully. Parents asking for advice about their child’s anxiety or poor sleep may not differentiate whether you are giving advice as a friend and fellow parent or as a professional. A friend who wants guidance how to access IAPT, or is feeling suicidal and needs to be taken to A&E needs to know you can support them as a friend, but not as their psychologist. We may well know the system and the right things to say, or the right people to approach, but it is important not to end up muddling the role. You can’t ring up someone you know’s treating clinician and say “Hi, this is Dr Silver and I’m wanting to ensure you understand my formulation about my friend Jane”. They are entitled to confidentiality in their therapy and trust within their friendship. But you may also feel a greater obligation to act on concerns about someone’s mental health, or a child protection concern, than a general member of the public.

It is all too easy to get sucked into an uncomfortable place in between. What of someone that approaches you in a way that appeals to both the personal and the professional? They just find you so easy to talk to that they tell half their life story, and next thing you are feeding back a formulation at a dinner party. Where do you go from there? Do you reciprocate and tell the ins and outs of your life, or give them a business card if they want to follow up the conversation with a formal session? Or the friend who just can’t get an assessment for their dyslexia, but is self-critical about how stupid they are, when you have the psychometrics needed in the office and your assistant has a spare hour on Friday. Surely that’s not so personal? Or the friend of a friend that never seems able to access the services they need. Do you step in and advocate for them? Its a very difficult decision to call sometimes. But in my experience it is these situations that are most likely to fall down around your head.

A colleague of mine was concerned that a friend of a friend (lets call her Sarah) was discharged from an inpatient stay without proper risk assessment or follow-up. He spoke to the GP and inpatient team to raise concerns, but nothing was done. Sarah later committed suicide, and my colleague was interviewed in the enquiry that followed. The coroner did not seem able to differentiate between a concerned friend who happened to be a professional, and someone with professional responsibility, and he got given a really hard time. This was on top of the guilt he felt for not having been able to prevent Sarah taking her own life.

Another colleague ended up having to drop everything to collect a friend from various complex situations all over the country as she had psychotic episodes, and would not trust professionals when she was not taking her medication and did not have a good support network.

I ended up writing to the GP of someone I shared an office with early in my career, to report an eating disorder, suicidal ideation and risky behaviour. I felt like there was little else I could do after a supervisor said it wasn’t their problem, because I felt like it was unfair to burden me with the information without allowing me to act on it. I was very clear with the person involved that this was what I was going to do if they continued to confide this type of information, and they had written down the contact details of their GP for me during the conversation. They went on to get appropriate therapy.

When I first met my husband it was evident he was dyslexic. I did some informal assessments so that I was sure my hunch was correct and then pushed him to get formally assessed at university. This confirmed the diagnosis and enabled him to get concessions made about his spelling and handwriting in exams, and I learnt to help by proof-reading his course work. I felt like the assessment needed to be independent to have any authority, and that I could not take on this dual role.

A decade later, I started at a new post and started to become friends with the IT guy who covered CAMHS. It was clear he had a specific deficit with his memory that had never been assessed, and I owned the WAIS and WMS that were current at the time. With the consent of the directorate manager and my supervisor, I did a full psychometric assessment. We have gone on to be lasting friends, and he credits me with helping him to understand that he is a bright guy with a specific deficit, rather than a guy of mediocre intellect who has done well for himself. However he has never wanted to use the assessment formally.

More recently I spent 24 hours taking an acquaintance to A&E after they confided detailed suicide plans in the wake of a relationship breakdown. They asked me to be with them in the room and share some of their abuse history with the assessing clinician, but I had to be very clear to identify as someone from the personal network. I was not a professional to them, but I was also not somebody who could take responsibility for this person on discharge as I lived in a different part of the country.

Each of these has been a learning experience and shown the importance of differentiating the personal from the professional, but it is something I will continue to grapple with both personally and through supervising others. The third role of speaking to other people on the internet is one I will blog about at some future point, and brings with it a plethora of new and challenging ethical issues, not just the way that the informality of the medium makes roles blur more between personal and professional.

