A number of publications are directly relevant to the wellbeing of healthcare professionals – you can find these below:

The Burnout Booklet

The Burnout Booklet: A Health Resource for Patients and Practitioners By Katharine Murphy and Olivia Glaze

This beautifully illustrated booklet draws on lived experience of burnout to offer a range of metaphorical ways of describing burnout. I often talk about how the word burnout can mean many different things, and it’s important to understand the individual experience of this to be able to respond in helpful ways. This booklet can help individuals find ways of expressing their experience and also help supporting professionals think in a more nuanced way about the issue.

Creative hobbies and work recovery

Recuperating, Revitalising, and Reaffirming: the experiences associated with creative hobbies, and their impact on recovery, wellbeing, and work by Delores Hill

This research project explored ways in which creative hobbies can support work recovery. This is a concept I often explore with health professionals I work with. It is the idea that what we do outside of work can help to replenish what is depleted by our experiences at work. It requires us to be attuned to our needs and be intentional about how we can support ourselves with what we invest our time in outside of work. Creative hobbies offer ways to meet a range of needs through supporting detachment from work, providing a sense of mastery, lifting our mood, and connection with values. This article describes Hill’s research in a very digestible way, and offers useful practical applications.

Creative Toolkit for palliative care professionals

Co-producing a ‘creative toolkit’ to support the mental health and wellbeing of palliative care professionals: a community case study By Marie A. Clancy, Caitlin R. Kight, Jessica Stein, Naome Glanville, Anthony C. Wilson, and Richard G. Kyle

This publication explores the growing pressures faced by professionals working in palliative care, particularly in the wake of COVID-19, and highlights how a culture of prioritising patient needs often leads staff to neglect their own wellbeing. It presents a co-produced, arts-based “Creative Toolkit” designed to support the physical, psychological, social, and spiritual health of staff through reflection, relaxation, and connection.

Drawing on a small-scale case study, the paper demonstrates how creative approaches can help staff process difficult experiences and build a sense of community, with highly positive participant feedback. While the findings are context-specific and further research is needed, the publication makes a valuable contribution by showing how creative, arts-based interventions can be meaningfully integrated into workforce wellbeing support.

Art therapy to reduce burnout

Art therapy to reduce burnout and mental distress in healthcare professionals in acute hospitals: a randomised controlled trial By Megan Tjasink, Catherine Elizabeth Carr, Paul Bassett, Gehan Soosaipillai, Dennis Ougrin, and Stefan Priebe

This study examines whether a brief, structured group art therapy programme can improve burnout and mental wellbeing among hospital-based healthcare professionals. In a large, multicentre randomised controlled trial involving NHS staff across a range of roles, participants were assigned either to six weekly art therapy sessions or to a wait-list control group receiving usual support.

The findings show that those who took part in the art therapy programme experienced significant reductions in emotional exhaustion, alongside improvements in stress, anxiety, depression, and detachment from work, with benefits sustained at three-month follow-up. While the study had some limitations, including its reliance on a wait-list control and limited subgroup analysis, it provides strong evidence that a relatively short, manualised and theory-informed art therapy intervention can meaningfully support staff wellbeing and could be integrated into hospital workforce support services. The lead author, Megan Tjasink has been a guest on the When Work Hurts podcast – you can listen to her talk about her work here.

The Body Hotel Self-Care Suite

The Body Hotel Self-Care Suite: Evaluation By Teresa Filipponi, Carolyn Wallace, and Thania Acarón

This publication evaluates The Body Hotel Self-Care Suite, a creative, movement- and body-based programme developed to support the wellbeing of palliative care staff within NHS Wales. Focusing on teams at Velindre NHS Trust, the study explores whether embodied, creative practices can enhance wellbeing, psychological safety, and day-to-day working relationships.

Drawing on interviews and pre- and post-programme questionnaire data, the evaluation found that participants reported increased energy, emotional resilience, self-awareness, confidence, and self-compassion, alongside a stronger sense of connection with colleagues. Staff also described applying tools from the programme to manage stress, communicate more openly, and foster more supportive team dynamics. While based on a small, self-selecting sample, the findings suggest that creative, body-based approaches can play a valuable role in supporting workforce mental health and cultivating more compassionate and sustainable workplace cultures.

It’s clear that the arts and creative practice can play an important role in supporting the wellbeing of healthcare staff. Creativity & Wellbeing Week is coming up (18th – 24th May 2026) – this is a great opportunity to consider how you might be able to bring more creativity into your workplace and life.

On 19th May I am running an online workshop for doctors with Dr Alison Smith of Earth & Bloom called Shaping Self Compassion. It’s a hands on workshop using clay to explore and nurture compassion for yourself, something many of us in helping professions struggle to access. It will be a gentle evening combining the soothing and tactile experience of working with clay and other natural materials with a listening circle. Booking closes on 5th May (to give us time to get your goodie bag to you), so secure your place today!

The post Creative health and wellbeing for healthcare staff: a research roundup appeared first on Dr Paula Redmond, Clinical Psychologist.

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Full transcript below

In this episode Dr Paula Redmond speaks with a team of colleagues in Wales about their groundbreaking and award-winning work on avoidable employee harm within NHS complaint and disciplinary processes.

Working at the intersection of psychology, HR, and healthcare quality improvement Benna Waites, Dr Adrian Neal, and Andrew Cooper highlight the wide-ranging psychological and systemic impacts of complaints processes, not only for the staff under investigation and their teams, but also for the managers and HR professionals handling these cases.

They discuss interventions and initiatives designed to reduce harm and promote psychological safety in this arena, with meaningful impact at both operational and policy levels.

This episode shines a light on what it takes to build cultures of care within organisations, where accountability and compassion can coexist — and how clinical psychologists can bring something unique to organisational systems change.

About the speakers:

Benna Waites: Consultant Clinical Psychologist, Joint Professional Lead for Psychology, Counselling and Arts Therapies for Aneurin Bevan University Health Board (co-leading around 300 staff). Programme Director for Leading People – a successful in house intensive leadership development programme currently celebrating its 10th year. Seconded part time in the national improvement team in NHS Wales and chaired the national Psychology for Improvement project funded by the Health Foundation’s q Community. Co-founder of http://compassionpractices.net – set up during the pandemic to make compassion practices – a highly structured conversation to support compassion in groups of staff – freely available.

Dr Adrian Neal: Consultant Clinical Psychologist / Head of Employee Wellbeing Service, Aneurin Bevan University Health Board

Andrew Cooper: Head of Programmes for Employee Wellbeing, Aneurin Bevan University Health Board

Resources

• New book out November 2025: Bristol University Press | Under Investigation – Transforming Disciplinary Practice in the Workplace

• The Avoiding Harm programme by the HPMA – www.hpma.org.uk/avoiding-harm

• Paper on harm to investigators: Understanding the Impact of Employee Investigations on Those Who Lead Them: A Case Study from NHS Wales

• www.compassionpractices.net

• https://www.linkedin.com/feed/update/urn:li:activity:7364310949052219394

I’d love to connect with you so do come and find me on LinkedIn or at my website and do check out the ACP-UK and everything it has to offer.

Follow and subscribe so you don’t miss an episode!

Transcript

Paula Redmond (00:04)

Hi, I’m Dr Paula Redmond and you’re listening to the When Work Hurts podcast, which is brought to you by the Association of Clinical Psychologists, the representative professional body for clinical psychologists in the UK. In this series, I’ll be covering the difficult topic of surviving formal complaints, particularly for psychologists. I’ll be bringing you conversations with brilliant guests, offering their expertise, experience and wisdom on this tough topic from a range of different perspectives.

This is the final episode in this series. I’ve learned a lot doing this and I hope it’s been helpful for you, whether you faced a complaint yourself, supported someone who has, or just want to be more informed and prepared, should it be something that crops up for you in the future. I’ve covered a range of angles, looking at the research evidence around the impact of complaints on psychologists, understanding the practicalities of HCPC fitness to practice complaints and how best to navigate these, and hearing directly from those who’ve been through this. To finish off the series, I wanted to zoom out again, broadening the discussion to complaints in the NHS more generally and the organisational and systemic issues related to this. To explore this, I spoke with a team of colleagues in Wales about their groundbreaking and award-winning work on avoidable employee harm within NHS complaint and disciplinary processes. Working at the intersection of psychology, HR and healthcare quality improvement, Benna Waites, Dr Adrian Neal and Andrew Cooper share their insights into the wide ranging psychological and systemic impacts of these processes, not just for the staff under investigation, but also for the managers and HR professionals involved. We talk about the interventions and initiatives they’ve developed to reduce harm and promote psychological safety in this field and how their work is influencing change at both operational and policy levels. Please do check out the show notes for links to some really helpful resources, including their brand new book, ‘Under Investigation, Transforming Disciplinary Practice in the Workplace’. We kicked off the conversation with introductions.

Benna Waites (02:26)

So I’m Bena Waits, I’m a consultant clinical psychologist by background. I’m professional lead for psychology, counseling and arts therapies in an Aneurin Bevan University Health Board. And I also run a leadership program along with Adrian and Andrew in Aneurin Bevan.

Paula Redmond (02:44)

Brilliant, thank you. And Adrian?

Adrian Neal (02:47)

I am a consultant in psych. I guess the day job is head of employee wellbeing for an Aneurin Bevan University Health Board. Yeah, been doing that for about 10 years. But work closely with Benna and Andrew across a number of projects. I think that the leadership programme and the avoidable harm are the two key preventative focused projects we’re working on and have been doing for quite a while now.

Paula Redmond (03:13)

And Andrew?

Andrew Cooper (03:14)

Well, hi, my name’s Andrew Cooper. I joined Aneurin Bevan Health Board about three or four years ago to develop the Available Employee Harm Program with a particular focus on the application of the disciplinary policy and process. And it’s been great working with Adrian and Benna over this time to develop this as really trying to make a difference and perhaps a gear change in how we do things.

Paula Redmond (03:39)

Great. And maybe we could start actually with just defining what avoidable employee harm is. I don’t know who would like to just say a bit about how you understand that concept.

Andrew Cooper (03:51)

So we developed the avoidable employee harm concept, really drawing lessons from the patient safety movements. And the patient safety movement established around 40 to 50 years ago, recognised that actually they were causing harm to patients, the healthcare professionals around the world, recognised that they were causing unintended harm, but also avoidable harm. And the recognition grew that there was no negligence or malice, that it was actually down to working in complex systems, that healthcare is complex. We work in systems that involve multiple layers, multiple people, multiple groups and interactions. And it is within all those interactions that sometimes harm takes place. And the patient safety movement started by recognising the potential and the possibility for harm, and then started identifying areas where harm was most prevalent. And then when they were identified to develop an interventions to address them. So that really underpinned our thinking for avoidable employee harm, reflecting on one of some of the things that we do, perhaps through our processes and our policy application that causes avoidable harm to our staff. So we’re a bit behind on the patient safety movement, but just starting that conversation around, are there things that we do that causes harm that can be avoided?

Paula Redmond (05:20)

And I guess the question to kind of all three of you about what it is that brought you to this work, Benna, shall we start with you?

Benna Waites (05:29)

So I think over many years as a professional lead, I had noticed the enormous impact both on colleagues from within my own service, but also peers and colleagues from elsewhere, the huge impact that investigations and complaints had on people. And often, because in a sense, it’s a process you work your way through, but the emotional impact felt enormous for people. And often these were very long and drawn out processes. So over many, many months, sometimes well over a year, you would see people and the ramifications and the ripple effect in their lives were huge. So it had been around for me for a long time, that sense of this really doesn’t feel okay. And is there a better way of doing this? And could we approach this differently? Could we think about it differently?

Paula Redmond (06:22)

Brilliant, thanks Benna. What about you, Adrian?

Adrian Neal (06:25)

So I guess acute reds. I, career wise, about 15 years or so, I started moving from a more traditional adult mental health role into staff work, did an organisational psychology masters and then kind of moved sideways. One of the, I guess one of the things I got interested in back then was the impact of organisational processes. Not so much disciplinaries or complaints process, but more organisational change on staff, first-hand experience, and a kind of very prolonged, uncomfortable, fairly miserable experience led me to develop that interest even further, but also leave the job I was in. So that was the kind of the driver personally. Landing in a new job, I guess, one of the things as a head of an employee wellbeing service for years and years, a kind of dominant core business was supporting people going through processes like this and others. But, so it’s not just my reflection on that, but my, you the entire team, the clinicians and the team feeling like this was a very tricky area because therapeutically, it’s actually very challenging to work with somebody caught up in a process, bit like a legal process, recovery tends not to really happen until it’s finished. And then there’s the whole wider systemic ripple effect, which you don’t tend to see in external legal processes, but you definitely see internally when it affects systems and departments and function and ultimately patients care. So for me, on the radar was always it’d be really helpful to do something in that area. And I do also remember a conversation with a senior psychologist not long after I’d started doing some support for a team and they were saying, can you do something about this? And at the point I was thinking, yeah, that’d be great. But no idea. You know, little seeds along the route, you know, and I guess from a wellbeing perspective, the Holy grail is prevention. We know it’s damn near impossible, but we know if you can do something systemically and you can make it proactive or preventative, the benefits are huge. So all of these things back in my mind, and then I can’t remember the timeline, but certainly kind of five years ago or so, meeting Andrew and with Benna, a conversation developed around, could we do something in this space? What could we, what could we do? And for us, that was the kind of beginning of the piece of work which we’re now talking on.

Paula Redmond (09:08)

And Andrew, what about you?

Andrew Cooper (09:09)

So my background is a little different. I’ve spent probably 10, 20 years in marketing and communications. And actually, how do you tell the story of change? How do you understand impact? How do you turn Benna’s description of what’s happened to somebody through a process, into something that’s relatable, understandable, and that can drive change? I’ve also been involved with the patient safety movement within Wales that recognised the harm that sometimes our treatments can do to patients. And I guess it was the conversation that the three of us had around, is there anything that we can draw from that learning and insight into how processes are applied? So a key part of patient safety movements has been a focus on quality improvement. How do we understand why things go wrong? And in understanding them, how do we develop new ways that can be tested to see if they’re tested and they test well, that they can be built into process and scaled up? So I guess bringing some of that insight into that wider conversation of how these processes were impacting people was really the start of this piece of work. And we use the term avoidable employee harm as a bridge between the two. We work in healthcare. Our healthcare colleagues understand the concept of avoidable patient harm. How do we take our non-clinical colleagues involved in management and administration and HR on a similar journey that actually acknowledges unintentionally often our processes can cause harm. So what can we do to mitigate or change that?

Paula Redmond (11:03)

Sounds like you guys are a dream team with your range of skills and expertise. So, Adrian, maybe I could ask you, thinking about the work that you’ve been doing in this programme, and I guess you’ve all mentioned the impact that these processes can have. I wonder if you could give us some more detail around that. What have you noticed in terms of the impacts of disciplinary and complaints processes?

Adrian Neal (11:30)

I mean, we published a paper about three years ago, I think, which we use as a case study that was reviewed by… or part of the paper was a kind of case study review methodology, so with multiple professional perspectives on a case. You know, that paper outlined a whole range of different scopes of impact. So we, you know, there is the obvious, and saying obvious, it’s obvious to us, but actually still not obvious, about the individual impact. We know that, and I think it doesn’t, given our audience, won’t take too much imagination to kind of appreciate the individual impact, whether it’s, you know, someone’s impact on their level of anxiety through to, you know, career changing decisions, you know, and lasting psychosocial scars. So I think we know that. I guess what we also discovered is a whole wider range of impacts, most of which are undocumented. There’s minimal literature out there. So we know that this causes a kind of cascade. So we often use the metaphor, it’s like dropping a pebble in a pond, but we’re only really focused on one angle, which is the individual. There’s a direct ripple into a team, into a system, be that because of disruption to usually tight knit teams, distribution of workloads, simply by virtue of somebody not being present and nobody being able to talk about it. So things like that, really difficult for teams. Anxiety and fear across team members who then think, you know, what bearing does this have on them? Suspicion and paranoia, you know, quickly follow because people don’t know what to say or do. So we know this really wreaks havoc with teams. We also know that people often go off sick either because they are simply not functioning and therefore not safe to work or as a means of getting some control over what little they have. So we know that impacts on capacity to deliver care. And that then ripples out in terms of a wider social, economic and financial cost. I guess more recently we’ve looked at the impact of people doing the investigation. So we know that even hardened HR and managers will, there will be, which kind of is a bit of a kind of, you know, d’oh moment, of course they’ll be affected because this is a distressing, they’re exposed to the distress of others. But we also know that people develop ways of coping with that over time. But we know that even hardened professionals struggle with this stuff and how they cope often doesn’t help. They will often cope in ways we know. People will seal over, will harden. It doesn’t make them better, having done this for years. But of course, that professional group has no history or tradition of psychosocial resources to support them. So they are pretty vulnerable, frankly. And you could argue, therefore, vulnerable to making mistakes. So that’s another area we’ve noticed. We know that it affects the person who’s being investigated’s family. That’s often not accounted for. So there’s this wider kind of arc of impact that happens once you start asking the questions. And what we were surprised with when we started doing this research is there’s very little out there. A kind of rapid evidence review a couple of years back, and it’s really poor. There’s nothing out there and it’s not consistent and it’s not great quality. So this is a, wow, this really is, if the patient safety movement is kind of 40, 50 years in its evolution and things are still happening, you know, errors are still being made. People’s relationship to accepting errors and embracing learning is still very much alive in the patient focused areas. We are way behind, in the human process is just so… you know, parts of our businesses. So yeah, lots of work there.

Paula Redmond (15:37)

Yeah, I can really relate to all of that you’re saying, Adrian. And I mentioned before we started recording, but I was part of a disciplinary process when I was working in the NHS as a witness, supporting witness. And it was for sure the worst, absolute worst professional experience of my life. And definitely one of the worst, you know, top 10 of my life, you know, and still those psychosocial scars that, you know, are still still present for me and just as being a witness as part of that. So I can for sure, yeah, relate to that. Was it Benna, was there anything you wanted to add?

Benna Waites (16:15)

I think in relation to the individual impact, although I think that’s easier to see, I think historically we’ve massively underestimated that, underestimated the harm. So purely at that level, just to be clear that the harm, as Adrian was saying, goes across multiple systems and areas of life. So kind of professional, reputational, financial, physical health, mental health, social life, family life. So it sort of spreads out across all of those systems, but also just the extent of it. I think what became increasingly apparent to us as we started sharing our experiences of being alongside people in this work, that sense that people are really traumatised. I mean, you can do an impact of event scale and you can score really high for PTSD as a result of going through a process like this. And that’s important. You know, I don’t think that’s widely understood by HR colleagues that there are those kind of costs and they last, they don’t stop when the investigation stops. They can last for years and years afterwards. So I think it’s just really important. And I suppose that that leads us into the work around how we might avoid that. But I guess really important to understand that when you embark on those kind of processes, and sometimes they’re unavoidable, sometimes there’s nothing you can do about embarking on the process, so a complaint will be, a patient complaint would be a good example of that, although I think you can be thoughtful at the beginning of that. But in terms of our internal disciplinary grievance, those kinds of processes, those are the areas where we need to be really careful about what our first steps are and what we think an appropriate response is to a set of concerns or difficulties or challenges, because I think we get it wrong all the time.

Andrew Cooper (18:12)

I think to pick up as well in terms of Adrian’s comment, in terms of the impacts on the investigator, that actually when we started this, was very much as Benna’s just set out, the individual who was the centre of the investigation, that’s where the red flags emerged, that’s where the concern was. But as we’ve developed this work and taken hundreds of HR colleagues and managers through our training, almost every training event, somebody will come up to me or one of us and say, I’ve actually been harmed by this process myself in terms of in that investigator role. And we’ve really looked to understand and explore that a bit more. What does that look like? Where is the harm? And just recognising that investigators are often carrying the workload of an investigation alongside all their other commitments. There is not enough space created for them to do it. The level and the information that’s being shared with them can often be distressing. They often see the impact of the investigation lived out on a daily basis of the person they’re taking through the process. So all those elements add up to a real sense of impact on the investigator. The paper we had published recently actually highlighted that no matter how many investigations an investigator does, it still doesn’t equip them to mitigate the harm to the person going through the process all themselves. So you actually, you bring that into consideration, and I guess we spent increasing time there because if there are to be improvement, it is about understanding that impact. Because I think there is a real sense that if an investigator, the more investigations they do, there’s the real potential for desensitisation because what they are presented with is so traumatic themselves and in a sense, how do they manage and regulate themselves in that space? And then I guess if desensitisation is one of the outcomes, that can quickly lead to compassion fatigue. So we believe a good investigation is absolute diligence to process, process is there for a reason, but also managing the wellbeing of the individual being taken through it. And there’s real concern that actually if we don’t look after our investigators, if we don’t create a sense of an opportunity for them to debrief, to understand what they’ve gone through, then actually it’s going to be a downward spiral in terms of subsequent investigations that are taken forward. And I guess for us that was one of the big learning points that wasn’t even on our radar when we started this work.

Paula Redmond (21:11)

Thank you. So I wonder, maybe if you could talk us through the work that you have done and what changes you’ve sought to make and how that has unfolded?

Andrew Cooper (21:21)

So we’ve taken a quality improvement focus with this work. And one of the key things within quality improvement is to look at the data. What is your data telling you? And our HR team conducted a review of investigations that had taken place over a 15-month period and discovered that of the 109 that had been undertaken, over 50 % of those had led to no sanction. So we were putting individuals through a process that we increasingly knew to be harmful, where actually looking at that data, perhaps they could have been taken through a more informal process, which would have addressed issues without the related trauma that we’ve been experiencing. Second element around quality improvement is to look at what interventions that we need to build to bring about change. And our HR colleagues have done an amazing piece of work within this space. They actually looked at what they call their initial assessment document. So that was a document that managers use to summarise the issues that might lead to an investigation. And they realised that in an earlier version that they weren’t collecting all the right information. They were collecting the information related to the issue, but perhaps not the wider context issue. So what was going on in the organisation at the time, who was the person sitting before them? What was their record like? Was their PDR and training up to date? So I actually looked at how do we improve that decision-making document that would consider those mitigations and not just focus on the issue. And then again, HR colleagues have done a job around coaching managers to help them understand the options for addressing workplace issues. Some managers had said to us, well, we thought the disciplinary policy was the only policy to pursue. And we actually were able to highlight, no, there’s less formal ones that they can pursue and also help managers understand what are the mitigations that might lead to making a different decision. So I guess there’s data, there’s building interventions, and it’s working with colleagues in the system who are responsible for making those changes and also helping them understand why those changes need to be made.

Adrian Neal (23:54)

And if I could just come in there, I think there’s a bit of context as well, which is helpful to frame what Andrew has just explained. So I’m sure Andrew wouldn’t disagree, one of the reasons we’ve been able to do this work, certainly because there was internal interest from HR in being curious about the numbers and the disproportionate amount of numbers and certainly the outcomes. But actually, even before that, what we had is we’ve had kind of the work authorised by the director of workforce. And actually, we started to develop the ideas with the previous director, who then retired and was replaced, and luckily, we had continuity of support, which has only grown. But a key area of support was an acknowledgement, and I still kind of think this was a key point. So my manager, the director of workforce, a kind of career HR, operations HR professional said to both Andrew and I, you know, I, this is uncomfortable, this idea, but I recognise it and I’ve done it. And that still is a really important moment, I think, in giving us permission to proceed, that recognition of the discomfort the profession has. And we can come back to that point later, I think, as we’re looking at it, you what’s turning into us, into a bigger culture piece beyond our organisation, but was a kind of cornerstone moment where a senior professional in a NHS role, which is highly politicised, Wales is very political, said, yeah, this is a problem and it’s uncomfortable. And to me that helped us immensely because each, as we, as you know, every colleague we talk to now, I think has their own moment of discomfort around this. And that’s pivotal for change. But centrally it authorised us to do this work within our organisation because, and I also think you know if we if we’d started this conversation a couple years before it wouldn’t have got off the ground, so there was something about timing and the right people were opening the right doors to allow this to happen.

Paula Redmond (26:06)

Benna, I know that you’ve got a particular kind of interest around psychological safety in particular and I wonder what that brings to this work?

Benna Waites (26:15)

Yeah, so I do. I’ve been teaching psychological safety on our leadership program along with Adrian for 10 years. And I now appear to be doing a PhD in psychological safety with all that spare time that I have, but it’s a real interest of mine. I guess part of the reason it’s of such interest to me is that I think in health teams that I see around me, it’s an enormous problem. There are lots of structural issues that make getting a climate where people can really have a voice and people can speak and raise concerns and ideas and feel connected, it feels a real challenge to make that happen. And of course, what we’re talking about, so engaging in formal processes, will make that so much worse. It will have a huge impact on not just the person and their voice and their ability to feel safe in that team, but also on colleagues and it’s really interesting you saying earlier Paula that you’ve had an experience of being part of an investigation. So often these investigations involve interviewing multiple, sometimes tens and tens of people to gather witness evidence. And that whole, that paradigm really of investigation, which feels for most of us, I think in our heads belongs more in a kind of criminal type context sets up, it is a massive counter influence to anything that would support and generate psychological safety. So it can be really challenging. I think if an investigation were done incredibly well and held really well and supported really well, you might be able to create enough safety for people to feel that they’ve said the things they need to say. I think it is not impossible that those two things can’t go together. But most of the time, I think the experience of it will be that it is suppressing of voice. And what we know about psychological safety is that when you lose voice, you lose team functioning, your teams just don’t function so well, your performance goes down, all the outcomes that you want, patient care suffers, all of the outcomes you want to see in healthcare get worse when psychological safety is damaged.

Paula Redmond (28:35)

I think it’s also, I mean, my experience was one of, you know, sometimes it was scary, like really scary in lots of ways, in ways that I never expected that it would be. And that thing of, as you say, feeling like you’re part of some kind of criminal investigation, but you have to go to work every day and be with people and just the impact of, you know, you want to avoid maybe conversations because it’s awful, you know, patient conversations, because to go and be in a room with people and all this stuff is going on and, you know, we don’t know who knows what and what, you know, it’s just, yeah, really horrible.

Benna Waites (29:16)

Yes, really, really messy and, and difficult. And so often I think a lot of these processes emerge in environments where there’s… that are interpersonally very complex. There’s a lot of dynamics flying around and often lots of claims and counterclaims. And I think we really need to ask ourselves, you know what, if we recognise that, what is the best way of addressing and supporting? And I think there is value sometimes in bringing external support and external eyes on the challenges that teams are having, but whether those external eyes should be coming with their sort of tick box investigation kind of lots of questions, sort of gathering evidence, whether it should look like that, I think is really questionable.

Paula Redmond (30:03)

And what are the other things that you have sought to change in this work? Things that you haven’t mentioned yet?

Andrew Cooper (30:11)

One of things that we’ve been doing within NHS Wales, so within NHS Wales we’ve got a once for Wales policy approach, so the NHS Wales disciplinary policy is for every organisation within NHS Wales and about two years ago we started a journey to review it, but also for it to be informed by this work, by this research, by the insights that we were drawing. Interesting that Adrian talked about a piece of research that we did where as part of this disciplinary review, we didn’t want to just tweak the policy, we actually wanted to understand what does good policy look like in this space, you know, what does good process look like, what does textbook approach to run disciplinaries look like. So we undertook a rapid evidence review of key HR literature. And as Adrian mentioned, there is so very little out there. And if you pause and reflect and think, actually, we are running thousands of investigations every day around the world, and yet there is very little evidence that suggests what good looks like, I think it’s a real challenge to the profession, but also to all of us involved in either supporting or running investigations. And that curiosity and that need to try and identify the best way of doing things is really critical to this work. I guess, because we’re so linked and connected to healthcare, we know that if there’s a healthcare issue that arises very quickly, we’ll have academic colleagues around the world taking it apart, seeking to understand it, testing medical interventions to address it. And yet we don’t have that same approach for processes that seismically can impact populations. And then actually that’s the journey that we’re on at the moment is, whilst we started with very much an individual impact, how do we understand policy design, policy development, policy implementation to actually improve this? And I guess one of the things that we’ve looked at is how do we support the individual going through it better? Because actually that’s good for them, but it’s also good for the investigation. Actually, if we looked at the investigation more positively and said, this is an opportunity to perhaps improve or correct something about how our organisation operates, then we also see the person being investigated as part of that solution, and actually taking them on that journey, looking after them, ensuring a really good duty of care should be an equal part of that process. When Benna was talking, I was reminded of Deming who said, a bad system will break a good person every time. And that actually, you know, you replace that word, a bad process will break a good person every time. And whereas perhaps a couple of years ago we were thinking that person who’s broken is the person at the centre of it, the list is growing in terms of, and Paula you’ve identified that, the list is growing of the people that will be harmed and broken by it. So it is very much how do we step back and really understand how to deliver these things better.

Adrian Neal (33:52)

Just to build on Andrew’s contribution. So I think there’s a pivotal idea here, which I think threads through so much of how the NHS as a kind of massive bureaucracy operates and how it responds to individuals versus system factors. So one is from a, I guess a quality improvement or just a systems learning process. We know we’re not very good at learning. Why is that? Every inquiry kind of repeats the same thing. So how, why do we struggle with learning? But also, so to me, one of the harms is failure to, each of these investigations, unless you really understand the systemic factors that have contributed, of which it’s more than likely to have contributed some way because of the complex nature of our work and also the kind of interactive multilayeredness of how most people work, you never find out actually why this thing happened. Whether it’s a complaint, the cause of the complaint or whatever, why the relationship broke down. So it never gets really reviewed and repaired. We just kind of amble on. But as part of that kind of, maintaining that process, which I’ve always been uncomfortable with because it is just a massive waste, but the airline industry’s going yeah, it’s the pilot again, just sack them and let’s move on. We need to know why, whether it’s a drug error, whether it’s complained about, you know, alleged poor care, there’s always going to be more than an individual involved. In our leadership program, we have a colleague who’s influenced us all quite a bit, but his kind of model of leadership is a systems leadership approach. And he tends to say, look, most people are not mad, bad or stupid. So why do we keep blaming the individual? I think certainly in the NHS, a lot of the process is designed to target individuals. I don’t think it’s intentional either. I think it’s just culturally, habitually, how these processes end up. But it’s also the same from a wellbeing point of view. We know up until fairly recently, it’s really just been, well if somebody needs some wellbeing support for the individual, that’s possible. I mean, even now that’s questionable because of cutbacks. But the support for individuals is much stronger than support for systems or the ability of systems to learn. Burnout is a system problem. So all of these things. So we’re working within the space of trying to shift things away from the individual to support learning. And it’s going to certainly outlive me. But this is why we think this is the beginning of this journey. There are layers of relevance, I think, that take us into other motivations. But certainly one is this big idea about trying to create work, trying to create an optimal environment in work. And this is certainly, you know, it touches on psych safety, it touches on our capacity to learn, it touches on systems being able to understand people’s needs, as we would want to understand patient needs. And we’re still getting that wrong sometimes. So I think we are definitely very early days, but it’s very exciting.

Paula Redmond (37:07)

And what have some of the outcomes been? Benna, maybe you can…

Benna Waites (37:10)

Yeah, so a couple of areas where I’d say some quite concrete things have happened. So one of the things that was really clear to us exploring experiences of being investigated is that predictability is a really significant factor. So we know, and it’s basic undergraduate psychology, that predictability and control are the two kind of key mitigators really for stress and in fact social supports, and of course we know that people, because of the shame that often goes along with investigations and the requirement not to talk to any of your work colleagues. So very often people are absolutely deprived of social support. They’ve lost all control. The one thing that potentially if you’re going through a process like this, you could hang on to is predictability if you did what you said you were going to do. And what we’ve noticed is that so often these processes are set up with entirely unrealistic time expectations, and people don’t deliver and they don’t do what they say they’re going to do. And that’s often because investigators are overwhelmingly busy and have got loads of other things going on, but understanding the impact that that has on the individual. So Andrew, Adrian, I don’t know if you want to talk more about the guide, but it feels if the guide that we’ve put together for HR professionals leading these kinds of investigations and also for people undergoing them, is a kind of helpful just building that sense of the understanding of the process, trying to make it a bit more predictable, trying to mitigate a little bit if you are in a position of having to go through it. So I don’t know if you, Andrew and Adrian, if you want to pick that up and say a bit more about the guide.

Andrew Cooper (38:55)

So as part of the review of the disciplinary policy, we actually wanted to think about how do we support individuals better going through the process. And as Benna has mentioned in terms of predictability, it’s a key thing that often colleagues report after meetings changed, being advised that they’ll get an outcome on one date and then it gets cancelled and dropped. And each one of those experiences, whilst might be an administration factor for the individual leading the investigation, for the individual going through it they are crushing blows each time, because actually they are living their lives waiting for feedback. So we worked with HR colleagues, wellbeing and occupational health colleagues to identify what were the top 25 questions that people ask when they are being taken through an investigation process. So we looked at them on multiple levels. They could be questions like, am I going to be paid while I’m taken through this process? When you say I can’t talk to anybody, do you really mean I can’t talk to anybody? When this is over, what about when I come back to work? What does that look like? What will it feel like? And I guess what we were looking to do is that if we could provide answers to some of those fairly straightforward questions, it could minimise or mitigate some of the anxiety. It was never going to remove all of it, and you could argue to how much it removes, but actually we had a sense that it could manage some of that anxiety. So the aim is when we launch our policy, that that guide will be issued to everyone who receives the letter telling them that they are now the subject of an investigation, here’s the policy, but here’s the guide to help you through it. Because in terms of the process, and Benna would be able to kind of advise more on this, but we know that an individual’s cognitive ability is reduced during times of stress and anxiety. So their ability to read a complex document like a disciplinary policy becomes even more challenging. And again, the reason that we wrote this guide, we took the model of a patient information leaflet that recognises that when a patient receives a diagnosis, they often remember very little of what the healthcare specialist has said to them, and that’s where a guide might come in from, like Macmillan Nurses to say, these are some of the questions you might have. And again, it feeds back into that piece of, we want the person to be in the best place they can be for themselves, but also to contribute to the investigation process well.

Adrian Neal (41:53)

Just to add and correct me if I’m wrong, Andrew, but you, didn’t you do a piece of work looking at the reading age of the previous policy and what was the reading age?

Andrew Cooper (42:04)

So as part of the review of the process, we had the current disciplinary policy reviewed and were told that actually you had to be at a graduate level reading age in order to make sense of the policy. And as I’ve mentioned in terms of cognitive ability, that is significantly reduced when we feel stressed and anxious. So in one sense, the policy wasn’t necessarily the best document to help somebody through the process, which is where the guide came in.

Adrian Neal (42:34)

So even in how we convey these ideas, be it formal policy, right down to individual letters, think that it’s all, you can create interventions at multiple levels. And often you need to, because it’s kind of the failure to understand how people process information is just, it’s endemic. But I’m pleased to say that at least within, well, we know that within Aneurin Bevan, and within a number of organisations we’ve worked with, they’ve looked at that set of very tangible things they can change. But the guide is, I think, is a key piece of work, just to help mitigate that sense of lost control and kind of social distress around this thing is happening to me. But only mitigate, can’t remove those things you need to look at.

Paula Redmond (43:25)

And Benna, I know you’ve been, one of the things that’s been important for you in the work is thinking about suspension in these processes?

Benna Waites (43:31)

Yes, there’s often a presumption, I think, in these processes to suspend. Often that’s kind of part of the process that you follow. So a complaint’s received or a process is initiated, and the assumption is that you suspend, and to send somebody home. And I’ve seen that happen so many times. And I think what really struck me about that was it feels really punitive. It feels as if it increases the impact because suddenly we know don’t we the impact of unemployment for example on mental health, we know it’s pretty catastrophic for your mental health to lose all structure but to lose all structure at a time when your whole professional identity, your work life, your financial security, when lots of things feel like they’re on the line that’s really hard to do that. I think there are times when, because the interpersonal dynamics are so enormously complex, that it’s better for everybody, including the person at the centre of the process, to be removed. But there are options around finding other places and other opportunities and other ways of working, really. So I guess there’s something about fighting the presumption to suspend. But what I’ve noticed when I’ve been involved in those processes, is how hard I’ve had to fight, you know, and even now, you know, even relatively recently in our organisation, it feels as if that’s still, I think it’s almost baked into HR training, that sense of, this is your starting point, just take everybody out of the situation because that will be better, it will be kinder. And it is messy. Paula, you talked earlier about that experience of being a witness and then having to have a conversation with somebody, those things are tricky. They’re really tricky, actually. And I think there are ways you can manage that. So it might be that, you know, somebody’s going through a process and there are bits of their job they continue to do, but you know, bits that they don’t, or as I say, you can shift them into a different role. But I think we shouldn’t underestimate the enormity of removing somebody’s occupational structure from their lives at a really stressful time. I just think it’s a very damaging thing to do.

Adrian Neal (45:50)

I completely agree. I guess the other, and Benna alluded to a little bit, I think there’s something about how, and this is possibly a healthcare professional specific, but probably not. I suspect other industries have the same thing, probably education. But in terms of people’s relationship with their work and their identity and their sense of who they are, their sense of self is often intertwined with their work and with their sense of purpose and those they work with. So I think what at one level might look like an operationally neat thing to do to remove the person from the stressor, it’s never neat and it’s never straightforward because often people’s working environment and their relationships with them is hugely protective. I think that can add a dimension which I think a lot of HR colleagues don’t get because they often haven’t been through it themselves, but also they may have a slightly different relationship with their work, although that may be unfair. So I think the, and if you, the more complex and messy the situation, often the simpler the solution is really, not a simple solution because of conflicts and the intense expressed emotions, but yeah, so the suspension idea is a fix is really flawed. This has to be an absolutely case by case decision. And I do worry that sometimes less experienced HR colleagues don’t feel confident enough to sit there in the fray and not make a reactive decision. I’ve certainly seen more experienced colleagues able to sit there and tolerate the not knowing and the pressures from different angles. Because again, our work is very politicised, isn’t it? We sit in, HR colleagues often sit in the middle of competing social groups, got pressures often from patient safety angle, legal pressures often. So it’s a hugely distressing position to be in. So being able to tolerate that, I think is key. And I pretty much guarantee nobody gets any training on how to do that if you’re an HR professional, whereas clinicians, psychologists might, but don’t always.

Paula Redmond (48:08)

Yeah, it’s a sort of that, I mean, it’s a literal exiling and shunning, isn’t it, of, which is such an absolute kind of primitive, and scary for the people left behind too, that someone can be ripped from their midst and we can’t know. And yeah, that’s really…

Andrew Cooper (48:27)

I think for me though, as we kind of talked about that impact of suspension and clearly a major one, but Adrian’s just touched on, just that difficult space for HR colleagues to inhabit. And I think I’ve certainly had an increase in appreciation for that. So in terms of where they are perhaps in their career, so often if you’ve got young HR professionals who have probably been trained and kind of driven into them, you follow the process, you follow the process. And because of that anxiety of kind of coming new into a profession, you do what you’re told. And it is only often seen with those colleagues who have more experience that perhaps understands the process better, perhaps have got some experience of how it’s impacted, and that they’ve got perhaps a greater sense of autonomy in order to question and challenge and kind of all within that context of an organisation’s appetite for risk, all around in terms of changes in legislation, you know, granting more rights to the employee and that’s right, but at the same time, it makes that pathway much more difficult to navigate. So, you know, certainly with this work, it’s been very much seeking to appreciate and understand what our HR colleagues and managers, because managers often don’t often feel confident to apply policy because they may not do it very often. And because they don’t do it very often, they become more rigid in their approach. And then how do you help a manager balance that focus on process and the person. So this journey has really been, actually, how do we appreciate, understand and take our HR colleagues and managers on this journey just because of the challenges that they face in doing it.

Benna Waites (50:34)

What you were saying, Andrew, reminded me that another area where I think we have quite a significant skills deficit in our organisation, in our healthcare systems generally, not just in our organisation, is around having difficult conversations. And what I notice is that that ability to be able to engage with tricky, difficult, interpersonal concerns is just not really present in our leaders within healthcare. So we’ve been running a having difficult conversations session on our leadership programme, and it’s consistently the one, or it’s consistently one of the ones that’s right up there, we cover a lot of material, but it’s consistently something that people come back to and say, oh, thank, that was so helpful, so useful to think about how I might frame it, think about how I might approach it. But I’ve noticed over the years when I’ve perhaps expressed concerns about some of the things going on in a team where perhaps I’ve done an exit interview with somebody and they’ve raised some informal concerns, they don’t particularly want them to go anywhere, but I’m kind of thinking this would be useful for a manager to kind of hold and think about, and think about how it might kind of shape their interactions with a particular individual. And I’ve often had a kind of rebuttal from managers saying, well no, if there’s no formal process, there’s nothing, there’s nothing I would expect to do about it. And that feels like a real problem. It’s like, this is such a missed opportunity. If we can be catching these things by having the more uncomfortable, the slightly more challenging, the slightly trickier conversations sooner. So that’s something that I think connects well to this issue of prevention too.

Adrian Neal (52:16)

Just picking up the management leadership pattern really, and I’m sure Andrew will agree, so they are, I think, the key group. We talk about HR colleagues, but actually the vast majority of people that will make the decision whether to proceed with a complaint or a professional conduct type of investigation will be the managers. I think management in the NHS is an interesting one in terms of capability, competence, but also how we design our systems. I think we can often, I say, I keep saying this as a generalisation, but often you find managers that are not supported, not educated, and then not developed in very influential roles with a lot more people than they can manage. If you think about how many, you know, what’s the ideal size of a team? We know, you know, Aston model would say, you know, 12 to 14. We regularly come across people in the leadership program, they have more than that, way more than that. And how can you be a manager in that kind of system? And if you get a complaint or something coming in, it suddenly takes up so much more of your time. You’re more likely to be more transactional about it because you just don’t have the capacity to deal with it. That’s even before the areas around difficult conversations, which is the upstream stuff that might help prevent these things happening. So I think that as a professional group is, I think we have a real problem, not because there are bad managers, but because how we go about supporting, developing is systematically problematic, because I think it’s an almost impossible job. You can skill, you can support. One of the things we noticed in our leadership program is that often, the cohorts will stay together as a resource for each other because they’re all struggling with similar things. So again, if you’re trying to influence people’s experience of complaints or grievances or the managers are pivotal. And I know there’s currently a GMB union push to accredit management looking at some sort of accountability mechanism. I can see the logic, but I’m not sure that’s the right tool, but I think the accountability is a major part of the problem, as well as the support and the development of that professional group, given that most health professionals are regulated up to the eyeballs, professional managers aren’t. And neither are HR colleagues for that matter. So it’s interesting. I think there is space in that area to think about that in a useful way, not in a punitive or kind of controlling way, but how do we quality control and support and develop those groups?

Andrew Cooper (55:06)

Last comment from me on it, but it picks up the psychological safety piece that Benna was talking about, that often when we work with managers and we ask why have you initiated a process? Then it’ll often be fear, because the fear of getting it wrong, or fear of not following process because actually this could impact on them. So that sense of around that cultural impact, how psychologically safe a manager feels within the organisation also determines the course of action and the way in which they will commission and lead an investigation.

Adrian Neal (55:48)

I couldn’t agree more.

Benna Waites (55:50)

Absolutely.

Paula Redmond (55:51)

Any other kind of key outcomes or challenges that you’ve faced?

Adrian Neal (55:57)

Definitely no challenges.

(Laughter)

Andrew Cooper (56:02.21)

I’d almost like to pull Benna in on this, but we’ve taken this quality improvement approach so that the focus has been for 30 months, two years, how do we improve the approach. But, Benna, we know with improvement, don’t we, that it needs to have that constant focus on it and as the priorities come in, staff change, and I guess it’s how we keep the focus on a major cultural change piece because we know things don’t change overnight. It needs years of a consistent approach to bring about that change. So I think that’s probably more of a longer term challenge, what we feel we’ve been able to do here is raise it as an issue, identify the related harms and impacts, develop an intervention that might address it. But the long-term challenge is how do we bring about sustained change and not slip back into old ways of practice or if that psychological safety within the organisation is not strong, how do we keep people on that journey of change? Benna, any thoughts?

Benna Waites (57:25)

Adrian’s got his hand up, so let’s go to him first.

Adrian Neal (57:29)

Lots of thoughts. So in me, I guess thinking aloud, there’s two spheres of work. There’s the operational sphere, which is about individual systems, looking in detail at how they deploy, run, evaluate and understand these processes and how they can be used internally to help improve learning and to kind of navigate some of these very real psychosocial challenges and minimize harm. So that  to me is one thing, just good business. At the other end, there’s the idea, and I think that’s slightly more linked to the cultural dimension, so the avoidable employee harm idea. So it’s interesting because I think you get dissonant, you get people who go, yeah, no, this is, I can’t not think of this idea now. And then you look at the data and they still, you know, there’s still problems. So I think there’s, how do you keep both alive? Because they’re not necessarily, they’re interconnected, they’re, and they’re both necessary. But one of the things I’m, and Andrew will know this, but I’m gonna say it out loud, I’m particularly proud of is the two pieces of work. One is the policy work, national policy work, because if you’re gonna get anything to stick, that’s the way to do it. And I think Andrew could definitely tell you how fun that’s been, but it’s gonna get over the line. And the second piece is another piece of work Andrew has been working on, but it’s to establish an avoidable employee harm award category within the HPMA UK. So the idea that it’s so legitimised now, a national organisation for the accreditation of healthcare management professionals has created an award. So the idea that is so valid now that that organisation is taking it forward at that level, I think will help keep it in people’s minds. So that I think will seed, but we also need that on the ground, operational changes. And that I think is… both are challenging, but both are moving. I’ll stop talking.

Paula Redmond (59:33)

Thank you. Benna?

Benna Waites (59:35)

So picking up on Andrew’s point about sustaining gains, I think that’s a real challenge. So we saw some really incredible results of this work being picked up early and a reduction in processes and of course, all of the kind of harm we avoided and all of the time we saved, which is fantastic. But trying to keep that as Andrew says, when you get change in personnel and shifts. So that sustaining your gains is an ongoing challenge, I think. The issue about how we design the culture, how we create a culture that will prevent or massively reduce these kind of processes, feels really important. And I think there’s lots to be done in relation to leadership, because leadership, I think, has such a huge impact on the climate in teams, but also on the way that we talk about our work, the way that we think about our work. So another… Adrian was referencing our colleague Ian McDonald earlier who works in systems leadership, but Ian would talk about what’s the work and I think that sense that the work of leaders, the work of teams is to create an interpersonal environment that is psychologically safe, that works for everybody in it, that enables concerns and difficulties and disagreements to be explored safely. That is a really key part of our work and I just don’t think we give it the air time. And I think I’m really interested and we have done less work on this, but I think we will do more. Andrew mentioned the kind of to-do list that we have and are working on, but something about the sort of postvention that kind of aftermath, the sort of return to work, the, you know, what happens afterwards. And that feels really important in terms of how you might restore connection and psychological safety after a process. So it feels like there are lots of challenges and opportunities around this work. It’s yeah, it’s just finding the time to do it all really. But yeah.

Paula Redmond (01:01:40)

And can I ask a question, I’m curious about the… Adrian and Benna have been clinical psychologists in this kind of space that’s fairly unusual for most psychologists to be working in this way. What do you think you bring sort of uniquely as clinical psychologists to this and how has that been received, particularly thinking about the HR kind of work?

Benna Waites (1:02:02)

So my sense is it’s been absolutely welcomed. I think it’s been really well received in the main. So I, you know, Andrew, you and I did a session, didn’t we, in North Wales, and I was really struck by how grateful people were. I think that discomfort that Adrian described earlier, that sense of discomfort about there is something wrong here, I think is really widely recognised. And so I think there is a real appreciation of people bringing, shining a light on that and trying to think constructively with people about it. I think we’ve tried really hard, we may not always succeed, to understand the context that these things happen in, the context for people’s training. So I think there’s a really deliberate effort not to be critical and not to be, but just to say, look, can we all think about doing this differently? So my sense is that broadly it’s been welcomed and I think that will be backed up by some of the awards, some of the acknowledgement, some of the kind of publicity that we’ve had in that world specifically of HR. So I, my sense, it reminds me a bit of across my career, often as a psychologist in a system that doesn’t have any psychology. So I’ve done a lot of work in physical health settings in the past. There’s such a thirst for what you bring. There is such a huge enthusiasm for that difference in your expertise and it’s often really welcomed. So that’s my sense about it but I am a bit prone to wearing rose tinted spectacles, so Adrian I don’t know if you want to slightly shift the perspective?

Adrian Neal (01:03:42)

So, yeah, don’t disagree with anything that Benna said. I guess for me, it’s a bit like, you know, if you’re a psychologist working in an area where there’s not many psychologists, that’s a privilege, but it’s also an interesting area. As Benna was talking, I was kind of thinking, do I see myself as a clin psych? I’m not sure I do. You know, I’ve been mostly influenced by organisational psychology for the last 10 years in terms of literature and evidence. But I guess I tend to, yeah, so I tend to introduce myself as a consultant psychologist because the consultant brand carries weight as a symbol in the NHS. So that’s intentional. I guess I also talk about myself as being the professional psychologist involved. And that’s, I guess, my way of saying I’m the one who’s qualified in here, in the space. And it’s, there is a personal bugbear in many ways, because I guess, we’re proliferated with pop psychology, aren’t we? And we know a lot of our colleagues in the workforce sector are very passionate and keen to understand psychology. Brilliant. But the people that can promote themselves in that space are not always credible, but social media is great at making yourself look great. So I tend to use those kind of monikers as, to authorise me to speak in that sphere. Yeah. I guess also using the doctor title is useful again, like consultant, it carries weight in the medical areas. It’s less useful in some areas, but I think that helps a system that responds to symbols and is hierarchical. So that can be useful. So yeah, just something.

Paula Redmond (01:05:28)

And Andrew, I wonder if you’ve got any observations of what that’s been like to have this clinical psychology or psychology kind of involved in this work?

Andrew Cooper (01:05:36)

So I expected more kickback from HR. I expected there to be a reluctance to engage with this. Actually, for the main part, colleagues have welcomed it. And I think that was a sense of their own discomfort with it. You know, those conversations that we have at our training. A senior colleague said to me quite recently, Andrew, if you’ve been in HR for any length of time, there will be things that you feel uncomfortable about. So what the psychology perspective I think has brought, I think has brought a number of things. First of all, that understanding of impact, impacts to the individual and impact as Adrian said on an organisational basis to the system. I think the discipline is much more curious around why do things go wrong? How can we do it differently? Has been incredibly helpful from that perspective. And certainly the way that we position this work and actually disciplinary processes need much more of the multidisciplinary approach to them that whereas they perhaps historically have sat within HR, actually, if we are going to take a more recent trauma informed approach, then we need HR managers, trade union representative, wellbeing, occupational health in the mix to be shaping the approach and making better decisions than we might have done in the past.

Paula Redmond (01:07:10)

It’s really exciting to hear that you’re doing this work because I guess that, I mean even just from a personal perspective, that people are attending to this and it’s having an impact is really good. So what’s next for this work? What’s coming up?