Dressing for the job: Presentation and the art of neutrality

Everyone seems to have different ideas of how to dress for work as a Clinical Psychologist or therapist. NHS dress codes are often generalised from nurses on the ward and make exclusions including jewellery, open-toed shoes and nail polish which seem unduly controlling and irrelevant for a therapist. Others argue that diversity is a good thing, and that a therapist can dress however they want to represent their personality and culture, and should not be judged for it. Many settings exclude jeans, whilst others say that jeans are comfortable, practical and come in a range of colours and cuts that are hard to distinguish from other forms of trouser. Are my dark blue velveteen trousers jeans because they have rivet joints, rear pockets and a zip fly? Some employers exclude visible tattoos, piercings beyond a single stud in each ear and hair colourings that are not naturally occurring, whilst these choices are becoming increasingly prevalent in society. Some want staff to dress conservatively, excluding garments that expose the midriff or involve short skirts or low cut tops for women, but is this just sexist? Some make specifications about being clean and tidy, but this means different things to different people. So I figured I’d reflect on my thoughts on the topic of appropriate dress for work as a Clinical Psychologist.

Firstly at a personal level: When I dress for work, most of the time I try to be as neutral as possible. I don’t want my appearance to lead potential clients and colleagues to make judgements about me that form a barrier between us any more than the factors I can’t avoid such as my gender, age, ethnicity, or accent. I want to appear professional but not intimidating, clean and well presented but not ostentatious. I want my clothes to be serviceable if I want to sit on the floor with a child to play, and not to inhibit me if I want to use paints and felt-tips, and not to cause offence to anyone else. Plus I want to be comfortable and not self-conscious about the way I move or sit. For these pragmatic reasons I normally wear trousers, though I do sometimes wear a long skirt or dress. I also like to wear fairly colourful clothes. I suppose I think they are more cheerful than drab colours, and suit me better than paler colours. So you’ll often see me in navy blue, bottle green, chocolate brown, burgundy, purple, turquoise or multi-colour patterned prints.

Of course I have more scope for relaxed dress, as I am effectively the boss, so no-one can tell me off for what I wear! It also makes a difference that I work with children and families, which is generally a more eclectic and casually presented workforce than settings like neuropsychology or forensics where “power dressing” in suits and business wear is more typical. Likewise my clients tend to be younger and more adventurous about what is acceptable than older adults, and I don’t work in health settings where the stronger dress codes apply. Nonetheless I don’t want to be so casual that people think I don’t take the work seriously, and I know that as a senior professional I need to acknowledge the expectations of others who imbue me with status and power. Certainly when I go to court I will always wear a suit to show I take the responsibility of advising on people’s lives seriously, and when I train other professionals I think carefully about my audience and the message I would like to convey. But here I am thinking particularly about client-facing work.

In terms of others, I’ve had to grapple with all kinds of examples of inappropriate presentation over my career. I have had members of my staff wear ripped jeans and trainers to meetings with professionals and clients. I’ve had some who seem to want to look like surfers or a member of an indie band, in slogan T-shirts, bermuda shorts and unkempt facial hair. To me this seems disrespectful towards those who have come to see you. I’ve had staff who have shown too much skin, whether midriff, cleavage, or the dreaded builder’s crack. This can trigger very strong responses in certain people, whether due to their own abuse history, their assumptions about showing more skin indicating sexual availability, or through their religious beliefs about modesty. I once had an employee with significant body odour, and had to have a cringe-inducing conversation in supervision to feed this back. However, not only is body odour unpleasant for those around you, it also creates a bad impression to clients and colleagues, and would put us in a hypocritical position when observing or trying to improve poor self-care.

At the other end of the scale I’ve had staff who over dress. I’ve had graduates who turn up in power heels and suits for everyday work. Or those who look like they’ve just dropped into a session on the way to the catwalk or tea with a Duchess, wearing designer clothing, expensive jewellery and branded accessories. It isn’t very practical to have shoes that you worry about getting wet, or a coat you can’t put down in a dirty environment, and if a client knows you spent more on your handbag than they get in 10 weeks of Job Seeker’s Allowance this may cause understandable resentment. At a more practical level, doing a home visit in a rough area whilst wearing £1400 of accessories, expensive jewellery and talking on a £600 smartphone must surely increase the risk of being a target of crime.