Andrew Cooper (01:07:24)

Well, we’ve been working within healthcare for the last two or three years, really seeking to understand the impact, looking at what interventions that we can develop and seeking to bring change, working with HR colleagues in this space. What’s been interesting, we’ve increasingly engaged with other sectors and we’ve talked to them about this work and generally the common response is we don’t have it right here either so that actually this isn’t an issue just for healthcare. I think if we think about that approach to understanding disciplinary policy and not really understanding what a good process looks like across these sectors. So we’ve been working, we’ve started to work with local authorities, we’ve got other sectors coming on board equally interested and then delighted that the three of us have been involved in a book that’s coming out later this year. The book’s called ‘Under Investigation, Transforming Disciplinary Practice in the Workplace’. And really the aim is to continue a conversation with HR colleagues, managers, organisations across sectors to see whether some of the journey we’ve been on, and certainly the journey others have been on in terms of making improvements in this place can be scaled up and make even greater impact, not only for individuals going through these processes, but also their organisations as well, so that it’s a better experience for work, but also organisations can deliver better outcomes as a result too.

Paula Redmond (01:09:01)

Well thank you so much guys, that’s been fantastic.

Thank you for listening. If you’ve enjoyed this episode, please support the podcast by sharing it with others, posting about it on social media, or leaving a rating or review. I’d love to connect with you, so do come find me on LinkedIn or at my website, and do check out ACP UK and everything it has to offer. All the links are in the show notes. Thanks again, and until next time, take good care.

The post Avoidable employee harm: Rethinking NHS complaint and disciplinary processes appeared first on Dr Paula Redmond, Clinical Psychologist.

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Full transcript below

Dr Paula Redmond speaks with two clinical psychologists — Caroline Taylor and Dr Amber Johnston — about their personal stories of receiving a fitness to practise complaint.

They discuss what it was like to go through the process, how it affected them personally and professionally, and what they’ve learned along the way. Together they reflect on themes of shame, fear, and isolation, but also on meaning-making, growth and the importance of support.

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About the speakers:

Caroline Taylor is a Clinical Psychologist in private practice. You can connect with her via Psychology Today or LinkedIn.

Dr Amber Johnston is a Consultant Clinical Psychologist and Neuropsychologist. She runs the Healthy Mind Psychology clinic. You can connect with her on Instagram or Linkedin.

I’d love to connect with you so do come and find me on LinkedIn or at my website and do check out the ACP-UK and everything it has to offer.

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Transcript

Paula Redmond (00:04)

Hi, I’m Dr Paula Redmond and you’re listening to the When Work Hurts podcast, which is brought to you by the Association of Clinical Psychologists, the representative professional body for clinical psychologists in the UK. In this series, I’ll be covering the difficult topic of surviving formal complaints, particularly for psychologists. I’ll be bringing you conversations with brilliant guests, offering their expertise, experience and wisdom on this tough topic from a range of different perspectives.

In this episode, I’m joined by two clinical psychologists, Dr Caroline Taylor and Dr Amber Johnston, to talk about their personal stories of going through a fitness to practice complaint. They speak openly about how it affected them, but also what they’ve learned through it and what they’d like others to know. I’m so grateful to Caroline and Amber for sharing their stories with such generosity and honesty. I hope this conversation will help others feel less alone and open up more compassionate discussion about complaints within our profession. We begin with Caroline’s story. 

Caroline Taylor (01:13)

My name is Caroline Taylor. I’m a clinical psychologist and I work in private practice now. I’ve been qualified for about 15 years and the complaint was about, well during COVID, so it was about three or four years ago, yeah. 

Paula Redmond (01:29)

Okay. And what… can you say a little bit about what the context of that was? We’re not going to go into detail for obvious reasons about the nature of the complaint and who was involved, but just to set the scene for us a little bit about the context of when you received that? 

Caroline Taylor (01:47)

Yeah. So I received the complaint in the late summer 2020, and I’d left the organisation where the complaint came from. So the complainant was a member of my team, the context of the complaint was we were in a very busy CMHT and we had a lot of the clinical leadership off sick and then absent and us not having a full team. And I was probably one of the most senior clinicians and there was a lot coming to me. And of course, when you’ve got a lot and you’re overwhelmed, then of course you’re gonna drop the ball. That’s just… just normal, right? So yes, so I actually left my job because of what had happened. So I was taking ownership of my part in a difficult situation by leaving the organisation which I, that was the of my NHS career really. So that’s, that was the first impact really of pre, that was pre complaint. Yes, so that was all very difficult because I really love CMHT work and I don’t feel able to work in that trust again because I think my reputation is completely damaged. So it’s quite difficult really. Yeah, so that’s the context. 

Paula Redmond (03:26)

So you had a sense that… I suppose it wasn’t a surprise maybe that the complaint came or was it? 

Caroline Taylor (03:36)

Actually it wasn’t really a surprise. Actually when I first left my role, I was sort of like expecting a phone… Like every time I came back from London working, I was sort of expecting a letter on the door mat. So then it passed and other things happened and then, you know, Covid happened and I sort of let go of that and then… and then it arrived by email, was just a casual email really, by something quite serious. It was the allegation. 

Paula Redmond (04:10)

And that was from the HCPC, you had an email?

Caroline Taylor (04:15)

Yeah. Yeah. A case handler from HCPC. But it says very little. It says very little. And then, so you, you know, you’re kind of, it could have been, it could have been about anything, you know, or everything like it was, yeah, it was just difficult. It’s just difficult, little small amount of information you don’t really know the gravity of what’s been said. 

Paula Redmond (04:38)

Does it tell you who made the complaint? Yeah, okay, so it’s sort of something like this person has made a complaint against you, but that’s about it.

Caroline Taylor (04:50)

Yes.

Paula Redmond (04:52)

And what was that like to receive? 

Caroline Taylor (04:56)

I mean, I was just gutted. I was just gutted. You know, I, actually I completely own what, that part of what, of why the complaint was there and like why it happened, like why, why there was a complaint. I suppose in a selfish way I was like, well, you know, I, I know I’ve given up my career in the NHS because of this, but you know, that doesn’t mean anything. You know, if someone’s concerned sufficiently about your ability to be a clinical psychologist, then it should be reviewed. So that’s, I didn’t have a problem, it was fine. It was a bit, I was gutted, but okay, let’s see what happens. But it was a long process. 

Paula Redmond (05:44)

Yeah, so how did that unfold? 

Caroline Taylor (05:46)

So, yeah, so I got the email through, and you don’t hear anything and I instruct, as I was in therapy actually at the time because of what, because of what led to the complaint, I was in therapy because of what led to the complaint and then and the complaint. So I talked to my therapist about it, my psychologist, and they said have you got a solicitor? You need to instruct a solicitor. I was like okay, which I hadn’t even thought of, so I instructed a solicitor and they were great. But then it’s just like radio silence for ages because what I was told by the solicitor is that, you know, don’t go poking around in it because they just want to, they didn’t say don’t go poking around in it, they said, you need to wait until they contact you, and that you just have to sit and wait. Because if you are trying to find out what’s going on, there’s a lot about your conduct during the procedure, during, so there’s a lot of conduct, there’s a lot of, because they’re looking for a pattern of behaviour, right? So that’s what they’re looking for. So you have to be really careful about your behaviour. Yeah, so I was really grateful for that, that psychologist telling me that. And I did that and I got a solicitor and the solicitor was absolutely fantastic. I also took some advice from somebody outside of the country who spoke, you know, I just needed somebody that was completely not anywhere near any of it from me. And they were very helpful in my thinking about, you know, where I dropped the ball. They were super helpful. Yeah. 

Paula Redmond (07:35)

So there’s two parts there. There’s this kind of the practicalities of how you respond, how you get through the complaints process, you know, what’s the right thing to do, but also an ongoing reflection about the nature of the complaint itself. What does it mean about you? How you kind of reconcile that. So it’s a lot to be holding. 

Caroline Taylor (07:58)

And that’s before the allegation comes. So you say you have this, you’re waiting, you know, so HCPC do their initial investigation. They say yes or no, it’s worth furthering. So they went to… I knew it would go. So then they’ve done their investigation and then you get the allegations. And of course, they are the worst things you could ever have said in the whole world. They’ve picked the worst, they’ve found the worst of you. Somehow they’ve found the worst of you. And then you get to doing your defense. 

Paula Redmond (08:46)

And how long did that take from getting your complaint to getting the allegations? 

Caroline Taylor (08:50)

So the complaint came in August 2020 and the allegations maybe came in June or July 2021. 

Paula Redmond (09:03)

Gosh, yeah. That’s a long time. 

Caroline Taylor (09:06)

Yeah. And then you do your submission and that takes quite a long time. Because you have to own everything, you have to own everything because otherwise you don’t learn. So, I have to own and reflect more than I had already. And then you’re running up to that submitting the 10,000 word document for your defence. And that’s another huge part of work, the labour, emotional labour, that you’re going through. I learned so much about myself. Of course, I didn’t want to learn a lot of it, but like I did, you know, it really, you know, I can’t say it was a bad… I can’t say in retrospect, I can’t say it was a bad experience overall. It was just not, it wasn’t, it could flow better and it could be quicker and it could be… because I just think there’s a lot of hanging around for people, not just the person with the allegations, for everybody. A lot. You know, people’s partners, people like the person who’s complaining, their partner, there’s a lot of people. 

Paula Redmond (10:25)

So you submitted your defence document and what happened after that? 

Caroline Taylor (10:35)

It’s really, you just wait a little while and then you get a letter through saying what they’ve decided. And so what they decided was that if these allegations were proven, it may count as misconduct. But my understanding was that there wasn’t a great deal of evidence. Well, looking at the 100 page bundle that came, the evidence, there wasn’t, it was a bit, it would have been potentially, I think, a bit word… my word against your word, like I think. So there wasn’t much data to back up the complaint, I think, basically. So it was no case to answer. There was no cace to answer. And the relief was extraordinary. And I didn’t quite know how much I was holding before it.

Paula Redmond (11:42)

And how long did that whole thing take to get to the no case to answer? 

Caroline Taylor (11:49)

Good six weeks, maybe more. Can’t really remember. Yeah it’s just a very long process for people being a lot. 

Paula Redmond (12:02)

Yes, so about 18 months altogether. And how… What was the impact when you look back, how did that all affect you? 

Caroline Taylor (12:12)

I mean there was quite… I was impacted quite significantly, I’d say. So yeah, I definitely had a couple of periods, so when the complaint was first raised and then when the allegations came through, I was in very much of a bad way for about three weeks at a time. It was three weeks, two lots of three. Yeah, I was not, yeah. It was very, very challenging. Yeah, I was very scared and very ashamed and very sad about it. 

Paula Redmond (12:48)

And you mentioned that you were in therapy and you had support from a solicitor. Was there any other support that you were able to tap into or access? 

Caroline Taylor (13:02)

No, but looking back, you know, I could, think, I think there was a lot more I could have tried to get some help. I could have tried to get some help from the British Psychological Society and I did have a quite extraordinary experience. I was working as a network therapist in an organisation and then as an employee at the same organisation. And they’d asked me to apply even though they asked me to apply for a job, even though they knew that I was under investigation. And I did have extraordinary, unyielding support from them, which was amazing. But it was also a huge amount of work for my line manager to be writing a lot of things about me. Then, you know, you need to get lots of people to say whether I’m an okay person. You know, letters of support really. It’s quite a lot of work. 

Paula Redmond (14:03)

And what support do you think you maybe needed at the time and maybe didn’t seek or wasn’t available, what would have been helpful? 

Caroline Taylor (14:16)

Yeah, I think just more understanding of the process and understanding how the allegations mapped onto the code of conduct. That wasn’t very clearly defined. I think that maybe I should have approached the BPS to see if they could have helped me. I don’t know otherwise really. 

Paula Redmond (14:41)

Did you feel able to talk about it with other psychologists, with friends, family? How did that? 

Caroline Taylor (14:48)

Yeah, yes. I mean, some of it I couldn’t help, but just like, I’m just crying and stuff. I mean, I wouldn’t say I wasn’t supported. I was supported, but it’s just nobody else can understand what that feels like unless you’ve had that, it’s like a very unique experience, I’d say. But yeah, I think it’s really helpful for people to know where they can go to and I don’t, maybe I just didn’t look, maybe I just didn’t look and I didn’t see, but I think maybe some more support and awareness around that if there is support, that would be really helpful for the complainant and for the person that’s made the complaint. For both parties, I think for them to have, you know, HCPC, they do give a very long, you know, they give loads of guidance. It’s a very… a lot of like, wordy stuff and diagrams and things to tell you what’s going to happen. But you don’t get much, like, it’s hard to take in and you don’t, there’s no empathy in it. 

Paula Redmond (15:59)

Okay. And you spoke about the sense of relief at when it was resolved, no case to answer. But it sounds like maybe there was some kind of, it kind of hit you maybe after that a bit that you hadn’t quite realised, you said what you’d been holding. 

Caroline Taylor (16:21)

Yeah, well I was, you know, I had to prepare to, I had to prepare an alternative income. I had to prepare for that, for that possibility. I didn’t at any point think of this lightly. So I had to really think about what I would do if I wasn’t allowed to practice. 

Paula Redmond (16:51)

Yeah. And what’s your recovery been like since that? 

Caroline Taylor (16:56)

Oh, it’s taken, yeah, I mean, yes, it’s taken a long time really to kind of talk about it. It was interesting when you, yeah, it was interesting symmetry when you asked me if I would do this. I just, it’s a huge thing to lose your career that you’ve, potentially lose your career, that you’ve worked so hard to have. You know, has something been, whatever we’ve done that needs to be corrected and reflected on and thought about. I don’t really believe many people would do that out of commission. I just, my sense is that, you know, it’s messed up. Like you’ve messed up, but you didn’t do it on purpose. Like it wasn’t your intent to harm. So it’s taking a long time to let some shame go and some guilt go and think about the future in a way that I want to go forward in. Yeah, it’s taken a long time. 

Paula Redmond (17:59)

And I’m curious about whether you have any thoughts on if you were able to kind of go back to your younger self who was going through that at the time, what might you want to say or give her that could have been helpful? 

Caroline Taylor (18:17)

I would give her a hug, because that version of me would know what that feels like and it would be a different hug than anybody else could give me at that time. So it would have been a very different knowing hug. And I would, I would hope I would say to her that this is really good learning for all sorts of reasons, supporting others in this moving forward or just, just really learning because that’s, that’s what it’s for. It’s for… to make sure that you don’t just disregard what, what somebody’s concern has been, like, this is a serious thing and it needs to be treated appropriately and so I wanted to respect that as well, rather than dismiss it like I really… I remember this is to say could you reflect on what you, what you could have would have done differently and I wrote 21 things. And sometimes I see the document in my, in my files, like hidden away and I’m like I’ve said that. Gosh. 

Paula Redmond (19:33)

Well, thank you so much, Caroline, for sharing that. And I’m just going to bring Amber in at this point. And Amber, whether you have any kind of reflections on Caroline’s story there?

Amber Johnston (19:50)

Just that last piece about somehow they’re hidden, well I too have made sure that I will never encounter any email that will pop up, that has this need to move it away out of sight, out of mind, has been an important part of the closing off of this experience. So, I mean, again, we’ll get into my experience, but I can very much empathize with so much of what you talk about and how much emotion we can see that you have, you know, that’s still part of this journey of you know, the concept of it is traumatic when we think of the sense of loss, fear of, you know, our safety in terms of our integrity and our profession and our passion and the things that we love and possibly losing that, you know, is traumatic. You know, I can see that within you and, you know, I felt that and it’s a really tough thing.

Paula Redmond (20:53)

And also, guess, I was thinking, I suppose, Caroline, just that the courage to kind of remain open to thinking about it that you’ve shared in terms of how, you know, in the face of threats, it’s so easy to get very defensive and, you know, really block things. But part of the work for you has, I guess, been to try and stay open to what you can learn, to what… you know, to listen, to hear, which, you know, is hard just in itself. 

Caroline Taylor (21:29)

Which was why it was really important to have a voice outside of… So my therapist, my psychologist therapist, was quite local. So I said, oh actually, I need to take this somewhere else. And that’s why I went to another. And I didn’t, like it didn’t feel safe. I didn’t feel safe in my, in my… I just needed to reflect outside of the country. I felt that it, yeah. 

Paula Redmond (21:57)

It felt that big. 

Caroline Taylor (21:59)

I also really wanted to know what I’d done, where I’d gone awry. Like it definitely, there was no intention to harm, absolutely not, but there was harm. You know, there was. For both of us, for both people. 

Paula Redmond (22:18)

And just, yeah, just really appreciate your courage in holding that position, but also talking about it in today’s. Yeah. Thank you. So Amber, let’s, let’s kind of come to you now and maybe you could start by just saying a bit about who you are and yeah, and I guess setting the scene again, not going into the details, but how, how this complaint, you know, what the context was when, this complaint arrived.

Amber Johnston (22:50)

So my name is Amber Johnson and I am a clinical psychologist in neuropsychology and director of Healthy Mind Psychology, so a private practice. And this complaint came to my attention through an email just a couple minutes before I held my next client case. And yes, when you see this funny thing and you look at it and then you kind of try and make sense of it and then I was in an adrenaline crisis panic state for probably three hours or so, but at least that whole next session until I was able to come back and try and read that again, just figuring out what this was I came through. It really, that was a really tough moment that I remember very clearly, which is funny because I actually don’t remember a lot of details of this whole process. That’s one that I do. I remember. But the complaint was through a hospital that I was working at. From not the patient that I was seeing, but from the family of the patient I was seeing. And I was not the only one who received the complaint. There were multiple people in the facility who got a version of it. And it was about a failure to safeguard, so a serious allegation about a failure to safeguard. And the client was actually no longer at the hospital either. And so that was another part of this. All of this came kind of out of nowhere, really.

Paula Redmond (24:46)

And so how did that unfold? How did the process unfold for you? Or can you remember?

Amber Johnston (24:51)

So, some of the other context was that, you know, I was employed with the hospital for this role, but it was a part-time role while I was also beginning private practice too. So I’d only been in private practice for probably 18 months or so at the time. And I think for anybody who has made that jump, you know, it’s quite a transition and it takes a while to learn things. So for instance, all the different groups that are out there now for private practice on Facebook or different… I wasn’t in any of that. You know, I still kind of knew my hospital people being the people who I know and support. And there weren’t really other psychologists there. I had my previous place of work, which I had recently, not that recently, two years ago or so had left, and of course I had access to people there that I knew. But again, it wasn’t the same as now how much I am involved with other professionals. So it was a very lonely process. And people at the hospital didn’t really know what to do with me in a general sense. You know, the psychologists that came in and out, and there was some confusion around all of that. So I think that was part of this context.

Paula Redmond (26:19)

That you’re quite isolated professionally?

Amber Johnston (26:20)

There’s a lot of isolation professionally, yes. I mean, in a way there wasn’t because we had the others who were part of the team, but they all were in different roles. But also there was a real consideration that we needed to have a bit more silo because the complaint was coming across multiple people. You know, we had to be really careful that there wasn’t any gossiping or something unprofessional that would be happening, which is so easy to fall into. So I think those who are involved really did take that seriously, that we had to be, you know, almost like we couldn’t use our social support in the same way, potentially, because this had come across multiple people. And so I received the email and actually quite quickly after, so I guess I had a different experience, quite quickly after, I did receive what, it might have even been in the email itself, what the actual allegations were. So I could see who had made it and what the allegations were. If it wasn’t at the same time, it was quite quickly after. And so then the only thing I… now I know that I didn’t know what to do. They did instruct that you needed to let the hospital system, the director, your line manager know right away and that they would need to provide some detail. So I was able to do that. And again, my hospital, without going into detail, the complaint, the complaintee, whoever makes the complaint…

Paula Redmond (27:59)

Complainant.

Amber Johnston (28:00)

Yeah. Complainant. There was lots of difficulties. They were known to the hospital and there was lots of difficulties as probably a system with how they came in and then some of the challenges that perhaps were outside of the scope and expertise of the unit in general. And so in that sense, there was learnings across the board for everybody from, Admissions Director to CEO, to everyone around what had happened with this wider situation. And so they were very supportive of me and knew that there were others that were receiving this too. And so then I just had to go through all the notes, everything I could find, just data collecting. But I didn’t really know what else to do about this. I did end up calling the BPS and I called my insurance and neither were able to support me. And I don’t really know why, and I can’t remember which one, so I don’t want any liability here, but one of them said to me, sorry don’t you have somebody at the hospital who can support you? And to me that was awful that I was paying for services and for support and contribution for what I thought would be these kind of incidents and to be that line, another one I remember, sorry don’t you have somebody at the hospital who could support you, was so even further isolating. You know, I just felt like this was completely down to me on my own. So what happened was that once I got all this information together, it was just a, I had the complaints and the specifics and it was about a failure to safeguard and then a few other little like minor points that were connected like note taking, something around note taking. And there was a couple other things but they were like these little minor things that were involved with the big one. And so I got all my notes and I put everything together and I put some kind of response that was a little briefer of one to just, you know, respond to that. And they took information from the hospital who also had to send off all things and that was when we went into COVID. So it was at that point that then everything shut down. So everybody shut down, the hospital unit shut down. So everything had discontinued at that point. And that meant that, including my ability to really contact anybody. So then I just waited. And during this time, I was having supervision. So I had my senior supervisor and I also had my peer supervisor, a friend that’s a colleague that we have very similar, that we have very similar like, trajectories of career. So those were two different supervision kind of strands that I always use and had used during this time to really think about what I was supposed to do and how to respond to this. But during that, I waited forever. And I called a couple times and every time I called HCPC to just say, anything happening? I might get something from a case handler. And then I got something else saying, well, the last case handler quit, so you’re being passed on and then I would call and nobody would call back and then I would talk to somebody. I talked to a one case handler who was so lovely, who was just like don’t worry about this, these are things that we just need to do our job. We need to go through the process and that’s what you just need to respond as we ask and you know really just containing of you know, this is not something to panic about, we just are going through what we need to go through. So I knew I had a complaint to respond to like it met the threshold of having to answer to it. And then I heard nothing else from anybody forever. Up to a point where I started to wonder, like, has it just gone away? Like, did they lose it? Is it just not part of, I mean, is the whole world imploding anyway? So, like maybe, maybe this is apocalyptic now and nobody’s worried, I don’t know, like it just… it was really just a time when it’s just left on your own at home, isolated from everybody anyway. It was a really strange thing.

Paula Redmond (32:40)

I was just going to ask what impact that had on you? Did you have the sense of like, well, oh God, this is really scary? Or did you have a sense that it’s frustrating, but it’s going to be okay? How did that impact you?

Amber Johnston (32:59)

I think that, so I guess the situation around the complaint itself was one that was a little bit different, I think, than Caroline, the one that… My feeling around this was that I had done wonderful. In my view, we had such a great relationship with this patient. But that there was, and there’s so much compassion that I really pushed forward and there was a lot of work that we had done and there’s a lot of movement and a lot of lovely moments of rapport and connection that the people who made the complaint would never have known or seen or would not have been part of this. And the truth was that the formulation was that there was retaliation, and maybe even some evidence of secondary gain by doing this, especially across a number of groups. So this mismatch between potentially doing something for a purpose versus the impact on a person’s life that that had, when I felt I had given so much, it was those pieces. So I was clear that I had made some mistakes and one of the biggest mistakes I had made, which is a tricky one because I still wrestle with this a little bit, was that when there was a safeguarding concern revealed, I had taken steps to go through the process of safeguarding and went to my unit manager, who was also the safeguarding lead and reported the information and took, did what I was required to do and the guidance from that lead. But what I didn’t do was write in the formal, what I call public medical notes, the details of that confidential piece of information from our session. So when others receive that big chunk of notes that anybody had access to within the system or anybody who was coming into the system, including people who got a hold of the notes and then said, well that was not written in there. So therefore it was a failure of reporting and a failure of documentation, which was not quite accurate. So it became down to how to be proving these things and including going through supervision, even coming up with things like, well, maybe we should tape an envelope and seal it and put something and write it in there and then seal and then, know, tape and seal that in and these are the things that were like the learning points from it, which again, it’s still really tricky because this is a systems question, you know. But anyway, so I felt that actually the main and the more egregious parts of it I could defend but just needed other people to write the letters and to say that I had done the right things to demonstrate it. So, and then there was this piece that I had failed at, but I did for a reason, and there was a formulation I had around all the patients and the reasons for the behaviors and why this complaint was coming through. So it was just, there was a lot there. So I guess throughout that whole process, I felt like I would be able to defend something, but I didn’t know how, I didn’t know when, I didn’t know what the process would look like, if they would find holes in things, if it was sufficient. If I was potentially guilty of something, how bad would that be? Like, what would that mean? So, yeah, I guess the answer to the question is a little bit different because I had to sit with so much uncertainty for such a long time. And the truth was, I was actually really, really angry. That was what was below everything else, was the sense of absolute injustice and the fact of putting in so much to somebody and being punished in that way for a gain, you know, that it just felt so awful to me. Now, I can also say that I can also see that that is a singular way of viewing the situation and that there would, if there was a reason for gain, there are a lot of reasons for wanting to gain. You know, at the end of the day, there’s a very difficult situation that’s been life changing and everybody is trying to just do their best in this world to get their needs met. So trying to find some of that compassion as well, but yeah, I had to sit with a lot of anger. I mean, I remember times during that period of just noticing myself sitting on the couch in the dark, just ruminating for who knows how long, you know?

Paula Redmond (38:12)

Yeah. And so how did it kind of resolve and how long did that take in the end?