I am acutely aware that many of the families that we see come from high levels of socio-economic deprivation, so I would feel very uncomfortable if I felt that any of my clothes or accessories spoke of excessive wealth. I remember the feeling of visiting a conservative MP at home in a seven-figure mansion full of antique furniture, and a member of the household staff being sent to make the drinks. My mind immediately asked “what can someone who lives like this know of what real life is like for the majority of people in their constituency?” I would hate for a client to think that about me, and to take longer to build trust, or not to be able to confide the whole of their story because of it.

As a result I rarely wear branded clothing, and tend to stick with shopping for most of my work wear in department stores or supermarkets. Likewise I wear quite practical and mid-market shoes. Beyond my wedding ring I wear little jewellery. I rarely spend more than £60 on any item apart from a suit, and I don’t wear things to work that I would be too upset to spoil. My approach is also wider than physical appearance: I try to also be aware of what I talk about  to clients, in terms of whether it reflects my relative wealth and education, or my cultural values. How much of this is my personal taste or my bargainaholic nature and how much is 20 years of cultivating the most neutral appearance possible is hard to separate. Also in the mix are the dress styles of the supervisors and mentors that I have most admired during my career (mostly very down to earth people, of humble appearance) and of my own parents, especially as my mum is also a Clinical Psychologist.

I expect my employees to also find this balance between being themselves and appearing professional and neutral for clients. This includes being clean and tidy, not wearing overly revealing clothes, and being smart but not ostentatious.But beyond that I am happy with some personalisation to reflect their own style and culture. I wouldn’t want a team of clones. I also encourage my staff to reflect on what they bring of themselves to a session or meeting, whether in terms of appearance, body language, accent or content in conversation. We are often unaware of how this would be perceived by others outside of our familiar social circle (which is often defined by similar age, socio-economic status, culture, political values, education or other factors we won’t necessarily share with our clients).

For interview I would always advise presentation that is one step smarter than you’d expect to wear in the job, whilst being something you feel comfortable wearing and not so bland that you are instantly forgettable.

Finally, I wanted to clarify that although I think it is helpful to dress neutrally in a professional role, I don’t consider a person’s dress to be an excuse for how others react to them. Intolerance of appearance or dress relating to someone’s culture or religion is unacceptable and a form of harassment. Using skimpy clothing as an excuse for sexual harassment or assault is likewise totally unacceptable. A person is always responsible for their own behaviour, no matter how others look or what they do. So what I am talking about in this blog entry in terms of reactions to appearance are thoughts and feelings, whether conscious or subconscious, that may have an impact on the therapeutic or professional relationship, not actions that cause harm or fear.

How much do you have to prove? A tale of the modern NHS marketplace

I took a voluntary redundancy from the NHS in 2011. Since then I have run a small company providing clinical psychology services. I mainly do expert witness work for the family courts, which I have blogged about before, but we also offer therapy, consultancy, training, research and other services.

In 2012 we bid for a grant from The Health Foundation to offer brief psychological interventions into the diabetes service for people of all ages at the local hospital. We wanted the bid to be innovative, and so we were determined to think differently about how we structured the service and hoped for it to be commissioned. We decided we would use the grant to set up a Social Enterprise to deliver psychological services, and that we would aim to get commissioners to agree to fund the service in retrospect according to the outcomes we achieved. You read that right – we planned to deliver a service for no cost in return for an agreement to pay for the outcomes we achieved. No more “spend-to-save deadlock” in which the NHS can’t invest in the things that will save money; we were providing the service for no cost to the NHS during the project period and offering to continue to do so, based on retrospective returns dependent upon whether we improved people’s lives and saved costs for their medical treatment. We also agreed to survey the level of mental health need amongst the population using the diabetes service at the hospital, and look at whether this related to their blood test results (which are the best indicator of adherence to medication regimes and lifestyle advice, and of physical health prognosis).

Diabetes is a hot topic because it is predicted to “bankrupt the NHS” due to the rising incidence and cost of treatment. It already costs the NHS £10 billion to treat nearly 4 million people with diabetes in the UK, and this is set to rise to £17 billion by 2035 as the incidence increases to 6.25 million diabetics. Once the loss of working days, early death and informal care costs are factored in, these costs more than double. Even more shocking is the fact that 79% of this expenditure is preventable, if patients followed the lifestyle advice and medication regimes recommended. Studies consistently show that around 40% of people with diabetes have mental health problems, and around 14% of this cost is prevented if there are services to support the psychological health of patients. That is £2.4 billion pounds of avoidable NHS expenditure per year, and around £3.2 billion more in the wider economy. Yet psychological services for people with diabetes are far from universally available.