Amber Johnston (38:21)

So a little over a year after getting that, the something that I needed to answer to, I then got something that said you have 30 days to submit your evidence. So, which again I guess my fault maybe, I kind of just hoped you know, that it had all just disappeared, but I got straight into supervision and actually my supervisors both were willing to write statements of support for me and how much reflection we’ve gone through and how much you know, we’ve taken learning points and one of them went through a wonderful piece of advice which was like to answer this you take the HCPC code of conduct and you just go through what are the areas that have been hit and anything that you think you have or haven’t done and you just structure it out just like that. And for me, I think that was the most valuable piece of information about how to write this because I wrote something first. I wrote a defense and it was a, it was piece of creative writing for a therapist. It was not something to submit to the HCPC. But it was just this whole like, mess. And I needed to do it, it was probably a really good exercise. But you know, my supervisors, I thought that out. Now let’s take this and let’s structure this into a way that just matches up with each of the criteria, the areas where you feel that you have a defense for, what you did do, what’s outside, the areas where you could see that there was a learning point or something that, you know, you’ve been, and to have that openness and put that into writing as part of your defense. And so I then submitted that, I submitted letters from the supervisors, I submitted letters from the safeguarding lead who, you know, could confirm that I had taken all hospital procedures. And, you know, then wrote the formulation of the clients as well, including where some of the trickiness had come into and why, you know, putting these things into the public documentation has been, was a difficult bit. And I think they then had 30 days to respond to that. There was a possibility it could go to panel, which is the group or, but they responded at that point to say that I was cleared of the major considerations. The one was the note taking, but that they felt that my reflections demonstrated sufficient learning and openness to consider that I did what I needed to do following it. So it was closed at that time.

Paula Redmond (41:10)

Yeah, and what was that like to have that closure?

Amber Johnston (41:14)

Well, to be honest, the thing that was most, I mean, it was a massive relief to know, and it was a huge piece of work, like you’re saying, Caroline, a 10,000 word, or yeah, it just feels like it was this huge body of additional work to do, to go back through everything, to go through the HCPC standards, to write this big case conceptualisation and formulation. And to submit all that was a huge amount of energy and activity on top of the work I had been doing and with so much of the emotional toll too. So to have all that done was just such a huge, huge amount of relief. But they then say at the end that if you receive an additional complaint in three years following the conclusion of this, they could reopen this case, which I mean makes sense, they want to make sure that there isn’t, you know, some kind of repetition of offense or, or… So I get it, but that just meant that there was three more years of having this thing held over you potentially. And given that the original complaint came so out of the blue with somebody that I wasn’t actively seeing, it just sets up this lack of predictability that at any point, at any point, you never know. And I think that’s always going to be the thing that stays with me. Two things, my notes. My notes. Notes, notes, notes, notes, notes, all the notes, supervision notes, all the notes. And then the second is just knowing that, you know, you always have to be thinking, you always have to, you know, just be on your toes for remembering the guidelines and remembering what you’re there to do and being able to think through and justify, you know, your activity and how you do it and why. And yeah, I just think that that’s been kind of the lasting… But I actually then ended up supervising somebody else through their HCPC complaint, which was interesting to be on the other side, on the other foot, and probably something cathartic as well, because, you know, somebody is… it’s such a vulnerability, such a vulnerable place to be. And so, you know, anybody going through these complaints to recognise that it’s, it does happen and that we’re here for each other, to support each other through these terrible things. It was something was really nice to be able to help someone else, you know, to go through that and help with the shame and help with the vulnerability and remind them that you don’t go through 10 years of university to just be, you know, making all kinds of, being an error to humans. Like, there’s a lot more to what’s coming on in here and how can we work through it. And I felt like that was a really nice way to go. But at the end of that process for that person, they actually decided to discontinue private practice. It wasn’t worth it once you got through one of those.

Paula Redmond (44:30)

Yeah. Yes. And what, that question about if you could sort of go back in time and say or give something to your younger self when you’re in the midst of this, what would that, what might that be?

Amber Johnston (44:43)

I don’t think I did enough to get support because I think there was so much shame and also not knowing what to do. Now I don’t know if that would have been something I could have said to myself. I feel like I learned along the way that there are all these different ways with which we can connect with other people and other professionals. But yeah, trying to make that more clear to more psychologists, potentially even those who are well embedded in employment systems, just for letting people know that these groups are out there and they are there to be on your team. I think that was a big piece of it. I think also something about, I remember when I was going through some of the medical notes, looking over every single word and looking at what had happened and how I responded. And I would just be like, yes, I wrote that. I wrote that down. So there was these moments of going through… yeah, I got that! It was something about trusting myself, know, trusting myself that I did actually think through a lot of this at the time and just because I couldn’t remember it doesn’t mean that, you know, I hadn’t been making good decisions at the time of making them and trying to put them down into a way that made sense. So there was something in that as well, you know, me thinking back and going, my goodness, I did everything wrong and actually looking at it and going, no I didn’t, no I didn’t. I was following a lot of the procedures here and I was thinking through and I was making decisions and I just need to justify them. But that’s different than, you know, being totally out of it, an unethical practitioner, you know. But that’s what you feel. You feel like they’re saying you are an unethical practitioner, you defend yourself. And so you take that on.

Paula Redmond (46:39)

Yeah, thank you, Amber. Just turning to you, Caroline, any kind of thoughts, reflections, responses to Amber’s story? 

Caroline Taylor (46:48)

I would just say that the parallels are quite extraordinary, really. Like, it’s very similar processes and especially in relation to, you know, what, what the concerns were about, what the complaints were about were, were both about omission rather than commission, right? Like, it’s interesting that that is the case. In some ways, I’m sort of thinking, well, isn’t this great? Isn’t this great that we’ve got this structure to help us when we’re going awry, right? Like, look, it’s great, but it just needs to be quicker. And also, like, because Amber also talked about the shame. And I think, you know, to have that shame resolved a lot quicker would mean that the practitioner could bounce back quicker and then be more effective in the workplace. Like, it’s not just about the impact it has on us personally. Like it impacts on how we are. We’re cautious, like during that whole 18 months, the caution I was having, like I was being so cautious. So, you know, to a neurotic point. So I think it’s not just happening in the here and now. It’s like, what is the legacy for the complainants and the case handlers? Like, what’s happening? I find that really interesting that we’re so ashamed and we’re ashamed for a long time. But also just that it was, you know, there was neither of us had no intention to do, there was no intention of harm. 

Paula Redmond (48:43)

And thinking, I guess, just more broadly, I wonder, you know, you’ve mentioned some things like, you know, it being quicker, that, you know, the length of time it takes is clearly a big problem. And you mentioned, Amber, kind of your HCPC case handler changing and just not getting much response and, you know, I guess being in the midst of COVID as well, I’m sure it didn’t help. But are there other things that you think about the system and the process that could be different?

Amber Johnston (49:20)

I mean, I do, I think the same as you just said, Caroline, you know, this process needs to be there. It serves a very important function. You know, it’s the same as, you know, for any form of hearing and, you know, organisation that requires some way of being able to sort through and have accountability. I feel though that there just seems to be, the quality of sides doesn’t seem to be there. You have this big organisation that is terrifying but maybe a little chaotic. And then I think you have what’s often a lone practitioner not knowing clearly what to do or where to go. Even if this body could do more to be able to help somebody know what resources they should consider. Anything that just helps feel like there’s a little bit more weighing up, I think, of the big organisation that feels like it’s out to get you versus the lone person wondering, how did they end up here and what to do next.

Paula Redmond (50:32)

And it really struck me Amber, what you said about, you know, calling the BPS and calling your insurance and not getting any support. That’s really scary. And I know as, you know, as a counterpoint that the ACP do offer support to their members and, you know, they have sort of, both kind of support on a sort of emotional psychological side, but also being able to support with the more practical things and signposting to legal advice and, you know, accompanying you know, members to the panel and stuff like that, which, you know, I think is, I’m really grateful to know that that exists. Because I think you sort of assume, you know, like you did that, you know, that’s what a professional body is there for. But then to discover at the moment you need it, that that’s not true is scary as well.

Amber Johnston (51:25)

And it felt like a solicitor felt too much at the time. Like that felt like, especially when you’re going through a submit some… so my first contact and then submitting this evidence and it felt, I didn’t get it. I didn’t know what was supposed to happen. So again, my big evidence and all my real, that came after I had a case to answer. I didn’t know that it should happen beforehand because all that was really quick. So there wasn’t in my head, why would I have a solicitor involved? Like it just didn’t make sense to me. And when I call them and nobody, you know, don’t you have a hospital to go to? That means that, you know, obviously I didn’t want to make it bigger than it needed to be. So I think it was just confusion of what do you do? What are the steps? What’s the process here? And gosh, if I would have submitted my rant about this case, I wouldn’t have known.

Paula Redmond (52:25)

No. And I guess that is, I suppose, part of why, one part of why it’s so important to have conversations like this, that, you know, we are isolated and shamed into not talking about it, then it’s hard to know. Any other thoughts from you, Caroline, about what? 

Caroline Taylor (52:42)

There’s a call to arms here, that’s what I’m thinking.

Amber Johnston (52:45)

The fight response.

Caroline Taylor (52:48)

Well you know, but both of us felt unsupported. I’m sure lots of people, that means that lots of other people felt unsupported. So I think that maybe we should be talking about it more and then there’s more awareness then of how to manage what it’s like, what the sorts of things so that people can cope. Because if they’re like, I just hid for three weeks, and like was terrified. So, I just think, let’s support people, let’s support each other. That’s my line, that’s what I’m taking away. I’m like, well, we’ve got to do something. We’ve got to do something. I mean, we can’t ask the HCPC to change, but we can change as a profession in the way that we help each other. 

Paula Redmond (53:38)

And to hear, I guess, also from people like both of you that it’s survivable, that there is kind of light on the other side and I think that’s really helpful. So yeah, I really appreciate you both coming on to talk about it.

Amber Johnston (53:56)

Well thank you for having us and for pushing, I think, both of us into feeling safe to be able to talk about something that was really tough. And like you said, if more of us are sharing, and I know there’s a group set up on Facebook for those who are going through this kind of thing, and you know, I think that the more that we can kind of turn to each other to create more sense of this happens, this is normal, and we are human and we will make mistakes and that’s okay and we can own them and we can learn from them. And you know, one of the bits for me was that, you know, HCPC did say, well, you have shown that you have thought about this, you’ve sought guidance and you’ve reflected and you’ve made practice changes and that’s good enough for us. You know, that was a really important piece of this. It wasn’t just punishment. It was actually, okay, you’ve demonstrated that you are going to be a better practitioner now, so we’re happy with that. That to me was something really interesting. And I think it’s important for everybody out there. You know, we could have made mistakes and we can own up to them and show growth and they are happy that we are doing that.

Caroline Taylor (55:09)

So thank you, Paula, for bringing it to everybody, you know, like on the podcast. That’s so, because that’s the way of letting people know about how the process works and that there is help and you can go and talk to people about it. So that, yeah, that’s great. Thank you so much for packing that tricky topic.

Paula Redmond (55:36)

Thank you for listening. If you’ve enjoyed this episode, please support the podcast by sharing it with others, posting about it on social media, or leaving a rating or review. I’d love to connect with you, so do come find me on LinkedIn or at my website, and do check out ACP UK and everything it has to offer. All the links are in the show notes. Thanks again, and until next time, take good care.

The post Experiencing a fitness to practise complaint: Psychologists’ personal stories appeared first on Dr Paula Redmond, Clinical Psychologist.

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Full transcript below

What should do you do if you get a fitness to practise complaint? What can you expect from the process? How long does it take, what are the possible outcomes, and where can you go to get support?

To answer these questions Paula spoke with Nicholas Stöckling, who works with psychologists and other health professionals as a regulatory adviser providing legal Fitness to Practise guidance, as well as webinars and training for professional bodies.

In this conversation, Nicholas discusses his extensive experience with fitness to practise issues and the Health and Care Professions Council (HCPC). He shares insights into the emotional and professional impacts of fitness to practise complaints on health professionals, particularly psychologists. The discussion covers the purpose of the HCPC, the investigation process, potential sanctions, and practical advice for professionals facing complaints. Nicholas emphasises the importance of understanding the process, seeking support, and maintaining mental health during challenging times.

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To get in touch with Nicholas you can contact him via email or LInkedIn.

Listeners may find the following resources helpful:

• ACP-UK Webinars (free to members):

• • Demystifying the HCPC Part 1

  • Demystifying the HCPC Part 2

  • Navigating the Grey Zone: Everyday Boundary Dilemmas in Psychological Work (live on 16th October 2025)

• Emotional Agility by Susan David – an accessible book offering practical strategies for navigating uncertainty and psychological pressure.

I’d love to connect with you so do come and find me on LinkedIn or at my website and do check out the ACP-UK and everything it has to offer.

Follow and subscribe so you don’t miss an episode!

Transcript

Paula Redmond (00:04)

Hi, I’m Dr Paula Redmond and you’re listening to the When Work Hurts podcast, which is brought to you by the Association of Clinical Psychologists, the representative professional body for clinical psychologists in the UK. In this series, I’ll be covering the difficult topic of surviving formal complaints, particularly for psychologists. I’ll be bringing you conversations with brilliant guests, offering their expertise, experience and wisdom on this tough topic from a range of different perspectives.

If you receive a fitness to practise complaint, how should you respond? What should you do and not do? What can you expect from the process? How long does it take? What are the possible outcomes? Where can you go to get support? To answer these questions, I spoke with Nicholas Stockling, who works with psychologists and other health professionals as a regulatory advisor, providing legal fitness to practise guidance, as well as webinars and training for professional bodies.He began by telling me about his experience working in this field.

Nicholas Stöckling (01:12)
I have quite a long and detailed experience working within fitness to practice. So my background is actually in criminal defense law, but I worked in human rights as well. I worked in the UK, London, a little bit in Africa as well. And then I worked for the HCPC. So I spent quite a few years working as part of the fitness to practice team as in their serious case review team and also representing them in tribunals. So that was a prosecutorial role, which was contrary to everything I’d done previously. And to be honest with you, it was something I didn’t feel particularly comfortable with. So my natural position in my legal mind was always looking to assist people as opposed to prosecute them. So when I was working with the HCPC and we had to prosecute social workers, psychologists, and people who I felt were primarily doing their best, I found that difficult. So I often tried to close cases, which didn’t always go down too well with my supervisors. So yeah, after I decided that morally it wasn’t really something I wanted to do, pursue people who work in health, then I created my own consultancy company where I now work representing people, psychologists, physiotherapists, anyone who’s under the HCPC regime. I also assist bodies such as the ACP UK. So I’m involved with them as well, which I think is a really worthwhile and important organisation in terms of standing up for the rights of psychologists and actually one of the more powerful representative bodies when they are questioning some of the motives of the HCPC and holding them to task. So I really enjoy that work. So I work with clients who are involved in the HCPC process, fitness practice process. And I also am involved with representative bodies like the ACP UK and delivering webinars on really how to deal with the fitness practice process and how to, yeah, how to manage it in a legal sense and also helping them understand the various emotional issues that can be involved, which I’m sure we’ll get to as we progress. But yeah, I’ve had quite an interesting career that’s led me to fitness to practice. I wouldn’t have imagined that’s where I was going end up, but I actually find it really, really interesting. I often say that outside of restricting someone’s freedom in a criminal sense, the harshest sanction you can give to someone is to restrict them from practicing something they’ve dedicated their life to. So it’s really important. It’s really important. It’s seen differently to criminal law and in terms of sanction. But for me, it’s something I really enjoy dealing with people and helping them through the process.

Paula Redmond (04:15)

Great. And I know you’ve done, as you’ve mentioned, some work with the ACP UK and there’s a couple of webinars that you’ve done, which are great, which are available to members. So I’ll put links to that in the show notes as well for people to check out. So given this work and your experience on sort of both sides of the story in terms of prosecuting and supporting registrants, I’m curious about your observations around the impact of fitness of practice complaints on health professionals. And I guess also curious about psychologists within that and whether that looks different or was experienced differently from other professional groups?

Nicholas Stöckling (05:04)
Yeah, I mean, it’s an interesting question because, you know, having worked with various professionals, health care professionals, so physios, paramedics, sometimes nurses, which is in a different regime that are not under the auspices of the HCPC, psychologists are a really interesting one for me because the nature of the profession means that sometimes they… the actual personal impact can, I’d argue, be a little bit greater than other professions. And the reason why I’ve come to that conclusion is the fact that psychologists take their profession very, very seriously, as do a lot of other people, but the nature of the profession can often be such that it’s almost like a calling for some people. And the question I often asked people that I’m involved with, clients, and also interesting, both my parents are psychologists, which is giving me sort of an understanding of, of the psychology, behind why people become psychologists. And I think there’s a couple of different schools of thought, and obviously you guys are the professionals and it’s your, it’s your area of expertise, but why people become psychologists, maybe you’ve done podcasts on it? I would argue some people become psychologists to analyze themselves, other people become psychologists because they really want to help people. And it’s really a profound sense to assist others in a, in the capacity they feel best capable to do so. So when you have an FTP complaint raised against you and your sense of worth is… and sense of self is so intrinsically linked to your profession, it can be really rupturing. So I have seen professionals across all the HCPC professions really suffer as a result of FTP investigations. I’ve seen divorces, I’ve seen people change professions, long service leave, retirement, you know, serious anger towards those who have raised the complaint, serious anger towards their place of work, because they feel like they haven’t been properly helped. So the fact that psychologists you know, feel that like everyone else feels it, but I’d argue they feel it even more deeply, at least in my experience. But fundamentally across the board, it is a highly rupturing experience. It is a really destabilising experience. It’s something that a lot of people are unaware of in the sense that they know there’s a chance that a complaint is going to be raised against them, it’s the nature of the profession. But the fact that it’s out of their control once the concerns been raised and the time limit is often unknown, which I’m sure we’ll get to later. That can be really, yeah, undermining and really, you can lose your sense of self and I’ve seen it. So yeah, how does it impact psychologists compared to other professionals? I’d say a little bit more deeply, but across the board, it’s a really unsettling experience.

Paula Redmond (08:16)

And you use that word rupture, but it’s a really kind of significant rupture. And that’s really striking, I guess, on lots of levels that a rupture with your relationship to your profession and I guess, relationship to the HCPC, whereas it might be something that you’ve seen as a body that, you you’re proud to be registered with, or, you know, it kind of shows off your credentials and, you know, you can establish yourself as a legitimate practitioner and, you know, in psychology, we get, you know, really cross with people who are saying they are psychologists and not registered with the HCPC. And you know, with some, you know, have a kind of attachment to that as a positive thing and then to be on the receiving end of what can feel like an attack from that organisation. Big rupture. And as you mentioned, that sense of a rupture between, you know, relationship to your clients or whoever has made the complaint, whether that’s a colleague or a client, that you know shock of of you know when you are wanting to help and be of service and that’s coming back at you in that way… yeah.

Nicholas Stöckling (09:31)
Absolutely. I mean, it’s a really conflicted relationship people have with the HCPC. As you said, I mean, the protection of title is something people work very hard to, they study their life for. They study for many years of their life. I mean, psychologists, clinical psychologists, and I’m sure there are different types of psychologists on the different domain names listening to this podcast, but people study a long time to get to, to receive their accreditation to, you know, all the various time that they have to give to this profession. So to then have the HCPC accord you the right to be labeled a clinical psychologist, educational psychologist, whatever it may be, is a proud moment. And then it can at the same time comes the recognition that well, now all my actions are under scrutiny, which I think people understand, but at the same time, that can be really difficult to go, wait a second, I’ve been waiting for the support of this organisation. And now they’re after me. Now, what I try and do with clients and when I’m running webinars or seminars, is I think what’s really important is for people to understand what the purpose of the fitness to practice regime is. What’s the purpose of fitness to practice? What’s the purpose of the HCPC and other regulators? And in my experience, those who accept that and understand what the purpose is and thereby want to interact with it, they have a much better time dealing with a fitness to practice regime. So what is the purpose of it? The purpose is to protect the public. Fundamentally, the purpose of the HCPC and any regulatory body is to protect the public. So I think as professionals, we don’t want people who are unfit to practice demeaning their profession. It’s about upholding the integrity of profession. And, you know, when I was working at the HCPC, there were many examples of people who did not deserve to be registered. So it does happen. There are people who are bringing the profession into disrepute, whether through poorly backed scientific therapy, through inappropriate practices, and I think as a profession, we don’t want those people working with us, amongst us. So the ACP UK actively pursues, will be involved in making sure that the integrity of the profession is upheld. And if there are some, for want of a better expression, cowboys out there who are dangerous to the public, it’s understandable that FTP cases are raised. So once we understand that the purpose of the system is there to protect you and also protect the public, it means that all the failings that are inherent within the regime, within the HCPC regime, and all the timeline issues and the various case manager changes and all the imperfections that exist, they can be dealt with a bit easier once we go, well, end of the day, this is what it’s there for, and fundamentally, I agree with the idea of public protection. And that’s, I sound like I’ve got my HPPC hat on, and trust me, later on, I’ll take it off because there are major issues with the organisation, but fundamentally, it is a body that is there to do good as all regulatory bodies are. And if we look at some of the issues that arise with psychotherapists and counselors and their desire to, you know, in many circumstances to have a regulatory body, and the movement through government petitions and through various avenues to seek recognition and have a governing body shows just how important these bodies are because the fact that there is no, there is limitable, there are regulatory bodies, but there’s no recognised statutory body that regulates these two psychotherapists and counsellors has led to some major issues and significant problems in the family court. There’s, you know, it really is, it’s an, it’s not a good situation. And I think the ACP UK is involved in that as well. I mean, it’s something that needs to be addressed. So we can see where there isn’t a regulatory body, the inherent dangers that exist. So yeah, it’s important to understand what the purpose of the HCPC is, and thereby that can assist you in how you deal with what’s coming when you have an FTP investigation.

Paula Redmond (13:48)

So what is the process? Because, you know, I have been qualified for over 15 years and until I started this podcast, I had no idea. So what information do you think would be really helpful for psychologists or other health professionals listening to know about what happens when a complaint is made?

Nicholas Stöckling (14:16)
Yeah, I mean, I think now that we’ve sort of established what the purpose of the HCPC is as a basis, I think it’s really important to understand the likelihood of you having a case raised against you, understand the various stages that may arise, and to understand the possible sanctions, because these are issues that I’m often asked. A case is raised against me am I going to get struck off? So I often get, I have phone calls from very, very distressed people about a complaint, which once I’ve read the facts of the case, they’re not going to get struck off. And sort of alleviating those fears is only possible through an understanding of the likelihood, statistical likelihood, an understanding of the process, understanding of the steps. So as I mentioned before, there’s approximately 27-28,000 practitioners, psychologists in any year. And about 280 complaints are raised a year against these psychologists. Now that’s not an insignificant number, but it’s not a large amount either. So if we think about it as a profession, it’s the second most complained against profession. So paramedics have more complaints raised against them than anyone else, psychologists are second. We know that about 0.7% of psychologists in any given year will have a complaint raised against them, which is higher than the actual average, which is about 0.5. So what I often ask various bodies that I’ve worked with is why do we think that is? I mean, I’m curious to know your opinion. Why do we think that psychologists have so many complaints raised against them? I have my personal opinions, but I’m curious to know as a psychologist what you think?

Paula Redmond (16:00)

Well, I guess the complexity of work, maybe the often quite, I suppose, intimate nature of the work in an emotional sense, and you would be working, I guess, much more privately with people than maybe other health professionals who are working in teams and, you know, contexts. And… yeah, the kind of boundary challenges that can show up in the nature of therapeutic work that can be tricky.

Nicholas Stöckling (16:36)

Yeah, I mean, they’re exactly some of the reasons that I’ve thought personally and a similar, it’s a common list of reasons why. From a legal perspective, I’d add to that the vulnerability of patients. So by definition, people come to psychologists due to whatever the issue may be, and this can be, as you know, relationship breakdown, monetary issues, all the way to serious psychiatric disorders. And what happens in those circumstances is that, and I’ve seen this working with the HCPC, highly vulnerable patients of psychologists can be very active. So if, for example, and I think of a case that I’ve worked on quite extensively, there has been a case where the psychologist has signposted their termination of the professional relationship very, very well. They’ve had a 10 year relationship with a client who has a mental illness. And as it draws to an end, the client becomes somewhat upset about that. It’s purely a personal reason that the fact that psychologist is moving overseas, so it was quite clear that there was no way the relationship could continue. The relationship, professional relationship ends and then the patient starts raising complaints. Now, in these circumstances, this had to do with onset of health issues, the reoccurrence of mental health issues due to the breakdown of the relationship. And some of the allegations raised were incredibly serious. So if we look at the HCPC having to deal with that and having been in that position, you’ll receive a bunch of emails from a person who may be in a state of semi-psychosis, but does not in any way, shape or form mean they cannot write a very coherent email. In fact, that may even assist their ability to write their email, if we understand the nature of certain mental illnesses. And they’ve written 18 pages of very clear issues about what this person did wrong. It’s structured, it’s not completely off the air. And they’ve raised allegations of inappropriate touching, they’ve raised allegations of privacy issues. Now this is an extreme case, but it gives an example of what can happen. Now the HCPC has to deal with that case. And I, having worked in that situation, I’m reading this and I’m going, okay, well, this is going to go to final hearing probably. As the case progresses, and this is a sort of symptomatic of the nature of the HCPC cases and the FTP process, as the case progresses, it becomes clear to the case manager that this person is unwell because repeatedly you’re getting 20 emails, 30 emails, and it becomes quite clear, okay, there probably isn’t that much to this. But just because someone is having a mental health issue or crisis, doesn’t mean they don’t deserve to be heard. So I think as psychologists, you understand that better than anyone else. So the HCPC in there doing their job properly, when it is done properly, and I would argue when I was in that position, I did it properly. I’d investigate that and I try and get to the basis of it. And it becomes quite clear, quite quickly, actually, this person is not particularly well and let’s try and get some information elsewhere to determine that, some medical records, yeah, and inherently delve into the issue. And in this case, it was closed. It didn’t even reach ICP. So it became quite clear quite quickly that that case was closed. But it doesn’t mean that the psychologist who had the case raised against her was not deeply affected by this, deeply affected. An eminent psychologist with unbelievable experience across numerous countries, lectured across the world. Now, a very, very impressive person. And she actually dealt with it very well. She was one of these cases, which I talked about previously, where she understood very quickly the purpose of the process. And she coped with it very, very well, but it was an absolute shock to her. But once she understood who raised the complaint, the nature of the professional relationship, she had a position of empathy, which I think can be really useful. And I have a lot of clients, and I’d argue psychologists do that better than anyone else in my personal anecdotal experience, if you have empathy to the person, particularly if it’s a former patient, that can really help. You can have anger towards the HCPC, but that’s not going to help either. So understanding the process and why these concerns are raised. So in terms of why so many psychologists have complaints raised against them, there’s a good example, because this person raised a complaint against that psychologist, actually raised a complaint against everyone else in her team, her healthcare team. So there’s about six complaints that were fired out across one NHS trust. And that just raised the numbers. 

Paula Redmond (21:20)

Because it’s interesting when you think about HCPC, which you’re not necessarily aware of, regulates a huge range of professions. So you’ve got podiatrists and kind of, you know, I think like hearing aid technicians and, you know, a whole range who will have a very different kind of patient profile and also the nature of the work is very different. So I can see those parallels with paramedics being, you know, working with people in very high emotive contexts, that there’s similarities there, which is very different from a hearing aid technician. It will be seeing different people in different contexts.

Nicholas Stöckling (22:00)

And it also means that in terms of defending a psychologist, it can be more difficult due to the nature of the profession itself, because it can often be an argument of ideas. There can be different theoretical reasons of why we undertake a particular form of therapeutic intervention. While if you’re a hearing aid professional, if you’re working in podiatry, you often have a set amount of tasks that need to be done. If you don’t do them properly, it’s quite clear what you did wrong or right. And that’s why defending psychologists, I’d argue are the most interesting cases and also the most complicated. Because if you’re a paramedic and you arrive at a scene, you have to perform six different actions if it’s a cardiac arrest. If you don’t do those six different actions, then you’re in breach of your standards. So it’s quite clear your clinical knowledge is not up to scratch, but a psychologist having a personal relationship and deciding, you know, making a risk assessment at a certain point, but not at the point that the complainant alleges should have been done is a question of professional opinion. And also what type of intervention you use, what type of treatment you use. There is a broad range and obviously you understand that far better than I do, but helping someone defend that case can be far more complicated, particularly from the HCPC’s perspective, because a case manager may not necessarily understand the intricacies of psychological theory, but they can see this is the complaint and if it’s been properly drafted by the complainant, by someone who alleges that something wrong is done, it’s quite clear to go, well, that looks wrong to me, but if you don’t have much expertise in that. So therefore defending that and understanding as a registrant that, okay, the first stage of the process is triage. So a complaint is raised and that should in theory go to an investigating committee panel within six months. So the first stage should take six months. That’s what the HCPC objectives state. That’s what the literature says, that’s their standards that they want to adhere to. Now that is not the case. That is absolutely not the case. And I think it’s worthwhile here referring to the PSA, so the Professional Standards Authority have many times raised serious concerns with the HCPC. Now the PSA is the regulator of regulators. It’s a really important body. Regulates all different professions. So it regulates those who regulate. So it will determine whether you’re doing a good job. Now, when I worked with the HCPC, when the PSA reports came out, these were really tumultuous times for the whole organisation, because the HCPC was in breach of many standards of good regulation while I was there. Now, in fairness to them, it’s improved. The last report said they’d reached 16 of 18 standards of good regulation. But the two they didn’t reach relate to timelines. So again and again, the HCPC is in breach of their objectives in terms of how quickly they process cases. Now, those who have dealt with the FTP process, and those within the ACP UK are well aware of these timeline issues. So essentially what the HCPC wants is to have all cases resolved within a year. That’s their objectives. Now, in my experience, it’s closer to 30 months, even longer. So I have a case that I’m working on now, which is a case that was raised in 2021. And we are not even at investigating committee panel stage. And now this is really complicated and really difficult to understand as a practitioner. So that’s been that many years now and we still haven’t reached the first stage. So the reality is that it doesn’t take six months. It doesn’t take one year to get to a final hearing. If you go to an ICP, so that’s the first stage, if they decide that the allegations, the concerns raised are worthy of allegations. So the HCPC will receive the complaint. They’ll say, this is the broad area of concerns that we have. And then they’ll investigate more, and if they decide the threshold has been met, they will send a list of allegations with particulars. So allegation one A, B, C, D, you did not do this on this date. You inappropriately did this. Now, from that point onwards, you have a time, you have usually a month to respond so you can prepare your response to allegations. That’s where I get involved a lot before it goes anywhere near a final hearing. And during that period, that’s when you present your side of the case. But then it gets sent to an investigating committee panel, which is three people who listen to it, who read the case just on the papers. So there’s no one representing them. So that will be a panel chair. That’ll be a lay person and that’ll be a member of the profession. So you’ll have a member of the psychologist’s profession sitting on that panel. So that’s an HCPC registered psychologist. And that will decide whether there’s a possibility that these cases, these allegations can be proven at a final hearing. So that’s… the great majority of, I think it’s about 45% of cases are dismissed at ICP. So investigate on the committee panel. So if it goes to an ICP, it doesn’t in any way, shape or form mean that it’s going to go to a final hearing. And it’s worth noting that. So I think having an understanding of what types of cases go forward, obviously misconduct cases, behavioural attitude cases, communication issues. So these are the types of cases that the HCP looks obviously quite seriously into. If you have committed a crime outside of your profession, a drink driving crime, a violent offense, the HCPC, first of all, you must inform the HCPC of that and not doing that is problematic. But I think understanding that self-reporting is a really important step in the process as well. So if you have been caught drink driving, if you have had a criminal charge against you, alert the HCPC, in the long run, it’s gonna be good for you. I think that’s worth noting.

Paula Redmond (28:20)

Nicholas, I just wanted to check what, when do you find out about, that a complaint has been made against you? Is it like day one, the same day that HCPC hears about it?

Nicholas Stöckling (28:35)

Not at all. So as a registrant, you’ll have a phone call, phone call or an email, which then gets sent to a triage team in the HCPC. And I’ve worked in part of that process, not in triage itself. And they’ll determine whether it’s worthy of investigation, whether the threshold has been met. And at that point, you will then be alerted. Due to the backlog of cases, that can take a while. I couldn’t give you a number because I don’t know if there’s statistics out of reporting from triage to being alerted. But you’d hope, depending on the severity of the case, determination should be made as the threshold quite quickly. So you should learn within a couple of weeks, I imagine.

Paula Redmond (29:17)

And do you hear what that, the complaint is? Because I have heard from people who have been informed that a complaint has been made about them, but no detail as to what that is for months and months, years, and they don’t know what it is that they’re facing. Is that common?

Nicholas Stöckling (29:39)

I mean, yes, that’s probably one of the greatest gripes, both I have in a professional sense in my work and that clients and registrants have is the fact that you can have a complaint raised against you, and we will say something along the lines of we think the concern has been raised in regards to your actions, which suggests that you are in, that you’re not upholding standards one, two, three, five and six, which can be really broad. It can be communication, it can be the clinical issues. It can be really broad. And at this stage, they will say often, it’s in relation to your work with this person. So the person will be identified. And that’s the nature of, I think that’s something that people can find quite difficult. And I think that’s why a lot of people, from the other side, people raising complaints can often be a little bit wary of raising complaints because they will be identified. And I think if you’re a psychologist and you’re working with someone or a health care professional in any form, and you’re working with someone who’s clearly working, acting inappropriately or doing something in a clinical sense or I don’t know, I think of inappropriate behavior with colleagues or racism or sexism or one of these sort of things, and you want to alert the HCPC to that, which is I think the right thing to do in certain circumstances, that your name will be on the, or understanding that I think is… can lead to people not wanting to raise complaints. But at the same time, we can also lead to some workplace issues because I think members of the public, I think raise about two thirds of all complaints, it’s colleagues and your employment that raise about, I think 20%. You have members of the public and you also have self complaints. So you’re essentially raising issues about yourself. And these often relate to health issues. So if you have to cease working for whatever reason it is, and you’re essentially asking, you’re alerting the HCPC to the fact that you have a medical condition. Now, one of those can be an addiction issue. One of those that can be a cancer diagnosis. So they’re essentially the different types of people that raise complaints. Yeah.

Paula Redmond (31:52)

Okay, great. So it’s triaged, you’re informed, and then the next stage is a more detailed kind of breakdown of what the allegations are. And at that point, you would put your sort of response, a written response together that then goes to this, investigatory… what’s the C stand for?

Nicholas Stöckling (32:15)

Committee panel.

Paula Redmond (32:16)

Investigating Committee Panel.

Nicholas Stöckling (32:17)

Exactly right. So the way it works is that you’ll receive this sort of general complaint and then you’ll often wait a year, in my experience, and particularly in certain circumstances, three years. Like the case I’m working on, very serious cases. I mean, I don’t want to scare people, that’s quite an exceptional case, but you know, waiting a year, 18 months is not uncommon. And then you will receive the allegations and contained within the allegations will be a bundle of all the investigations made. So there will be all the reports, all those testimony. Now I think understanding why these issues and why these investigations take so long is really useful for registrants. So why does it take a year and half or two years for the HCPC to form its allegations? Now there are various reasons for that. One of the reasons is a lack of funding to the HCPC. Case managers turn over all the time. There’s too many cases, people are overworked. I think that’s one reason. So that’s just poorly run organisation in some circumstances. And the HCPC will, I would argue readily, admit that there are things they can do better. But in certain circumstances, and I’ll give the example of cases involving, say for example, the death of someone, the death of a young person, a suicide, a vulnerable person dying in tragic circumstances, what will happen there, there’ll often be an external investigation. So these serious case reviews in certain circumstances. So when I was at the HCPC, I worked with the serious case reviews. So what would happen if, for example, there’s a death of a toddler, which will get a lot of media attention, a serious case review will be undertaken. And in that review, it’ll identify certain people that are involved in the care of a particular person, social workers, psychologists, doctors, et cetera. Now, what the HCPC will do if they’re aware that a serious case review is being undertaken or even an investigation done within the place of employment, so an NHS internal review, they will wait for the completion of that before they draft the allegations. Now, understanding that, you know, and everyone’s worked in various organisations where it takes a while to get stuff done. So NHS Trust are doing an investigation into the attempted suicide of a patient who’s under their care. Getting all the documents in place to write that review can take a year. It just really can. The HCPC will defer judgment until that report’s been done. We think with criminal investigation, they’ll defer judgment until the police investigation complete. Now, we know how long a police investigation can take. So understanding that why am I waiting three years when the case of… a case I’m working on now, there was an internal review being undertaken by the trust she worked for. There was a serious case review being undertaken by an external organisation designated by the trust. And until that was done, the HCPC weren’t drafting allegations. So that’s one reason why it took so long. I think that’s worth understanding.

Paula Redmond (35:22)

So you get the allegations and as you said, all the bundle of all the reports, everything that they’ve gathered, and then you get to respond. And I guess that’s the point or, you know, that someone like you would be really useful to help. Is that part of your role, helping people respond to the allegations? Yeah.

Nicholas Stöckling (35:45)

Yeah, absolutely. I mean, I guess the first step that I’d suggest to people is to contact your professional body. Clinical psychologists, if you’re in that circumstance and you’re unsure what to do, have a chat to the ACP or the similar organisation for whatever domain you work under. And then seek assistance. So what I do in that circumstance is I will help a registrant prepare their defense, essentially. So you have six weeks, four weeks, you can usually get that double to eight weeks. And we’ll try and present their side of the story. So you respond to each individual allegation. On this date, you did not undertake a risk assessment. Yes, I did, and these are my clinical notes to prove it. Here are some witness statements from those who I worked with to prove that I did do it. And you can build a very comprehensive response that way. Witness statements are often highly valuable sources of evidence, as well as your view of events and having, you know, this is your chance to really explain that you disagree wholeheartedly with the allegations. So then that gets put into a response to the allegation bundle. And then that gets sent to the ICP, the investigation committee panel, who then will meet, the three of them together, and they will look at the allegations and they’ll look at the response panel and they’ll make an assessment based on that. So at that stage is, depending on the severity of the case, is where I strongly suggest people seek help, whether it’s legal, whether through consultants like myself or through your representative bodies. It’s very useful, and in an ideal world, you’ll have everything stopped at ICP because going to a final hearing is a far more expensive undertaking. It’s a similar, these can be week long, two week long. It’s less formal than a court, but you’ll often have barristers and, the HCPC, they use Kingsley Napoli. So they’ll have some really good lawyers prosecuting their case. And at that point, you really want to, yeah, if you can stop it at the ICP, it’s suggested. If you think the evidence is such that you present a strong, solid rebuttal of all the allegations, do it before ICP. Don’t let it get to a final hearing, because then it becomes far more serious and far more expensive as well. Then you have to, it’s suggested you get a barrister.

Paula Redmond (38:05)

Okay. So, and you said about 45% of cases might get, might stop at that ICP stage?

Nicholas Stöckling (38:14)

Yeah, I mean, it depends, but yeah, more than half, I think it depends on which report you’re actually reading. So if at a general assessment, 40% thereabouts. So you can, it’s quite likely it’ll be stopped at ICP.

Paula Redmond (38:29)

Yeah. And stop… does that mean they’ve decided there’s no case to answer?

Nicholas Stöckling (38:33)

Absolutely. That’s literally the words. No case to answer. That’s the end of the matter. Now there’s a five year rule, which means that the HCPC will hold onto the fact and will keep on their records that there was a case raised and for five years that’ll be on their system essentially, but there will be no public record of that. No, you do not have to inform anyone. On the register, there’ll be no mention of it. It is essentially, it’s finished. So I think, as I said, in an ideal world, you’ll have it stopped at ICP so it doesn’t progress any further.

Paula Redmond (39:08)

Okay. And if ICP decides it needs to progress, then that’s to final hearing. That’s the next stage?

Nicholas Stöckling (39:16)

That’s the next stage. And that’s when witnesses will be cross-examined. That’s when, yeah, as I said, it’s less formal than a criminal proceedings or a family court, but it’s still, you know, it’s a serious matter now.

Paula Redmond (39:27)

And how long does that take from ICP to final hearing?

Nicholas Stöckling (39:31)

I think again, the HCPC, their aims do not meet the reality. So that can be very often another six months, another year. So as I said, from the first time a complaint is raised to a final hearing, in my experience and according to the PSA, 30 months is not uncommon. So that’s what you’re sort of, essentially three years from beginning to end. If it goes to that end, that case. And as I said, there are certain cases where absolutely they need to be investigated. Amongst 30,000 members, 28,000 psychologists, there are going to be a few bad eggs. That’s just the law of averages. So these cases need to be prosecuted to the end. So what we don’t want is the less serious cases passing through ICP. That’s really a waste of everyone’s time. It’s a waste of the HCPC’s funding. If they’re hiring lawyers, registrants are hiring, sometimes QCs to defend themselves. If we can cut it off earlier, it’s really ideal, but some cases absolutely need to be thoroughly examined. And what I’d say to registrants is if you honestly believe that you have acted appropriately, if it’s a clinical issue or you’re a risk assessment issue or note taking or something of the like, and you’re absolutely adamant and you, and you know that you’ve done the right thing, the truth will come out. And it really will. In my experience I’ve never, very rarely seen, in fact, I can think of one or two cases where I disagreed with the final hearing outcome. So essentially, if it goes to final hearing and they’ve decided that the sanction is to be struck off or they decide that the sanction is to be a warning or the conditions of practice, usually it’s correct because they’ve had a full week, sometimes two weeks to thoroughly investigate the evidence. They cross-examine people. So the truth comes out. So rest assured, if you think that what your actions were appropriate, eventually that’s going to come out. You might think, how on earth is it past this step? It’s gone through triage. How’s it passed that? How’s it gone through ICP? Well, the truth comes out, that’s been my experience. And I think that’s something to hold onto if you’re confident in the way you behave. So in terms of actually being struck off, you have to really have done something fundamentally inappropriate for that to happen. So bear that in mind. When you have a concern raised against you to do with some of your actions, even if it’s involving a tragedy, even if it had a tragic outcome, you are merely a cog in a greater system. And the HCPC need to prove that you are unfit to practice. And that’s quite a high bar, I would argue. You are currently unfit to practice based on something that you did a couple of years ago. So rest assured, if you’ve done the right thing, you should be okay.

Paula Redmond (42:22)

And so what are the possible sanctions?

Nicholas Stöckling (42:24)

If you get to a final hearing, the panel or the tribunal decides that the allegations are founded, are based in reality. You can have a strike off order, which essentially permanently removes you from the register. And that’s approximately 25 to 30% of cases that reach final hearing. So we’re talking about the extreme end of it, the far end of the process. So 25 to 30% of cases that go to final hearing will end up with a strike off. And if we think of the nature of cases that go to final hearing, inappropriate relationships or some serious matters, some criminal matters, some issues to do with health, so that’s 30%. You can have a suspension order, which will temporarily remove you from the register, usually for six to 12 months. And about 20 to 25% of all cases, that’s the outcome. A conditions of practice order, which for psychologists is a very difficult judgment because essentially it means that often what the conditions of practice will be that you cannot have sessions without someone else in attendance. So you will have someone, a chaperone for want a bit of expression. So obviously in those sort of circumstances, it’s unlikely you’re going to be able to continue your job. So that’s about 10 to 15%. And then also a caution order. So that allows you to continue to practice and the caution order is usually one to five years. And you continue to practice, but you’re under caution. And that’s approximately 15 to 20% of all cases end up with those. So there’s quite a broad spectrum, but as you can see, if you get to final hearing, the panel decides based on the evidence that they’ve investigated and based on the cross-examination of witnesses and the evidence before them, that you’ve acted inappropriately or you’re not upholding the standards, then the outcomes are pretty serious. But again, it’s worth remembering, these are a small percentage of cases amongst a small percentage of people who have cases investigated amongst a rather large profession. Some 28 to 30,000 psychologists. Those who get struck off are very, small percentage. And it’s worth remembering that. So not to panic.

Paula Redmond (44:40)

I also just wanted to ask you, because you can, you know, anyone can go on the HCPC website and look up these cases. And well, what I’m not clear about, I don’t know if you know the answer, is at what point is it made public? At what point is your, you know, you can go on the HCPC website, you can find your name. It seems very inconsistent about how much information is available about… sometimes it’s just a name. Sometimes there’s huge detail, you know, text messages sent between people. And it doesn’t seem, you know, I’ve seen cases on there where someone, you know, couldn’t attend the trial because they were in prison for torturing someone, you know. And then you’ve got other people who, you know, they messed up the renewal of the HCPC registration, you know, let it lapse and for a period of weeks were using the title without actually being registered. I guess it’s sort of snowballed from there probably, but those are two cases where like all the details are public or there’s a lot of detail, you don’t know what’s not public, but there’s a lot of detail that’s public and that they’re opposite ends of sort of severity, I would think.

Nicholas Stöckling (46:02)

Yeah, I mean, essentially what is published depends on the actual nature of the proceedings, but at final hearing, obviously then the case will be uploaded. So that will be published on the HCPC website. Now what’s included in that publication depends on the nature of the case. So some cases will be more, they’ll anonymise more than others. I’ve got a case at the moment, which pertains exactly to what you’re talking about, whereby people were reluctant to give witness statements to support one of their colleagues because they’re worried about their statements being included in the public domain. So generally, I mean, would all reports and all text messages be included in a judgment which is presented on the HCPC website? No, not necessarily, but a great deal of information will be. Obviously, we understand the rationale behind that because it’s a fair process and people have a right to know what happened in terms of protecting the identification of people involved, particularly in psychology. Obviously there’ll be a lot of protection for those who deserve protection, children and the like. But in terms of what’s actually published, well, at final hearing, the decision will be made by the panel chair to include certain elements in the publication. So I’d argue that the great majority of the information will be made public if it goes to final hearing. These are essentially public proceedings. So you have a right and journalists have a right, and I’ve been in cases where there are journalists, to sit in on hearings unless the panel decides that this needs to be heard in private. And the HCPC can make an application to have a matter heard in private if it’s for protection of people’s personal matters in certain circumstances. But essentially they’re public matters.

Paula Redmond (47:57)

But that’s only at the point of it going to the final hearing. It’s not published before then?

Nicholas Stöckling (48:02)

Absolutely. Before final hearing, it’s not at all. And I think that’s a real fear is that, you know, what information can I share? People getting… garnering witness statements can be really difficult. People really worried about, I mean, I think of a case that I worked on not that long ago where this involved the death of a young person. And people were very nervous about providing supportive statements to my client based on the fact that the HCPC would read those statements and go, wait a second, maybe there’s something there we can raise against you. So there’s a fear that if I engage in the process at all, maybe they’re going to see fault in my behavior. And that’s, in my experience, the HCPC doesn’t really work like that, but it’s not impossible for that to happen. So if you’re reading complaints, there’s a concern raised against say a physiotherapist, and within that, you’re reading a report, which was commissioned by the trust. And within that report, they’ve raised concerns against the person who has the concerns raised against them, the physio. But there’s also some suggestions that some other people have not done the appropriate things from the internal report. The HCPC, in theory, can open investigations into them. So people don’t want to engage. And that’s one of the problems with the HCPC, which I think we’ll talk about a bit later, is something that they can improve because there is a real fear of, well, what’s going to happen to my testimony? What’s… should I even respond to this email? And the reality is, in the interest of procedural fairness, you should respond. You should be able to present your version of events or your supportive state without any of you being investigated yourself. So it’s something they need to work on.

Paula Redmond (49:44)

Yeah. So it sounds like, you know, in terms of the impact on people, there’s, you know, the sort of horror of receiving a complaint and the idea that, you know, things might be risky for you or that you might have done something to harm someone or that someone thinks you’ve done something to harm one, the sort of professional risk and horror of that. But the actual process of the investigation in itself sounds awful and sort of traumatic kind of adding insult to injury. That’s really hard.

Nicholas Stöckling (50:21)

It’s never easy. I think that’s essentially, there’s no way to sugarcoat it. It’s not easy to have your integrity questioned. Again, I refer back to my original sort of premise that if we understand why it’s there, we can sort of accept a little bit more readily that essentially the purpose of the regime is there for the public good, but the impact on the individual is intense.

The only way, I think that we, one can deal with it appropriately is to, to use some particular psychologists, is to use some of the techniques that, that you guys, help other people with in terms of, you know, meditation or whatever it is in terms of managing your own expectations, try not to catastrophise these sorts of issues that you talk with clients about. So for psychologists, I often say to some of my clients, I can hear you sound very anxious, I can hear you sound very angry. That’s a common experience I have. And what I’ll say is, well, that anger is really only affecting you, and your anger towards the HCPC and the case manager. And what will happen often with the HCPC, if you have a three year case, a case that you have in the system for two, three years, you will maybe have six different case managers. So the person that you’re dealing with, and that sounds extreme, but it’s actually not. In fact, if you have a one year case, you’re lucky to have three different case managers. Because the lifespan of an HCPC case manager is very short. You can get very, very good, you can get some great aspiring lawyers that end up moving on to being top… there’s not a reflection on the nature, the quality of the people that take that job, but it’s often a stepping stone to other things and it’s not very well paid. So if we understand that wait a sec, that person I’ve been dealing with for three months is now gone. And I’ve got another one who doesn’t even know who I am. And then I’ve got another one who’s sending me very blunt emails. Getting angry is the natural response, but it’s not going to help you. It’s actually, particularly as a psychologist, it’s something, you know, some of the systems that you have in place to assist your clients, to incorporate those into your daily life. Yeah, it’s not easy. There’s no other way to say it. Some of those clients that I’ve had that have dealt with a few complaints. And I’ve seen sort of heads of trusts, so very experienced, high up, in this case, psychologists who’ve been in the profession for 30 years and as the head of trust have had complaints raised all the way up the system. So they’ve had a few complaints. So as I said about previously, you may have a person in the example of the death of a young person. You may have the parents raise complaints against the treating psychologist, anyone involved in the DMTs, anyone involved in the treatment externally, head of hospital, the head of, so that’s eight complaints. The person at the very top will be like, well, this has happened before. I trust the process. I’ve been okay so far. So I look to those as ways, as examples of how to best cope with the ride, because it’s a ride.

Paula Redmond (53:39)

So if we think about, I mean, you’ve mentioned quite a few things, but what changes you would like to see in the process? What improvements would you like to see happen?