The Health Foundation loved our proposal and gave us a £75,000 Shine Award to deliver it.

We set up our Social Enterprise which we called Evolving Families. The name is designed to reflect the fact that people change in their thinking, behaviour, learning and roles over their lifespan (and a fair chunk of our work is with adults reflecting on childhood, with parents or with young people whose family circumstances have changed). A Social Enterprise is a business that is run for the benefit of a community, society or environment, and invests the majority of their profits towards that good cause. Our Social Enterprise was designed to invest in delivering psychological services that might not be otherwise funded, like doing research or subsidising people who could not afford to pay for therapy but were not eligible to get what they needed on the NHS.

We used our agility as a small company to employ staff very quickly, and we were up and running for the project to start on 1st Jan 2013. We accepted 65 referrals in the following year (52 adults and 13 children), and closed the project at the end of December 2013. Of those 48 (36 adults, 12 children) attended for psychological therapy and completed pre and post therapy measures, with an average of 6 therapy appointments each. We were able to see people at their homes, at schools, in the community and in our offices. We saw people in the evening if this was more convenient. We went to multi-agency meetings about some of the young people. And most importantly we didn’t have defensive service boundaries – if we felt we could improve psychological wellbeing then we offered services that didn’t directly relate to their diabetes or mental health, for example cognitive assessments, advice about employment, exploration of the impact of neuro-developmental difficulties or sensory impairments.

We screened 750 adults and 100 children who attended the clinics, using the PHQ-SADS (a measure of depression, anxiety and stress used in the IAPT scheme) and the Problem Areas in Diabetes questionnaire. This showed a highly significant relationship between all areas of mental health and HbA1c (the blood glucose score that is the best indicator of how well controlled the diabetes is). There was a very high rate of mental health problems, including a very worrying level of suicidal ideation in both age groups. There was also a very poor level of diabetes control; only 20% had an HbA1c score in the range considered to be optimal (<7) whilst 60% had dangerously elevated levels (>7.5), indicating that this hospital clinic serves a very complex and risky population group.

After the year was complete, we had clear evidence that our service was helpful and cost effective. We made a significant change to participants lives – not bad for 48 people getting  an average of 6 sessions of psychological therapy. Their mental health improved markedly. Fifteen people who were having frequent suicidal thoughts were no longer suicidal, 19 A&E visits in the months before therapy were reduced to 1 in the same number of months after therapy, 30 ward admissions in the same period were down to 5. The cost saved by this reduction in physical treatments was greater than the project cost to deliver. All in all we had pretty impressive results for providing psychological interventions at a cost per head that was lower than IAPT. We were Highly Commended in the HSJ Efficiency Awards.

But did commissioners bite our hand off to take up the offer of paying for the service based on the results it achieved? No. We couldn’t even get to talk to commissioners in person. The hospital told us to talk to the CCG, the CCG told us to talk to the hospital. They told us they need fixed cost contracts to put in their budget, not this outcome based stuff. The contract value is too small to be separately commissioned, and we are outside providers. The service closed to referrals a year ago, and although our service users are passionate about the need for the project and the impact it made on their lives, nobody seems to be listening. So we’ve written a business case and given it to the various service managers at the hospital, and we’ve presented our results locally and we wait, with dwindling hope that it will be picked up at some point in the future. Maybe in the next financial year. Maybe when they reconfigure the diabetes provision.

So I ask: how much do you have to prove in the modern NHS marketplace? If we can deliver a highly effective, life-changing service, and save the NHS more than it costs within the financial year, and we are prepared to accept payment in arrears based on the outcomes we achieve, what more can we do?

Video flash of powerpoint showing outcome data for the project is here: https://www.youtube.com/watch?v=sdyVfGOkdD0

Service user comments about the project are here: https://www.youtube.com/watch?v=KsQDgs-yDq4