Nicholas Stöckling (53:51)

Yeah, I mean, it’s a question I get asked quite regularly. Having worked there and seen the issues that exist, I mean, fundamentally, I would argue that the main problem is a funding issue. There’s not enough case managers. So in terms of expediting cases, they just need to have more case managers. So that’s the first basic, simple change that could happen. It’s just double your team. Have people working more closely on cases and having less cases. So for example, instead of having 20 cases that you need to investigate as a case manager, have five and then you’ll get better. But I think that’s not going to happen. That’s unlikely. So I think a more realistic issue that could be improved is transparency with communications. So I think a lot of people are really upset and I know the ACP dealt with that, is the, there’s limited updates from the HCPC, there’s unclear explanations about the process, timelines are unclear. And I think even just explaining, for example, what I just did, that we are waiting for the report and that is going to take a year and a half. And until then we’re reserving judgment. That is very, very rarely passed on to registrants. So knowing what I’m waiting for is a pretty basic step, and I think a decent step. What am I waiting for? I’m waiting for the conclusion of the police investigation, which has nothing to do with you personally, but you’re involved in that. And we’re to take some reading of that. So that’s one way it could be improved. And I think that’s probably the most common complaint. Like I’ve not been updated for nine months, for a year, and then suddenly a completely different complaint raised against me. So it was a very broad complaint and now it’s not even related to the original letter I received. That’s a very common one. Secondly, I think more emotional and psychological support for registrants. I don’t know how well the HCPC recognises the emotional toll that the FTP investigations have. They paid lip service to that. So there is an understanding at least publicly that this is a difficult process and they have some form of support systems within the HCPC, but in my opinion, they’re not really fit for service. So embedding or partnering with counseling support services might be a better way of doing it and really being kinder to registrants. So when I was there, I tried to do that and it was one of the reasons, you know, if you’re making 10, 15 phone calls, updating people, you know, understand that this is really important to those individuals and that’s to do with training. So better training into the psychological impact. That’s something HCPC could definitely work on. And maybe also a better understanding of proportionality. So early resolution for cases that are clearly going nowhere. So people are waiting in limbo for years for something that is pretty clear. When I, as a defendant, or representing someone as a defendant, talk to an HCPC case manager privately, I will say, OK, so what’s your view on this? And quite often, their view will be, well, we don’t think it’s really going anywhere. So in that case, you know, well, let’s resolve it. So there are, you know, managing that with giving everyone the opportunity to be heard is a fine balancing act. This is not simple stuff. There’s no fixed solution. It’s complex. If you talk to anyone involved with any regulatory body, it’s a similar problem across all bodies. So there’s not really any quick fix solution, but they could definitely improve, yeah, early resolution for cases that are going on nowhere, better training, more emotional support and greater funding. That would be the sort of my top suggestions.

Paula Redmond (57:49)

Yeah, great. So maybe just to end off with Nicholas, to think about what the do’s and don’ts might be, your advice for anyone who has the dreaded phone call or the email. What would you suggest?

Nicholas Stöckling (58:10)

First off, don’t panic. Straight away, the first instinct is to go into sort of crisis mode. And that’s, first of all, in a procedural sense is not the best approach to take and also in a mental health sense is not the best approach to take. So take the complaint seriously, but don’t panic about it. It doesn’t in any way, there’s no absolute certainty that anything’s going to be proven. It may not proceed beyond the initial stage. This is just the first step and it may be the final step. Secondly, look after your mental health. I mean that, it sounds simple, but in terms of how well, how best you prepare your defense, in terms of how best you continue to live with your life in your family life, in your professional life will be determined by how well you’re looking after yourself. So if you are in full panic mode from the outset, and this is going to go for three years, well, your life is going to crumble. If you accept that it’s, well, there’s a system in place, the truth is going to come out. I’m okay. I’ve done everything correctly. If I want to use statistics, it’s unlikely in a statistical sense that I’m going to be struck off. And I need to just look after my family. I need to keep connected with my colleagues. I need to look after my mental health. So the second advice would definitely be, you know, it’s common for people to feel shame, isolation, fear of professional ruin. That sense of shame is very common and it’s a wasted expenditure of energy because there’s no shame in having these issues raised against you. In fact, I would argue in some circumstances, the fact that you’re dealing with some very vulnerable people in highly complicated cases, it’s only natural that eventually in 20 years experience, someone’s going to raise a complaint against you. It doesn’t anyway reflect upon the fact that you’ve done anything wrong. Maybe you’re on the coal face, you’re dealing with those issues head on. So kudos to you. So that’s one other way of looking at it. I would definitely say engage. Now this is something that people do not do. Of course, psychologists in my experience are better than other professions, but some people are so angry, are so hurt that they just go, I’m not even talking to the HCPC. Now that does not work, it reflects poorly on you. You’re showing a lack of respect to the institution, whether you dislike it, whether you hate it, whether you think that the whole thing is a scam, whether you think it’s corrupt. I’ve heard that allegation as well. Accept the fact that the regime is there in place for a good reason. So therefore engage with it. Say you disagree wholeheartedly, put your voice forward. Absolutely put your case forward, but do not ignore letters. Do not ignore that phone call. Do not, not take it seriously because not taking it seriously and not engaging is really the worst legal step you could take because our panel will go, well what are they hiding? Just put your case forward, get some connections. I’d say get professional support very early, whether that’s with your regulatory, with your professional body like the ACP, whether it’s with people like myself, whether it’s with colleagues. Yeah, the way I essentially structure my work is to yeah, to be involved in the emotional support at the beginning, be involved in the preparation of bundles. We really have a proactive response because I think the biggest issue people have is they feel like I don’t have control of the situation. So after this many years experience, the first thing I say is, okay, let’s take control. We can’t wait for these emails. We can send chaser emails to the HCPC saying, when are you updating? What are you doing? But you might be throwing them into the ether. We can keep on trying to get them to respond, but what we can do is proactively move forward. So that means thinking about the types of evidence we need to start to collect, thinking the types of witness statements we can find. So talking with colleagues, okay, so this is the timeline, these are the dates, who am gonna talk to, to be ready? Get a list, a plan of action, things every week. And that once you’ve regained control of the situation, that I feel like makes people feel, yeah, more comfortable, less stressed. It’s not an elixir, you’re still gonna have that sense of anxiety, but it definitely helps. If you just throw your hands up in the air and go, ‘I’m not talking to anyone about it. I’m not talking to my colleagues. I’m not talking to my line manager.’ And people do this. ‘I’m so ashamed. I’m going to take a couple of weeks off work. I’m going to sit in my room.’ And I’ve seen that. And I’ve literally been the first point of contact for some registrants who haven’t left the house. And it sounds extreme, but this is some of the responses people have. Like, what do I do? I’m going to lose my mortgage. I’m going to lose my house, my husband, my wife’s gonna leave me, whatever it is, these are natural responses. It’s sort of a crisis mode that can happen. Try and be very careful not to slip into that crisis mode, because this is gonna go for a long time. According to statistically, even if you go to ICP, you’re likely to wait a year. So there’s a fair chance you’re gonna wait for a year. And to be on high revs in crisis mode, we know as psychologists, as you guys are, is not a healthy way to exist. You need to stay calm, seek support. Again, I refer to the ACP as one of the best representative bodies that I work with. I work with a few others in different professions. They work actively to support their members. I’ve got no reason to say that, they really are a great body. So if you have a question that you need to know, or you’re unsure about what are the support systems, contact them, contact legal consultants like myself as well.

Paula Redmond (1:03:56)

And would you, I guess you’d be contacting your indemnity insurance, your professional indemnity?

Nicholas Stöckling (1:04:01)

Yes, absolutely. I mean, that’s a slightly different discussion. I mean, who your insurer is, I mean, you’ll have a discussion with your insurer who’s going to actually run the case, because often your insurer will have a designated law firm they work with. It’s your decision whether you want to go with that law firm. In my experience, some people are not very happy with the care that they get. So that’s something for you to decide. But yeah, you definitely need to contact your insurer and determine which way you want to go. Whether you actually follow their suggested path, that’s something entirely for you and you don’t have to. It’s worth noting that.

Paula Redmond (01:04:38)

Yeah, okay, okay, great. Anything else, Nicholas, that you want to add or any final kind of take-home messages for the listeners?

Nicholas Stöckling (1:04:48)

Yeah, I mean, it’s a difficult and fraught process, the FTP process. So to understand the purpose of why it’s there, to realise that you are not alone in this and it is a possibility, a statistical possibility that if you have a career of 30 years, you are going to encounter the FTP regime. That may be that you’re raising a concern against someone else and that’s okay. You’re allowed to do that if you think someone’s acting inappropriately. You may be asked to provide a witness statement. You may be a professional appearing in a tribunal. To understand the process is very worthwhile and to really accept the fact that it’s there for the right reasons, to not panic, as I said earlier, and to understand that looking after your mental health as you approach what is very likely to be quite a drawn out process is really something you need to do. And finally, I’d say trust the fact that in the end, if you have acted appropriately, it will come out in the wash. The steps are there in place. Even if it has to go all the way up to ICP and final hearing, if there’s a rigorous investigation of the evidence and you are confident that what you did is right, it’ll come out. It will definitely come out. So be confident in your actions and look after yourself. That’d be my final word.

Paula Redmond (1:06:11)

Brilliant. And it’s so great to know that you are out there, that there’s people like you who can provide that support. That also wasn’t something I was aware of. And as you say, the ACP UK does have a great support scheme for its members to support them emotionally and practically through this process. So we’re going to include all the links so people can find you and find the support in the ACP as well, if they need it. But brilliant. Thanks so much, Nicolas.

Nicholas Stöckling (1:06:42)

Thanks so much Paula.

Paula Redmond (1:06:49)

Thank you for listening. If you’ve enjoyed this episode, please support the podcast by sharing it with others, posting about it on social media, or leaving a rating or review. I’d love to connect with you, so do come find me on LinkedIn or at my website, and do check out ACP UK and everything it has to offer. All the links are in the show notes. Thanks again, and until next time, take good care.

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Full transcript below

This conversation delves into the research conducted by Dr Naomi Hogben (Clinical Psychologist) on the impact of formal complaints on early career Clinical Psychologists in the NHS.

Naomi discusses the lack of existing research on the experiences of clinicians receiving complaints, the methodology of her study, and the significant emotional and systemic challenges faced by those involved. The findings reveal a lack of support during the complaints process and the profound emotional impact on clinicians.

Naomi highlights the need for better communication and support systems, and the importance of talking more openly about complaints within the profession.

Naomi mentions the published paper: How do healthcare professionals experience being subject to complaint? A meta-synthesis of reported psychosocial impacts

I’d love to connect with you so do come and find me on LinkedIn or at my website and do check out the ACP-UK and everything it has to offer.

Follow and subscribe so you don’t miss an episode!

Transcript

Paula Redmond (00:04)

Hi, I’m Dr Paula Redmond and you’re listening to the When Work Hurts podcast, which is brought to you by the Association of Clinical Psychologists, the representative professional body for clinical psychologists in the UK. In this series, I’ll be covering the difficult topic of surviving formal complaints, particularly for psychologists. I’ll be bringing you conversations with brilliant guests, offering their expertise, experience and wisdom on this tough topic from a range of different perspectives.

We return this week for the second part of our exploration into the evidence base around the impact of formal complaints on clinical psychologists. For this week’s episode, I was joined by Dr Naomi Hogben, clinical psychologist, who has conducted one of the few research studies looking directly at the experiences of clinicians who receive complaints. Her study focused on early career clinical psychologists in the NHS. And we started off by discussing what drew her to this research topic.

Naomi Hogben (01:12)

I think it’s really interesting. It wasn’t something that I had considered before I think. Prior to training, I had worked in, kind of outside the NHS in a private inpatient facility where there were lots of complaints made by kind of young people, staff, their family, the young people’s families, as well as kind of through the CQC, and I think it was something that was around a lot of the time and kind of witnessed a lot of staff, having a lot of anxiety about their complaints, a lot of kind of media backlash around some complaints and things and also a lot of the young people felt really strongly about some of the things that were being said in the media or some of the complaints were being made that didn’t quite align with their experiences of the care that they’d received. So was, yeah, I guess it’s quite an unusual place where I’d witnessed them from lots of different positions. And then my research supervisor, Noelle Robertson, had kind of a background doing some work with the HCPC and exploring complaints. And it was something we got talking about, and once we started looking into it, realised that there really isn’t very much research at all, and about the experience of kind of a clinician receiving a complaint, there’s quite a lot about patients who make complaints, but not what it’s like for the clinician to receive the complaint. And that’s kind of across healthcare professions. But there is one study that I’m aware of that’s explicitly looked at it from a psychologist’s perspective. So it was kind of a real big gap that we wanted to explore a lot more because we knew and had kind of seen around us the kind of really big impact that it does have, but was just a really interesting gap that nobody seemed to have explored very much in the past.

Paula Redmond (03:11)

Yeah, that’s quite shocking that there’s so little research. So could you give us an outline of your study? Tell us about some of the background details and how you went about it.

Naomi Hogben (03:27)

Yeah, of course. So my literature review as part of my thesis was on kind of broader healthcare professionals’ experience of complaint and that really highlighted the emotional difficulties, their experience following a complaint being made against somebody, as well as raising kind of lots of questions about the, like when complaints are made in a person’s career. So some research has highlighted that newly qualified staff are more susceptible to a complaint being made against them as well as kind of end of career staff, so the real tail ends of a person’s career and the research has kind of highlighted that early in a career people are trying to progress quite quickly, people are often feeling like they’re at their depth, kind of maybe putting themselves in situations that they’re not fully competent in or equally might be just trying kind of a lot harder and maybe not as aware of some of the processes, as some of the reasons for complaints. However, lots of the complaints documented seem to be more around kind of communication difficulties, interpersonal difficulties, and I guess differences in opinion around kind of where a person’s care should sit or how that should happen. And then I guess when we looked a little more specifically at psychologists in the UK, we’re regulated by the HCPC, also a pretty unique position in that we sit within the NHS, a publicly funded service which doesn’t translate or copy across to other countries where research has been explored in the past. So we were really interested in kind of thinking a little bit around that setting of the NHS and whether the fact that your training is funded by the NHS and whether that also would, I guess would potentially be different if you were working outside the NHS and there’s different systems for that. So we decided to sit quite firmly within looking at clinicians that work within the NHS. However, the HCPC data doesn’t differentiate whether a person is kind of practicing privately or within the NHS. However, we were really interested to see how many complaints had been made. We were quite shocked, I think, when you look at the data. I mean, maybe I was just really naive to it, but I hadn’t realized how many complaints are made each year to the HCPC. And then I guess it kind of led me down a bit of a spiral of thinking if that’s how many are made to the HCPC, how many are made at a trust level, or how many are made at kind of a service level, or how many are made that don’t get to a kind of a formal level, which I don’t think I’d quite appreciated beforehand how frequently they are made. And another part that really interested me is where the complaints came from. I think I had this idea that they would come quite heavily from patients complaining about wait lists or kind of the type of therapy that was offered to them or the type of care that was offered to them. But actually the HCPC used to break down why those complaints had been made and lots of them came from places I was quite surprised from, so from other professionals, from trusts and didn’t, yeah, I guess it was just quite shocking to me that a lot of it wasn’t from patients and that’s a bit of a difference for me. I think from the start, they led me thinking that actually there’s a lot of this that isn’t quite explored and isn’t as known about as maybe it should be or isn’t spoken about as much as it should be.

Paula Redmond (07:13)

So, tell us about your methodology. How did you go about setting up the study?

Naomi Hogben (07:19)

So we were looking at using semi-structured interviews. So we developed our interview schedule based off of primarily the research around doctors, but also Kirkcaldy‘s study on psychologists in South Africa. And I guess we wanted to give a space where people could really share their experience kind of in as much detail as they wanted to or were able to, to really understand what it was like for them and give them a chance to talk about it. I think that was something that was really important, particularly considering how many complaints are made, but how much research is out there. It doesn’t seem like clinicians who have experienced a complaint have had much of a voice about their experience of that. And it was really hard to recruit participants. It was one of the things that we had expected considering that it’s not really talked about and considering the lack of research already out there. We didn’t know whether that was one of the barriers that stopped people looking into it more or whether it just was something that hadn’t been thought about to be explored in the past. We went through the route of advertising through social media and giving people the option to kind of agree to the research in any way that they felt they wanted to, so didn’t want to be really specific about. I guess we’d considered recruiting through trust, but didn’t want people to be concerned that it would get back to their trust. So we wanted to do it in a way that people felt comfortable in sharing their experience in an anonymous way. We had explored kind of going through unions and different bodies to support that, however, came up with a lot of barriers there as well, which we thought was really interesting just for thinking about some of that difficulty around talking about complaints and supporting people through complaints, but we were able to get 10 participants who very kindly gave up their time to talk to me about their experiences and shared a lot of really kind of personal information and a lot of their personal experience that was really helpful for the research.

Paula Redmond (09:31)

What were your inclusion criteria?

Naomi Hogben (09:34)

So we were looking specifically at clinical psychologists who had experienced a complaint within their first five years post qualification. 

Paula Redmond (09:45)

And so that could have been a complaint at trust level or HCPC, including both.

Naomi Hogben (09:52)

Yes, so we didn’t differentiate kind of where it had to be made, but it did have to have been a formal complaint. So not something that was just informally managed to kind of by their manager, but something that had been kind of made formally.

Paula Redmond (10:04)

So what did you find? What were your findings?

Naomi Hogben (10:08)

So we had two overarching themes. One that was system indifference, really looking at the, I guess, participants’ experience of having a real lack of support during the complaints process and really feeling unprepared for that. A lot of the participants spoke about how they hadn’t realised that there was, I guess the possibility of experiencing a complaint so early in their career or hadn’t thought about the possibility of experiencing the complaint early in their career. And then when it happened, not always receiving the support that they had hoped they would or thought that they would through the process. So one participant spoke about having a supportive supervisor and how that really made a difference for them. But I think the key take home was around how the complaint was managed really matter to the participants’ experience. We had participants who had to go through the process again because it was so poorly managed the first time. We had participants who, so one participant had a really positive experience where they felt like they were really listened to and their information they felt was collected in a way that felt really kind of unbiased and really supportive of their position. However, the majority of participants spoke about a real lack of communication throughout the process. So always feeling like they were in a bit of a limbo where they didn’t know what was happening with the complaint, which then kind of led to worries about what would happen kind of coming up. But also I think, which I found quite kind of shocking was that they didn’t know or wasn’t aware a lot of the time of when the complaint had even ended or concluded. So they were left in this limbo for maybe potentially longer than they needed to be or just weren’t aware of what the process was or how long it would take to happen or what would be shared when it was happened. So they never really knew where they stood within that and that yeah, I guess really intensified their experience and how they felt at the time.

Paula Redmond (12:29)

Can I just jump in there? Because I guess, yeah, it sort of just made me think about the conversations I’ve been having around this podcast, and that theme has been really, you know, prevalent about people’s experience of the process being really traumatic, actually. And that thing of the lack of communication, the sort of lack of transparency just so much unknown about timelines, about processes, about where to get support, making a very difficult situation a million times harder to deal with.

Naomi Hogben (13:12)

Absolutely and a lot of participants also shared their experience of feeling quite blamed throughout that process because of how it was managed as well, and feeling like the person who was managing the complaint wasn’t always potentially the most suitable person, who didn’t really understand the clinical decisions or the rationale of why they had done certain things or understood the nuances of where they worked or the complaint as a whole, which then made that process more difficult because they were trying to explain themselves, it felt like the person maybe didn’t have all the knowledge they needed to be able to understand that and then didn’t know what happened after that or where it went, which was really difficult.

Paula Redmond (13:52)

Yeah, yeah. And that feels really important because I guess there’s something about complaints being an important part of our healthcare system. You know, we want to have processes in place for people to make sure they’re getting the right kind of care and that professional standards are maintained and all of that. But I guess, and so having the risk of having a complaint is going to be there and not avoidable, preventable entirely. But I guess some of these bits are avoidable, preventable, and not necessarily rocket science to be able to do something about transparent communication and decent timelines and all of those procedural bits.

Naomi Hogben (14:40)

Yeah, absolutely. And I think that’s where a lot of people felt a lot of frustration with how it was managed. And it’s, I guess, as an outsider, sometimes it seems like there are these key things that people could do differently or trusts could do differently and services could do differently. But nobody’s ever quite sure why they aren’t. Potentially it’s not being raised why they aren’t.

Paula Redmond (15:05)

Yeah and sorry, I interrupted you there you were just about to go on to talk about your second theme.

Naomi Hogben (15:12)

Yeah, so the second theme that we found was the question of, I am a good clinician. And this theme really explored the participant’s emotional experience of the complaint. There were lots of very strong emotions felt throughout the experience, both kind of initially once receiving the complaint, kind of this idea of being in disbelief, a lot of stress going into that fight or flight response, that almost panic, but then also throughout the experience of the whole complaints process, lots of participants reported feelings of shame and lots of people spoke about that kind of real difficulty of viewing yourself in that way of shame or naming yourself as… so one participant, the quote that we picked out that we thought was really strong was, they felt really disempowered and like a victim, but that is a disgusting attitude to have because they felt like they couldn’t be seen as a victim or feel themselves as a victim when they’re the one that’s had the complaint made against them. But the way that the process was managed and set up was making them feel like a victim at the same time. And there was this real struggle kind of internally about whether their emotional response was, I guess, acceptable, if they were the one that was having a complaint made against them. And we also found that the emotional experience went far beyond just the complaints process. When talking about their experience with me, for a lot of them, it was a number of years after their experience. However, a few still became emotional during their experience of sharing what it was like for them to receive a complaint or felt a few participants noted that they felt anxious before coming on when they were kind of going back over some of the information they had or documents they had of the time of when they had a complaint or yeah, just that kind of frustration re-bubbling when thinking about their experience and what they went through and how that experience had still sat with them now many years after it happened and it had been finished. And the other kind of really big part of that theme was this kind of worry and fear around their reputational damage. A lot of participants spoke about the impact of having received a complaint so early in their career and thinking about what that meant for them both at the time but also their future. One participant spoke about feeling like people were judging them based on not being experienced enough to have had a particular client in the first place, or participants spoke about being part of a team that didn’t really know you very well and how it potentially may have been different if you were already embedded in a team or in a service and a trust that knew you and knew how you practiced, where you’re trying to advocate for yourself in the complaints process but also trying to advocate for yourself in the service that you’re now working in, and trying to prove that you’re not the thing that this complaint is saying you are on top of the pressure that we all feel as newly qualified psychologists being thrown out into the world of psychology and feeling like we’re never quite good enough or we’re not experienced enough, then having a complaint almost reinforcing that belief and strengthening this idea that maybe they weren’t good enough or maybe they hadn’t been the right person for a particular piece of work, and that really intensifying that emotional experience that they did have. And a couple of participants also spoke about how they still don’t know whether there has been a consequence of having that complaint or whether there’ll be a repercussion in the future. One person stopped practicing as a clinical psychologist and another moved area entirely. And there was that kind of fear of what if they come across somebody from their previous job, or what happens when you change job? Do you have to disclose it? And lots of worries around kind of future impact of their career or if they see somebody from that time.

Paula Redmond (19:45)

So it still felt very live for the participants, even though it was something that happened some time ago. It feels like they were still, as you said, really still holding that and still really activating a threat system for them that’s hard even to talk about it with you. And it makes me just think about the… I suppose that I sort of work with a lot of psychologists, you know, even very, very experienced ones and that imposter syndrome is never far away even if you’ve been working for 30 years. But that early career time is such a vulnerable time for that developing your sense of self as a profession and you’re often still needing to recover from the experience of training. Gosh, such a really vulnerable time for something like this to happen in terms of how it shapes how you feel about yourself as a professional, as a clinical psychologist. And yeah, that comes through.

Naomi Hogben (20:54)

Yeah, and I think that combined with the lack of support that a lot of the participants felt. And I guess one of the things that Noelle and I reflected on from the findings was around, I guess, the difference from when you’re quite heavily supported in training as a trainee on placement, you’re fairly well protected, you’ve got a lot of support on placement, you’ve got support at the uni, you’ve got like a really close cohort and how then you’re newly qualified and you don’t see your cohort as much and suddenly you’re not protected as much and there’s lots of differences between kind of how much support is offered or how much supervision is offered, and I guess the impact of then receiving a complaint when you’ve already lost a massive support network that you had on training to them being newly qualified and then hit with a big complaint and feeling really unsupported through that, what that must be like at that point as well.

Paula Redmond (21:51)

Especially, I guess for most people, kind of, reaching qualification, you know, has seemed like this holy grail, you know, that you work so hard to get there and it’s, you know, going to be this amazing experience. You know, you’ve probably put 10 years plus into getting to that point, striving for that. And to have this experience at that stage must be pretty devastating. And there’s these two parts, there’s the trauma of receiving a complaint, and then just like with all traumas, how that’s responded to by your context really matters in terms of how you can heal from that, how you can process, how you can think about it and the shadow that it casts for your future life. And I guess I’m just wondering, that relationship you have with the NHS, with this profession that you’ve worked so hard to become part of, and yeah, really sad to hear as you say that some people think that couldn’t be, wasn’t repairable, wasn’t possible to continue.

Naomi Hogben (23:03)

I think there was a big disillusionment of the NHS and what it meant to be working in the NHS or whether you would or wouldn’t be supported through experiences such as kind of receiving a complaint that it sounds like happened really quickly for some of these participants who had experienced a complaint so early in their career that came, as you’re saying, as quite a shock at that point and didn’t quite meet the expectations of what they were expecting. And then having to find that support elsewhere.

Paula Redmond (23:38)

And how did, what were your observations on how the participants conceptualised the complaint in terms of whether they were a, you know, whether there was a level of kind of accepting the grounds of the complaint or how they related to the complaint itself?

Naomi Hogben (23:59)

I think it varied between the participants. I think some spoke about working in quite a specialist area where there was always this idea that people may potentially be unhappy with the outcome of their care they had received or an assessment that had been made. And there were other people who, I guess it almost felt like we’re looking for a place to place the blame, and almost saying that they saw the signs really early on that this person may have potentially made a complaint or that type of presentation from them or their family may have made a complaint. And other people who were just really shocked by the experience and didn’t quite know how to make sense of it and then would kind of slip into almost self-protective measures with their practice moving forward, and worrying about whether it would happen again because they’d almost been blindsided by it happening in the first place.

Paula Redmond (25:01)

I think it’s really complex, isn’t it, that the sense of, again, how we view the role of complaints as being important and, you know, needing to accept that we can screw up and that we can make mistakes. But I suppose I’m thinking about that lack of support bit, that if you haven’t got safe spaces to reflect on this process, you can’t really think about it in that way. You’re not going to be able to own what maybe is your part in that process will be too much maybe and it would be very natural to be locating that elsewhere whether that’s the problem patient, the vexatious family, the system and all of that may be playing a role but hard to sit and think about your own part in this if you’re not supported. Which is sort of ironic because the whole point of the process is that we learn, I guess, and that systems can learn doesn’t feel like that’s set up well for that, either for systems to learn or for clinicians to learn through this process.

Naomi Hogben (26:17)

Yeah, I think it’s really tricky. I think it, again, it varied quite a lot in terms of, as you were saying, the participant who felt quite supported and felt like they had a supervisor who did check in and ask things, the experience was very different from kind of participants who felt very isolated during the experience and kind of some people managed to find kind of colleagues they knew in other areas or other services that they could lean on, whereas other people said that they would just almost like ranting emotionally at family, but not really having space to actually explore what had happened or what was going on, further than just the emotions they felt in the moment, because that’s what they could talk about with people who don’t have an understanding of their job or career or kind of within the confines of confidentiality. But there doesn’t seem to be, I guess, our participants were from kind of across the UK in very different services. And there doesn’t seem to be like a universal process that is identified or followed to support people. So there are these really big differences in people’s experiences because of that.

Paula Redmond (27:35)

Yeah. And I’m curious for you what this process is like as someone who, when you were doing this, was still on the, you know, still on the path to qualifying, a trainee, stepping into this profession. What’s it been like for you to do this work?

Naomi Hogben (27:55)

I think it’s really interesting. I think initially at the time I was like, wow, like this happens a lot. And then kind of almost parked it to the side, I think, in the realm of doing a thesis and managing placement and kind of doing the busy life of a trainee. And then it wasn’t until kind of more like around, like preparing for my viva, that I sat and thought about it a bit more and was like, oh, actually, maybe I do need to think about this a bit more, like it does actually happen a lot and it has really impacted on the participants who are really kindly shared their experience for a long time after it’s happened as well. I think it definitely made me join a union straight away and think about kind of, yeah, I guess it just made me a bit more aware of kind, of where I work and what support is in place. I think I was really aware when I was looking for my first qualified job, thinking about kind of who was going to supervise me and what level of support I was going to receive and I guess, yeah, thinking about the trust probably more than what I think I would have if I hadn’t done this as my research and kind of explored into the depths a lot more, which I think is, yeah, it’s really interesting when you sit and think about it now, particularly kind of when I was thinking of like kind of going back through my research before meeting with you, thinking actually like, I’m nearly two years post-qualifying, some of these people had already experienced a complaint by this point, and to me, that just feels kind of crazy. Like, obviously I know that it can happen, but I don’t know, like, how I would manage that. Kind of being where I am now, like, I feel like you’re still so new to the profession, whilst you’ve been doing it for a few years and you’ve been building up your skills and things, it still feels very new, I guess there’s still that imposter syndrome is still very much there, that I can understand why it has such a big impact when it happens at this point in a person’s career.

Paula Redmond (30:01)

And what do you think for people who might be listening to this, any kind of key messages you’d like to get across for, I guess, other psychologists, maybe even newly qualified psychologists, trainees, training courses, trusts, the HCPC itself, what would you like people to really hear?

Naomi Hogben (30:23)

I guess just this idea of talking about it, I think the thing that seems to really make a difference is when you have that support network around it. One participant reflected really nicely on how it’s now they’re much further down their career and they’re supervising other colleagues and professionals, how they’re able to use their experience when it’s happened to another person to share and be like, this has happened to me. Like, I know that it’s really difficult and how much they feel like that’s valued and really appreciated at the time. And I think it is still such a taboo subject and it comes with a lot of shame and a lot of feelings of kind of blame and hurt that people find really difficult to share. But if we’re not sharing it, then we can’t also have like, receive some of that support or be able to find some of that support, I think kind of as colleagues being able to talk to our colleagues, talk to supervisors, talk to any staff that we might be supervising around any experience of complaint, or just the idea that it can happen. And thinking about making sure people know what those processes are, that anybody in the service your working could have a complaint made against them. It’s like being more transparent, what is the process around that? Where can people get support from, both within the service, through the wider trust, other services that can support them, such as unions and kind of wider psychology services that are out there. Thinking about that process and how if you’re the person that’s looking into a complaint, how you really clearly communicate what’s happening currently, what the next steps are, when that outcome has been made, kind of what that means for the person that’s involved, because that really does matter and it really does make a really big difference to the person’s experience of having a complaint made against them. So I went to the University of Leicester and one of the things that Noelle and I have been doing is talking to third years and having a teaching session on complaints and just talking about this does happen. We’re not trying to scare people, we’re not trying to say that this is definitely going to happen to you, but trying to just raise that awareness that it does happen. So it’s not so much of a shock if it were to happen. And thinking with them about looking at those types of things, like who are your support networks? Who can you go to for support? Making sure that you know who your supervisors are, who these people are that you can go and talk to when they’re at that kind of point. So we try to do it kind of earlier in third year, before they start looking for jobs. So the kind of things that they’re thinking about going forwards so that, yeah, it doesn’t become this massive shock factor when it may happen at some point in their career. And then I guess it’s the more the process side of things, just how do we become more transparent? How do we let people know what’s happening, how do we support people through that? How do we make that more structured instead of putting everything on to the person who’s already going through a really stressful time to have to seek out these things? How do we make sure that it’s offered alongside the process of investigation that needs to happen? How do we then have a place for reflection afterwards so that people can do some of that thinking about what can be done differently and thinking about their emotional reaction of that and the impact that has on their work.

Paula Redmond (33:45)

It just sounds like there’s these two key parts around the pragmatic sort of stuff around the process itself and the communication and the transparency and, you know, having clear pathways to access support, but also the availability of emotional support and that those two things are really important. I think I really like how you phrased it earlier about sort of how it’s managed really matters, that that really, really has an impact on the impact on how the experience lands and affects people and it seems like there’s a lot we can do around that that would really help.

Naomi Hogben (34:30)

And I guess just giving a voice to people to share what their experience was. Just because it may not be happening right now doesn’t mean that it hasn’t happened already. There may be psychologists out there who had a complaint early in their career, but that was many years ago. But I’m sure talking to people through this research has kind of helped me to see and understand that that’s still having an impact now. So just because it’s not something that’s happened in the kind of near past doesn’t mean that it’s not still playing on somebody’s mind and impacting on them as a clinician. So thinking about, I guess a little bit more long term around how that’s kept on the radar and how people are still checking in around that.

Paula Redmond (35:12)

And I guess if people are listening and realising that, you know, they’ve been through a complaint process and it is still something they’re holding, that, you know, getting some support for that would be a good idea, maybe.

Naomi Hogben (35:26)

Absolutely, and I think if we were more open about talking about when it did happen and there was less shame around, we’d probably realise that lots of people we both work with now and have worked with in the past have also had this experience, but everybody’s almost suffering in silence, which is making that isolation, this feeling, much worse.

Paula Redmond (35:47)

And I guess we don’t hear or see those stories of people who’ve been through it and survived and it’s been okay. It’s kind of this terrible black hole that you might be fearful of or find yourself in the midst of and there’s no, because it’s not talked about, there’s very little to hold on to to know that you can get through and it’ll be okay. So yeah, I think talking about it.

Naomi Hogben (36:14)

And it doesn’t necessarily mean that it’s going to happen again.

Paula Redmond (36:16)

Yes, yeah. Well thank you so much Naomi. Is there anything that I haven’t asked that you wanted to add?

Naomi Hogben (36:23)

I don’t think so. I think I’m just interested to hear the experiences of everybody else that’s in your podcast series. I think it’s such an important topic that we do start talking a bit more about. So thank you for the chance to come and share and talk about it. I guess I’m raising it as one of the things that we should be doing. So thank you for the opportunity to help me to do that.

Paula Redmond (36:47)

Great, well, you’re so welcome. Thank you for coming along.

Thank you for listening. If you’ve enjoyed this episode, please support the podcast by sharing it with others, posting about it on social media, or leaving a rating or review. I’d love to connect with you, so do come find me on LinkedIn or at my website, and do check out ACP UK and everything it has to offer. All the links are in the show notes. Thanks again, and until next time, take good care.

The post The impact of complaints on Clinical Psychologists Part 2: Early career experiences appeared first on Dr Paula Redmond, Clinical Psychologist.

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Full transcript below

In this conversation Clinical Psychologist Professor Noelle Robertson discusses the profound impact of fitness to practice complaints on psychologists and other health professionals. She outlines the research in this field which highlights the emotional toll these complaints take, the inadequacies of support systems, and the long-lasting legacy they leave on practitioners. The discussion also touches on the increasing trend of complaints, the importance of preparing for potential complaints in clinical practice, and the need for open discussions within the profession to foster better support and understanding.

Noelle mentions the published paper: How do healthcare professionals experience being subject to complaint? A meta-synthesis of reported psychosocial impacts

About the speaker, Professor Noelle Robertson, Professor of Clinical Psychology at the University of Leicester: I am a chartered clinical and health psychologist who has worked in clinical training for over 20 years, having managed an NHS department of Medical Psychology before that. I have had a longstanding interest in working with, and conducting research on how we are affected by the work that we do. Having worked with HCPC as a professional registrant have become increasingly aware of the impact of complaints on health professionals, and have sought to explore this within my own profession.

I’d love to connect with you so do come and find me on LinkedIn or at my website and do check out the ACP-UK and everything it has to offer.

Follow and subscribe so you don’t miss an episode!

Transcript

WWH S7 E1 Transcript

Paula Redmond (00:04)

Hi, I’m Dr. Paula Redmond and you’re listening to the When Work Hurts podcast, which is brought to you by the Association of Clinical Psychologists, the representative professional body for clinical psychologists in the UK. In this series, I’ll be covering the difficult topic of surviving formal complaints, particularly for psychologists. I’ll be bringing you conversations with brilliant guests, offering their expertise, experience and wisdom on this tough topic from a range of different perspectives.

I wanted to start this series by looking at the research evidence and we’ll be doing that over two episodes. In this first part, I spoke with Professor Noelle Robertson to explore what the literature can tell us about the impact of complaints on clinical psychologists and other health professionals, as well as her own personal and professional insights. Noelle also mentions the work of Dr Naomi Hogben, who I spoke with for part two, which focuses on research into the experiences of early career clinical psychologists who have received complaints. So make sure you tune into that episode too. I began by asking Noel to introduce herself.

Noelle Robertson (01:21)

I am a clinical and a health psychologist. I’m currently a professor of clinical psychology at the University of Leicester and I’ve had a long-standing interest in issues to do with governance generally from very early in my career, and more recently have acted as a professional registrant for HCPC in examining fitness to practice for clinical psychologists, and also have undertaken fitness to practice work within our medical school at the University of Leicester. So I’ve had a fairly long standing interest in this. And I think I, in an effort to be entirely candid, I experienced a complaint, which was a vexatious complaint, nevertheless, early in my career. And I suppose I’ve had a long standing interest in the impact that that had on me. And then obviously having been participant in fitness to practice processes and being involved in clinical training for a very long time, I’ve become aware of the impact of complaints that those in receipt of them can be very blindsided by the experience. And I suppose I became more determined to understand that better and think about ways by which we support practitioners to sustain themselves during complaints processes.

Paula Redmond (02:59)

So it’s really interesting to have that perspective, you know, personally, and then kind of supporting other colleagues, trainees, and also having an insight into how that HCPC process works. So I wonder if we could just jump into the sort of key question about what your observations are through this experience of the impact of fitness practice complaints on psychologists specifically.

Noelle Robertson (03:28)

Yes, well, the evidence for psychologists specifically is relatively circumscribed. Myself and my colleague, Naomi Hogben, published a paper last year where we reviewed the experiences of health professionals who had been subject to complaints. And perhaps unsurprisingly, the bulk of the papers that explore this focus on medical and nursing professionals, so that the evidence base around psychology comes from one substantive study that was conducted in South Africa where healthcare systems are rather different. So prompted by that thinness, we decided to have a look at what was out there in terms of health professionals. And I think what’s interesting is that the impact of complaint irrespective of the country, the profession, the responsiveness of the fitness to practice processes in that jurisdiction are remarkably similar, so that complaints are experienced as highly aversive emotionally, that when practitioners are asked in detail about how well supported they feel they have been during the process, there’s very little evidence of support that’s felt to be meaningful and helpful. And I think the thing that I would also emphasise is that a complaint, and I can talk to personal experience about this, has a lengthy legacy for people. That it’s not something that is easily dealt with over a short period of time, that it tends to influence practitioners for a long period of time. So I think overall, those three themes about intense and aversive experiences, a perceived inadequacy of support whilst going through a complaints process, and that having enduring consequences are the key messages I think I’d want to share.

Paula Redmond (05:43)

And that’s interesting that that contrast or, you know, the very aversive experience of having a complaint, the high levels of distress, are set alongside a lack of support, that there’s a real lack of, you know, I guess that being matched up that the emotional impact, the toll it takes on people. Do you think that, do you think part of why it’s so difficult is because the support is so bad? Or do you think there’s something about it not being recognised or talked about or acknowledged enough?

Noelle Robertson (06:25)

Well, I think it’s interesting that there is remarkably little evidence that the impact of complaints on practitioners is relatively under-researched. So that may reflect a number of things. I think there’s an interesting disjunction in modern healthcare systems where we do have clinical systems that seem to be, you know, in many respects, rightly, so intolerant of error. And yet there is an understanding of clinician fallibility. And I think that’s probably worthy of a bit more exploration. But I wouldn’t like to ascribe the impact solely to a lack of support. I think we can return to that. I think particularly for people who deem themselves to be caring professionals, it’s quite an assault to the self to feel that you might have done harm. So I think self-identity is challenged, professional identity is challenged. And I think the spectre of being stigmatised or shamed within your profession as being inadequate is powerful, as is, to be frank, and the research in non-NHS settings is interesting, and this is a curtailment of livelihood. So people are obviously fearful that their career is going to be curtailed or ended and that they are going to be somewhat vulnerable professionally and financially.

Paula Redmond (07:58)

Yes, it’s quite potentially quite a sort of existential crisis.

Noelle Robertson (08:02)

It is, it is potentially. And I think the, you know, there’s no particular blame ascribed to this, but the systems that then people enter may be quite unfamiliar to them. They’re not much talked about in training. Certainly as a trainer in clinical psychology, whilst we do some teaching on this, I’m not sure how widespread that is. So that the preparedness for difficult therapeutic engagement and difficult therapeutic conversations, I think is an implicit part of training. But I think that preparation for the potential for complaint is perhaps less developed. So, you know, we may have scope as a profession to think about better preparation and expectation management.

Paula Redmond (08:52)

Because I guess that shock is a big part of what people might feel.

Noelle Robertson (08:59)

Yes, shock, fear. I think the evidence would tell us that there’s quite a lot of ruminative anxiety, particularly if you’re being held in limbo during an investigatory process. Within the literature, you hear, you know, you see narratives of people describing the experience as worse than the death of a close family member that people do describe being quite traumatised from the experience. And certainly consequences, which I think is, the consequences of complex are perhaps better described, are to do with avoidance and defensive practice, which are understandable, but it may well be that actually we are losing good clinical skills because of the intensity of the experience.

Paula Redmond (09:56)

And I know that the research basis you’ve described is limited, but does that fit with your experience of people that you’ve kind of come across in your career who’ve gone through the complaints process?

Noelle Robertson (10:14)

I think seldom have I heard people talk positively about the experience. I think some of us see these processes as learning experiences. And the other thing I think I should emphasise, of course, much of the angst is carried by an individual where there may be wider organisational and systemic feelings that are less attended to. So I think, whilst I think, as is often the case, the individual holds this sense of responsibility, I should also say that complaint processes are often levelled at wider issues within health services. I think, forgive me, I think the data at the moment suggests that over 40 % of complaints are targeted more generically at the delivery of health care than they are the specific practitioners within it.

Paula Redmond (11:12)

And am I right, I think that there’s something you mentioned in your paper that there’s been an increase in complaints in recent years?

Noelle Robertson (11:23)

Yes, it’s a modest but growing pattern.

Paula Redmond (11:30)

And how do you understand that?

Noelle Robertson (11:33)

I think there are probably a variety of factors going on. I think if we think about why complaints arise, it’s often because expectations aren’t met. I mean clearly there can be deeply suboptimal care, but many complaints can arise through communication issues, expectations not being met and that can be within systems, colleagues, managers, as much as it can be clients who express dissatisfaction. I think it would be no surprise to say that the health service has been struggling for a number of years in the global north as the challenges of aging populations, cost containment, staff distress and burnout, you know, there is wider opportunity, I think, for distress to be expressed and complaints are part of that I suspect.

Paula Redmond (12:35)

So you’ve outlined there some of these, the individual, the sort of aversive experience of having a complaint and some of that really difficult and distressing impact on the individual. The other part that you mentioned was about the support structures in place and what people have reported that that has, I suppose, not been so helpful.

Noelle Robertson (13:01)

I think the evidence would just suggest that there is an absence of support, that there’s a lack of clarity about the processes that people become involved in. That sometimes, of course, if there’s a very serious complaint, then professionals will be restricted in terms of the professional activity that they can undertake. So there’s time to kind of be held in this limbo, which can be difficult. And I think because we don’t discuss likelihood of complaints and norming that as a possibility, then people may feel reluctant to expose the difficulties that they’re experiencing. I think Naomi’s work, looking at early career psychologists particularly, is instructive because as people are transitioning into the early stages of their career, they’re obviously concerned about how they might be viewed by others because people don’t know them well, they haven’t yet established themselves. So I think that that point, the points of transition can be particularly difficult for people, but the research base across professions, which would include psychology, is that in the event of a complaint, there are not really many things in the way of providing structured professional support. So anecdotally, what people talk to is talking within their families, which of course may put pressure on those systems and there may not always be sufficient understanding of the pressures on the clinician. And I think that often those who are in the process of being complained about will seek out peers who they know have also experienced something similar. So I think the scope for looking at peer support, but again, if we don’t talk about these things, then that might be covert. So I suppose we have to have a discussion as a profession about how open our engagement is and what reflective processes we encourage about this really from training onwards.

Paula Redmond (15:29)

Yes, I feel for me, I’ve been qualified over 15 years and these are the first discussions that I’ve had about, you know, about complaints. It’s really interesting, that.

Noelle Robertson (15:45)

I think there are opportunities. It’s very difficult. I mean, you know, as a trainer, being a clinical psychology trainer for a long time, finding sufficient psychologically safe spaces to discuss this sort of stuff when you’re under constant scrutiny and evaluation is an interesting paradox that you have to work with. But I’m a great believer that I think within the sorts of reflective processes we are good at, then I think we can talk about our fallibility and we can talk about what happens in the event of, and we can perhaps learn better to understand how and why complaints can arise and our role within the structures within which we work in terms of governance. And I think, you know, foster something that acknowledges the rigour that is expected of us absolutely as practitioners, you know, to be fit to practice means that we provide excellent service to our clients and that we maintain confidence in the profession. But we need to think about how we support people compassionately as they go through investigatory processes. I’m very struck that I’ve done work with jurors in the court system and the idea of acknowledging that through adversarial systems we provide trauma-informed support, I think, you know, thoughtfully be applied to these sort of contexts as well.

Paula Redmond (17:20)

The third thing that you mentioned that’s come up in the research is around the legacy of complaints. Can you say a bit more about that?

Noelle Robertson (17:30)

The legacy, what the evidence tells us. Well, it tells us, as I say, that the impact on self and professional identity lasts for a considerable period of time. When we looked at the research evidence in extremis, in terms of legacy, some practitioners described themselves as moving from a competent professional to becoming a pariah. And I think it’s most obviously demonstrated in, and again, the literature is mainly medical in defensive practice, what would be termed defensive practice, but within our own domain, I think you could see people avoiding particular contexts within the workplace, particular client groups seeking out additional support to maintain themselves in areas in which they wish to continue to work. But in extremis, people will leave the profession. There’s plenty of evidence that people will walk away. It has been that destructive. And that’s a great shame. But I do want to put in a caveat because I think it would be very easy when we’d consider the impact of complaints on us as practitioners to fail to consider the legitimacy of those complaints. So, it may mean many of these complaints may be entirely legitimate. The difficulty at the moment in understanding clinicians responses to complaints is we don’t have contextual data. The paper that we published did not provide us with contextual data on the nature and legitimacy of a complaint, but you could well imagine that the severity of a complaint or some very adverse outcomes might well have more damaging consequences for the practitioner. But we don’t really, from the qualitative narratives we have from healthcare practitioners, we don’t have that data. But in the instance, for example, if a complaint does not proceed or is found to be unsubstantiated, in terms of legacy issues and individuals holding that, then I suppose there is a concern that if you are expending a lot of energy managing your own distress, then of course you render yourself potentially more vulnerable to less optimal care if you’re not attending, or if you need to take time away then that’s a huge loss in resource to the health service if distress means that you take time away.

Paula Redmond (20:13)

And I suppose, I think that’s such an interesting point about the legitimacy of the complaint. And I guess that could be quite a subjective process as well in terms of how the person who’s been receiving the complaint relates to it, whether or not it’s found to be, whether there’s consequences or, you know, whether there’s a sort of case to answer or not, people, you know, whether they relate to it in a way that, where they hold some responsibility for what happened or not, I imagine would really impact, yeah.

Noelle Robertson (20:49)

Yes, I think that’s true. The difficulty and the hesitancy I’ve got at the moment is actually we just don’t know that much about psychologists. Much of the evidence that I’m drawing on is predominantly from medical and nursing contexts and often those which are high risk. So, for example, obstetrics and midwifery, staff with those contexts are prominent within impacts and of course you can imagine if there have been terrible things happened in terms of outcomes then the impacts are profound for clients, patients and the clinicians. But we just don’t know enough about psychologists.

Paula Redmond (21:36)

And why do you think that is? Why do you think there is such a limited research?

Noelle Robertson (21:41)

I genuinely don’t know. I think I would be speculating. As I said earlier, I think there’s this interesting disjunction between clinical systems who are rightly focused on the highest quality care that can be delivered for all of us as patients, and therefore wishing to ensure that human error or dysfunctional systems are mitigated. And yet there is an acknowledgement of clinician fallibility. And I don’t know at the moment, it may well be we’re very focused on the pressures of getting it right without considering that we need to balance that with all of our human frailty doing the best jobs that we can in systems that are challenging. But don’t know, sometimes I do wonder why areas aren’t examined. And I don’t think I have any easy answers. I’d be delighted if people would like to step up to the plate and start doing some research with us, you know, to explore this further.

Paula Redmond (22:58)

In wonder, again, in terms of the legacy of these experiences, what your thoughts are on how that may impact people’s relationship to the NHS as a system.

Noelle Robertson (23:11)

Oh that’s interesting. I don’t know because I suspect this is evolving. You know, I’m someone who’s been, you know, I’m a product of the late 80s and early 90s in training, so I’ve been qualified a long time. And, you know, because of my own background as a Scot, as a child of the 70s, I guess, then, of course, I view the NHS, if not quite like the national religion, then I’m deeply, deeply committed to its role in improving all our lives. And, you know, remember conversations with my father about what things were like in rural Scotland before the advent of the NHS. But of course, that’s my cohort and my parents’ cohort. How people view the NHS now, I’m not quite sure. I do think there is an expectation though that as your employer, you know, that your strengths and vulnerabilities are supported to be the best clinician you can be, and if you find yourself experiencing a complaint, then you would hope that your employer would provide support. I’m not sure that from our own experience of Naomi’s work on early career NHS psychologists that that’s what they felt. And I think that, you know, benignly there is huge variability in the quality of support available through what is a very large organisation. So there’s likely to be huge local variability. But, you know, it does often feel that in striving to deliver the best quality care, there can be a fear that’s engendered rather than an understanding. And I do understand that this difficult drive to ensure that, you know, when you receive NHS care it’s the best that it can possibly be and therefore where it falls short. But equally, you know, I hope what I haven’t suggested today that this should rest on the shoulders of us as individual practitioners, you know, there are clearly systemic and organisational features that are occurring within what has been an under resourced organisation, series of organisations for a long time that are particularly challenging.

Paula Redmond (25:48)

And what about your experience as a professional registrant within the HCPC? What kind of lens has that brought for you in thinking about this?

Noelle Robertson (25:59)

That’s an interesting question. I think it has offered me insight into some of the significant organisational and systemic issues in which psychologists are endeavouring to deliver best care. I think it has shown me the best and worst of practitioner behaviour. It has shown me the sensitivity and rigour with which the investigation process is undertaken and the very excellent legal advice that we have as panel members. And in recent years, it has revealed, as with many of our systems, a lengthy waiting time before people are necessarily seen. So there are parallels with our legal system at the moment in terms of a backlog of casework and staff within the tribunal service who are having a lot to do to juggle and do that. But I think it’s felt very worthwhile to do that. I would suggest to colleagues though to consider it as something that they could both bring their skills to but also learn from. I want to encourage people to consider actually becoming a registrant panel member because they can bring their formulation skills and learn and then be able to disseminate to others how these processes happen.

Paula Redmond (27:30)

Great, yeah. So what do you think is important for psychologists to know in terms of, you know, what you mentioned, preparing ourselves for the possibility that we might face something like this in our careers?

Noelle Robertson (27:46)

Well, I think, you know, we do a lot of work in preparing ourselves for challenging clinical environments and potentially difficult therapeutic engagements. So I do think as we learn, there ought to be an orientation starting in training to prepare and expect the likelihood of a potential dissatisfaction with something about what you do, that it might not ever reach the status of a formal complaint, but I it’s wise for us to start at a very early stage to say this is the type of work we do, we’re in a regulated profession, people have recourse to express their dissatisfaction. And that’s not an unusual part of being a regulated profession. I think that’s norming it. I think it’s important to understand, as I said earlier, the how’s and why’s of how complaints can arise, how dissatisfaction can arise and is expressed and encourage transparency really from the early stages about that. I think one of the key elements in training an early career is to understand how governance processes operate within your employing trust. And I think it is quite useful too, to have an understanding of if and when complaints arise or are formalised. mean, there are stages to this, obviously, then what processes do those encompass and what would a process entail if you were experiencing that? I think, you know, I could go on, I think, reflective space with mentorship, particularly early in career. And again, because you, I think, want to discourage the notion that this is necessarily an individually held locus or responsibility, actually, to discuss some of the challenges about working in difficult environments and what that might expose you to in terms of risk. Because I think one of the things I have seen through regulation work is people getting themselves into a pickle because they’ve actually been endeavouring to do their very best, but that might have meant, for example, that they’ve worked out with their competence or they have breached therapeutic boundaries or whatever. But you can almost see the system in which they’re working as they try to negotiate some of the things they’re trying to do, I think, in order to be most helpful.

Paula Redmond (30:18)

And I’m curious about what advice you might give to anyone who might receive a complaint having been on both sides of that experience.

Noelle Robertson (30:35)

I, that’s quite difficult at the moment. I think, I go back to in a sense to my previous point, I think you have to, perhaps better than I was, you know, five year qualified, be prepared for this as a possibility. I know that’s the kind of preemptive element before it actually happens to you. I think, you know, from the earliest work I did before I was working clinically, I researched in audit and governance and was somewhat familiar with quality management approaches early in my career, and I think I always felt that candour, transparency, openness, seeking out support, understanding one’s own fallibility was really important. I caveat that though, because I think, you know, for some people having talked over the years to people who have experienced complaints, it’s where do you take that? So I think, you know, as a profession, we need further discussions about those spaces and those supports that can be made available. I mean, you know, we have obviously organisations like ACP, you know, but there’s an issue about being able to discuss this at its earliest. And as I said earlier, there is suggestion from research evidence that utilisation of peers who have been through the process, so whether actually people identify themselves as mentors again pre-emptively might be a possibility. I think avoidance is not a strategy that’s going to work.

Paula Redmond (32:11)

I guess there’s something with all of this about just talking more about it. And as you said, you know, being able to have and create spaces where that feels safe to do so, I guess to, you know, just to hear, you know, those stories of peers who’ve been through it and survived and, you know, that kind of, I can imagine it must be a very isolating experience.

Noelle Robertson (32:37)

Yes, I think it can be. And I think we can do better as a profession. I mean, we are thoughtful, we are reflective, we are, I believe, you one of the most open of health professions in terms of our consideration of issues, and we are creative. And of course, we draw on best evidence. So I think, you know, with all those bits of scaffolding, I think we can do better.

Paula Redmond (33:07)

And just sort of along those same lines, whether there’s anything in addition you would say about, you know, those supporting colleagues who might be going through something like this, whether that is a trainee or a supervisee or those working in staff support who might have a clinical relationship with another psychologist.

Noelle Robertson (33:29)

Yes, I think I would welcome further discussion actually with colleagues. I don’t think I have, you know, specific answers myself. I think there are fora, there are fora where we could discuss the best way forward or create fora to discuss the best way forward, because clearly I realise, you know, I’ve been talking about a narrative that actually could be potentially fear inducing, you know, that the evidence is out there that being subject to complaint is not a pleasant process. And I think we can have discussions about how we can make it more endurable and actually that fosters learning and a capacity to thrive in an environment where that’s a possibility. So yeah, I think I’m not a guru in these matters, I do think I would welcome conversations with colleagues about their views because again that’s what psychology is good at, you know, coming together to formulate from numerous perspectives what could be better.

Paula Redmond (34:42)

Thank you for listening. If you’ve enjoyed this episode, please support the podcast by sharing it with others, posting about it on social media, or leaving a rating or review. I’d love to connect with you, so do come find me on LinkedIn or at my website, and do check out ACP UK and everything it has to offer. All the links are in the show notes. Thanks again, and until next time, take good care.

The post The impact of complaints on Clinical Psychologists Part 1: Evidence and insights appeared first on Dr Paula Redmond, Clinical Psychologist.

Health professionals often advise patients and clients to prioritise self care but regularly find it hard to follow their own advice.  Mindfulness is one of those self care tools that can feel like another stick health professionals beat themselves with. You may know it’ll help you manage stress, but just can’t get round to fitting it in. Or perhaps you tried it but couldn’t clear your mind of thoughts so it seemed like a waste of time. 

Despite mindfulness being an evidence based tool used in the NHS to reduce mental health problems, many people, including health professionals, have misconceptions about it which prevent them from using it.

This blog will clear up some common mindfulness myths and help busy health professionals find ways to use it that suits them, even on a busy day. But first the basics.

What is mindfulness and how can it help manage stress? 

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Mindfulness increases a person’s awareness, with a sense of curiosity and acceptance, of what’s going on in the present moment. This includes stuff outside you (i.e. what you can see, hear and feel) but also inside you (i.e. your mind, body and emotions). Being more aware of these things in a curious and accepting way helps us to manage our thoughts and feelings and therefore respond to stress more helpfully. 

However, the focus on “present moment awareness” leads to the first misconception – that you are meant to be clearing your mind of all thoughts. 

It’s impossible to clear your mind of thoughts and people can have very busy minds and still practice mindfulness (like me!). But when you are mindfully aware of your thoughts you can take a step back and react differently to them. A head full of “shoulds” or self criticism becomes more manageable when we label them as “”just thoughts”. 

But it doesn’t end there. In fact when it comes to managing stress, what happens from the neck down is just as important. 

Stressful situations create physical sensations in the body that, if we are not aware of them, will build through the day and get worse. The magic of mindfulness is that you become much more aware that this is happening and can take steps to release stress from your body by relaxing your muscles or taking some deep breaths. So even though it can’t change the huge, work based demands on health professionals, it can help you change your response to those demands by helping you regulate stress in the body.

Another myth is that you have to fit in long meditations which is another big no if you’re already feel short of time. But although a regular planned meditation will certainly help you to be more mindful, weaving mindfulness practices into a busy day can also be effective. A “ mini mindful moment” really can be done anytime, anywhere by loosely following these steps: 

How to practice mindfulness anytime, any place  

• Choose an “anchor” to focus on i.e sounds, feet on floor, taste of tea. Really notice the details of that. When (not if) your mind wanders away, simply acknowledge and label the thoughts i.e. I am having lots of busy thoughts, I am noticing I am being harsh on myself.
• After a few moments bring attention to your body as a whole. Briefly scan from the head downwards, paying peculiar attention to where you usually hold tension, e.g. shoulder neck and jaw.
• Spend a few moments naming the feelings in the body e.g. I am aware I am feeling stressed, I am noticing anxiety.
• Try to release stress from the body i.e drop your shoulders, loosen your jaw, take some deeper breaths.
• Return to the chosen anchor for a few moments and then carry on with your day.

Suggestions for mini mindful moments on busy days 

Here are some suggestions for mindful moments that busy health professionals can easily weave into their day:

• When showering in the morning, notice the water against your skin, the sound of the shower or the smell and feel of soap.
• When having your morning coffee, notice how it looks and tastes as well as the warmth of the cup in your hands.
• On your commute, instead of looking at your phone or catching up with emails, set a timer for 5-10 minutes. Use that time to focus on your breath and/or body and build in a short meditation practice.
• When catching up with client notes at your desk, notice your feet on the floor and body sat on the chair. Stop what you are doing and focus on the sounds you can hear around you. Zoom into the fine detail of the buzz in the office such as chatting and photocopier etc.
• If you’re on your feet a lot, tune into the soles of your feet a few times a day. Notice the contact points they make with the floor and then expand your awareness to notice the rest of your body too.
• When having lunch, instead of eating and working, spend time looking, smelling and tasting the food. 
• On your commute home, scan your body from head to toe and let go of stress before you arrive home.

Practising little and often, in the middle of everyday activities, is a great way to start being more mindful that doesn’t take up extra time. It can be tricky to remember at first, so it can help to set reminders or commit to 1 or 2 activities you will do mindfully each day. The more you make an effort to be mindful, the more it becomes second nature.

For more information about mindfulness and how to get started visit Mind. 

Rebecca Stambridge is a mindfulness teacher and integrative psychotherapist. She spent many years working for busy national and local mental health charities as a project manager but now runs the private therapy practice “Contentedmind” where she specialises in anxiety and low self esteem. 

The post How health professionals can manage stress with mini mindful moments appeared first on Dr Paula Redmond, Clinical Psychologist.

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Full transcript below

In this final episode of the ADHD miniseries Paula discusses ADHD and burnout with Dr Floriana Reinikis, a Clinical Psychologist specialising in neurodivergence, and an ADHDer herself. They discuss the connection between ADHD and burnout, including the impact of workplace environments, over-compensation, perfectionism, and emotional regulation. Dr Reinikis also highlights the importance of understanding your own unique needs to support self-advocacy at work and identify strategies for preventing and responding to burnout.

About the speaker:

Dr Floriana Reinikis is a Clinical Psychologist specialising in neurodivergence, with extensive experience in conducting ADHD and Autism assessments and providing post-diagnostic support. She is passionate about delivering neuroaffirmative care that recognises and builds on individual strengths. In addition to working directly with neurodivergent individuals, she also trains mental health professionals in the assessment and diagnosis of ADHD across the lifespan.

You can get in touch with Floriana at Oasis Psychological Services or on LinkedIn

Other links:

ACP-UK

I’d love to connect with you so do come and find me on LinkedIn or at my website and do check out the ACP-UK and everything it has to offer.

Follow and subscribe so you don’t miss an episode!

Transcript

Paula Redmond (00:37)

This is the final episode in this ADHD mini series and its focus is on burnout. I explored this issue with clinical psychologist, Dr Floriana Reinikis, a specialist in neurodivergence and an ADHDer herself. We spoke about the connection between ADHD and burnout, including particular risk factors and vulnerabilities, as well as strategies for preventing and responding to burnout.

Paula Redmond (01:08)

Welcome, Floriana, and maybe we could start by you telling us a bit about the work that you do?

Floriana Reinikis (01:15)

Thank you for inviting me first of all, it’s really a pleasure to be here. It’s always an honour because it’s something I’m really passionate about. So I have been working with individuals who present with different kind of neurodevelopmental conditions, mostly autism and ADHD across the lifespan for over 20 years, and I just I think enjoy being with them as also I feel like I’m quite close to these individuals as in the last two years, about two years ago, I was also diagnosed with ADHD so all of a sudden everything made more sense, not only for me in my personal life, but also professionally why I felt so aligned with individuals who presented with similar challenges and differences and strengths. So yes, so that’s what I do on a daily basis. I meet for either an assessment, that’s something I do weekly, or for post therapeutic support. And yeah, that’s in a nutshell, me.

Paula Redmond (02:40)

Yeah. And you also do training for professionals, don’t you?

Floriana Reinikis (02:43)

Yeah, thank you for reminding me that. It’s something quite new. I started last October, so actually it’s been a year that I’ve been training other mental health professionals in ADHD assessment and diagnosis from a more kind of neuro-affirmative point of view, but also in post-diagnostic support. And yeah, there are a few kind of online workshops and training that currently are either being ready on the shelf and people can join or yeah, as my mind is never kind of stopping thinking, there are new ones on the pipelines as you can imagine, yes.

Paula Redmond (03:33)

Great. And I really wanted to talk to you, particularly about the issue of burnout and ADHD. And I think for me, that is the way I came to wanting to work more with ADHD is because in my work with burnout, I was finding that coming up more and more, people either kind of coming with a recent diagnosis of ADHD and really needing that to be an important piece of the puzzle in understanding their struggles with work, you know, their struggles with burnout, how that contributed and how we needed to think about recovery and getting back into work and what that needed to look like with an ADHD kind of understanding. Or in doing kind of burnout recovery work, starting to recognize things that might look like ADHD. And so that was just becoming more and more kind of prevalent and more apparent to me and felt like a really important thing that I needed to get to grips with and understand more about. And so I think it’s an important thing, particularly when we’re talking about the workplace and what it’s like to experience that as someone with ADHD. I think burnout is something that comes up a lot in that context. And I wonder if, I’d really be interested to hear Floriana about your clinical experience around that in terms of what you’ve come across in your work with people with ADHD.

Floriana Reinikis (05:23)

Absolutely. And I’m glad we’re having this conversation because I feel that the work around ADHD and burnout is just kind of starting to be understood a bit more. So I think we need to really talk more openly about the difficulties that ADHDers may encounter and how this can then lead to burnout. So I do not think we understand everything at the moment compared, for example to autistic burnout. I think there is much more research, much more clinical understanding, but we definitely need to continue this conversation. And in my experience, what normally has happened in my kind of clinics is someone requesting an assessment for ADHD at this stage or when I am working with someone already at therapeutic level, and maybe I haven’t diagnosed them, I haven’t really followed them through, so it’s the first time I start working with them. So any of these two stages, at times I’ve met individuals where I just felt it was much more than just ADHD as presenting with a level of exhaustion, mental, physical, a cognitive load, a social kind of withdrawal that felt possibly as burnout. And I feel that often we are still missing it and we are overlooking burnout in ADHDers. Therefore, it’s really important we actually consider what else is going on for these individuals in order for us then to think of how can we support them, not only therapeutically but also in the workplace. So definitely I agree with you that when you start working with someone you may start thinking something else is going on for this person. And I mean, if we think about it, we shouldn’t be that surprised because I think ADHD can really lead to burnout in many ways, not only when it’s not been even diagnosed or even when it’s been recognized as a neurodivergent condition, I think often we are missing the burnout part and we may consider it’s possibly anxiety or possibly depression or just executive functioning skills. So definitely I find that very often in my clinical practice and I can think of several individuals I have seen over the last few months. What I find is interesting is that yes, the majority are adults who talk about burnout in the workplace, but I have definitely seen several university students who as ADHDers or undiagnosed ADHDer talk about what we would consider burnout. So, yeah.

Paula Redmond (08:41)

What do you think it is about ADHD that might create more risk for people to develop burnout? What are the kind of traits that come along with ADHD that might make people vulnerable to developing burnout?

Floriana Reinikis (08:59)

I suppose if we think with the idea of what burnout in neurotypical may look like, thinking of this complete mental, physical exhaustion, withdrawal from social relationship, disconnection, cynicism, but also this inability to do tasks that in the past were easy, ability to organise, stay focused, manage. If we think of burnout in this way, and then we think of what ADHD presents as a kind of a problem with self-regulation in general where everything from attention, focus, memory, hyperactivity, impulsivity, emotional regulation. So we think of it, it’s not surprising that you are already, as an ADHD, predisposed to possibly develop burnout because your executive function difficulties are already quite taxed by an environment that possibly puts a lot of demands on you. Therefore, you may find that even normal daily tasks are for you really a challenge. And when you have done that for a long time, and that’s I think why we see mostly in older teenagers, young adults and adults, when you have done it for a long time this constant battle for some of us behind closed doors or for others a bit more evident in catching up with life, it’s not surprising that ADHDers are so much prone to burnout because they already have challenges in the areas that we would consider problematic. And I suppose the other thing we need to consider is that also ADHDers don’t just come with exactly functioning challenges, but they also come with other challenges that possibly are the byproduct of being an ADHDer. So, imposter syndrome, overcompensation, overcommitment. Many ADHDers will say, you know, I will commit to do longer hours or coming to work earlier, finishing later, taking work home because they know their attention is so dynamic, so fluctuating that during the day they cannot manage. But add it every single day, and then you go home and you still have to manage a whole house whether you have children or maybe other people to look after or even just yourself. That accumulation I think if not understood and supported, it’s likely to lead to burnout. So I feel like there is a compounded effect there between the ADHD intrinsic challenges and differences, and then the stress of everyday life.

Paula Redmond (12:23)

And do you think in your experience that burnout presents differently for ADHDers than for neurotypical people?

Floriana Reinikis (12:33)

I think there are definitely elements that are different. think the normal, if that is a word, but the typical, as I said, typical presentation of burnout, feeling so exhausted, feeling like no energy level, at a mental level or physical level, or this kind of cynicism, this kind of detachment from others. I think that is probably what is quite similar, but I suppose the differences are that all the normal differences and challenges that we encounter in ADHD are exacerbated, are magnified. So someone who neurotypically encounters burnout and may struggle with attention and concentration and remembering things and organising time, from an ADHD point of view, ADHDers will have a magnified effect of those difficulties. So things that maybe in the past they were able, tasks that they were able to focus a bit better, stay longer, and manage maybe with some difficulties but they completed, they would have much bigger problem. The other difficulties that ADHDers I feel are more encountering is for example things like hyperfocus. I think as ADHDers we are really able to give so much passion on something and hyperfocus on something at the point of maybe creating or being incredibly proactive when we are in our in our vibes, in our passion. But when you’re in burnout, that hyperfocus that generally already leads to mental tiredness and physical tiredness, I think in burnout becomes a complete forgetful of the rest of your life. So you may go hours and hours without self-care, without recognising that actually you need a break and you need to maybe eat something. Maybe without drinking any water, going to the toilet, complete withdrawal from people around you. And people, I remember several individuals I have in mind thinking, I came out of these hours of work, which probably I enjoyed it as well, but I’m so tired, exhausted that then I have to spend two days, three days not doing anything else. So I think that’s another thing that is quite typical of ADHD, the burnout. And then on top of that there is this kind of vicious cycle of then procrastivity. I prefer the word procrastivity to procrastination because I find ADHDers are never not doing something even when they’re procrastinating they’re doing something okay. So procrastivity makes me think of the fact that they are avoiding a task that they find emotionally triggering for some reason, but they are busy doing something else. So in burnout what we see is differently from neurotypical, that they may still look like quite hyperactive, quite restless, while in neurotypical we find a burnout tends to slow people down. In ADHDer we see still that kind of hyperactivity coming out but I feel almost when I speak to people about it, it almost feels like a sense of agitation. That sense of agitation that comes out in doing so many things but not doing what they need to do and in the end the complete again, mental and physical exhaustion that comes with it. Okay so these are the kind of things I think that are more typical of an ADHDer compared to a neurotypical.

Paula Redmond (17:02)

Yeah, and I guess as you’re talking, I’m kind of, you know, thinking about the people that I’ve worked with, who have ADHD. There’s seems to be, I suppose, a couple of patterns, like one, a sort of real sense of overwhelm with like this kind of administrative stuff. I work a lot with health professionals, so that kind of aspect of the work that isn’t, you know, the core reason they went into the profession, but those things that get piled on and added on and that just becomes so overwhelming. People getting behind, you know, getting disciplined, you know, it seems like an impossible task to ever catch up and then that’s never motivating. So you’re, you know, stuck in this horrible cycle. Or people who are absolutely kind of enthralled with their work, throw themselves into it and maybe don’t notice the early signs of it being too much and kind of push themselves beyond, you know, kind of healthy limits and only realize too late that they’ve exhausted themselves.

Floriana Reinikis (18:12)

Absolutely, absolutely. I think what you’re saying is really important because what normally happens for an individual with ADHD, I think normally, as become part of who they are, they’re really overcompensating and overcommitting, very often. These are individuals that are not lazy, let’s be quite clear about this idea that we are lazy or we make careless mistakes. We are exactly the opposite, we care very much. And because we are so aware of the difficulties we have with our executive functions, what do we do as a consequence? We tend to find ways to mask them, compensate for them and therefore will take on more work, will accept to do more things, will create rigidity in order to remember that I’m going to do something. But then there is the demands of a workplace, like whether it’s a mental health or a physical health environment as in hospitals or services that, you know, if you’re a doctor or if you are an anesthetist, there’s a lot of research on NHS workers that are actually constantly under stress and burning out. Now, consider the difficulties you have as an ADHDer. Being put in an environment with high demands, because these are environments with high demands, things may happen quickly, you need to be quite organised, you need to be quite able to manage time. Your resources will soon be depleted and you constantly are in this kind of hamster wheel of trying to keep up, and I think that is a problem. Trying to keep up becomes impossible. You burnout, it becomes almost impossible. And then you see people, as you said, either taking too much on, or I think the other opposite, and I suppose it’s maybe phase four or five of burnout, is going off sick and not being able to manage any more. And then when you meet them, I’ve got a client I’m thinking of at the moment who has gone off after exactly doing what we were describing. Extremely successful, because these are individuals that can be extremely successful, they’re really good at what they do. But taking on so many responsibilities, not being able to set boundaries, that’s another big problem of ADHDers, we are not able to set boundaries for many reasons, for self-management but also because we want to compensate and show that we are able to do things. So he was doing this for a long time and all of a sudden he found himself working from home, working weekends, working all the time. Consequently, his whole life became just work. So that’s, you know, again, self-management, difficulties in understanding where I finish work and when I start personal life. And relationship went through the window, his mental health and physical health. Okay, these are other big, big things in ADHDers. The physical health, you were asking me earlier about other specific characteristics that we should consider for ADHDers here but now. It’s not something we talk a lot, but we know that there is a lot of research on somatic conditions, physical health, for example, migraines, allergies, and many others. But when I think of the clients I’ve been working on, they also have additional physical difficulties that are also impacting, that compound effect as ADHDers. So I see it as a cycle. You have the executive function difficulties, then the demands of a workplace, demands of home, your need to compensate whether you become a perfectionist as a consequence or you want to just mask constantly because you want to come across as someone able, inevitably the outcome would be at some point burnout if the cycle is not broken.

Paula Redmond (23:04)

And I guess I can also think of, of kind of examples of people who actually are managing, you know, to mask very well at work. So no one at work is picking up on any problems, but you know, home is tricky because as you say, they’re not able to kind of attend to other things that are important, you know, relationships or physical health or you have to go home and go to bed at 7pm every night because they’ve used up, you know, everything at work. And so I guess it can, from the outside, not, you know, be a bit of a, I guess a spiky profile in terms of where the problems might show up that, you know, for at least a while work might look okay, but other areas might be suffering.

Floriana Reinikis (23:55)

Absolutely. And I suppose another thing about, as we are talking, I’m thinking more and more about the ADHD that I’ve encountered throughout my professional life. And the other thing we need to consider is the emotional dysregulation, which we know is a core feature, is part of being an ADHDer. And not that all ADHD become easily emotionally dysregulated, but we know many do. When we think of burnout, this emotional dysregulation is even more affected. So if we think of, in general, of how emotions will go up and down, even during the day, you know, you just, you leave your keys indoors and you have just closed the door and you think, oh why didn’t I think about it? Why didn’t I put the keys in the right place? That will already create it. And then you go to work and someone says something and you feel like, was that directed to me? Did it mean anything? So your emotions go so up and down in ADHD. Little things, we are quite sensitive. They’re sensitive people. They will still remember times when they were 12, 14 and teachers made comments and they are now in their 50s so they will hold on to these comments made to them. So that emotional dysregulation that we see as part of ADHD, when burnout kicks in it becomes intensified. So again it’s not only the frequency, it is the intensity. And as part of that, obviously the impact is also again on relationships. So very often clients will bring their partners or their husband, wives, and you will hear these narratives on how more difficult it has become to be together because everything is so easily escalating. Okay. So the emotional dysregulation is another big thing we need to keep in mind when we think of ADHD and burnout.

Paula Redmond (26:09)

And you mentioned some research that you’ve come across. I wonder if, but you also said that it’s kind of in a really emerging area, and I just wonder if there’s anything useful to add there about what the research into burnout in ADHD does say?

Floriana Reinikis (26:27)

Yes, I think we’re still very much at the beginning. I was reading recently a research on ADHD and the mediation between ADHD executive functions and burnout in employees. Okay, this was quite a recent, 2024. I can’t remember when exactly. So most of the research, which is still quite limited, is about highlighting the impact that executive functioning difficulties of self-management at work, like time management, planning, organisation have on employees who are ADHDers. So that’s the majority of the research. I feel It’s much more than just that. I feel that it’s exactly what we’ve been talking about, that ADHDers also present with all the other difficulties that we are recognising being part of it as the imposter syndrome, not feeling able, feeling like I’m always the one who, why I cannot do this, underperforming constantly, the sense of underachieving, then the masking. So these are the other kind of things that they’re not considering at the moment when they’re doing research. They’re just looking at the impact of how the executive functioning are amplified by being in a work environment where support is not there. But what about the rest? What about the other things? What about the hyperfocus? That’s something I haven’t really read about, how the hyperfocus and the difficulties when someone is in such a hyperfocus, it doesn’t recognize anymore the signal of, oh my goodness, it’s been two hours, three hours, I haven’t had any food, and then, you know, the difficulties of going on. Many of my clients will say I go on all day without eating and drinking water or going to the toilet. I don’t think research is actually yet looking at all the different layers that can affect burnout in ADHD. So I’m hoping that there will be more understanding. In your experience of working with burnout, it seems to me that you encounter lots of ADHDers in the workplace? 

Paula Redmond (28:59)

I think there’s something about healthcare that when you get it right, you know, can really be a great fit for ADHDers in terms of, you know, the passion that is needed, the kind of variety of the work and, you know, the hyperfocus that is needed at times, you know, to get through training, so I think there is something about this field that can attract people with this, you know, neurotype. And, you know, for some people that can be a great strength and, you know, find your way and a way of working that fits that, then people can really flourish and thrive. But I think there are, you know, particularly in big systems like the NHS, there are a lot of real challenges. I mean, it’s challenging for anybody, but I think particularly if your environment doesn’t support your natural way of being and thinking, then it can be very difficult. One of our listeners put in a question that sort of touches on this about the move in recent kind of years, and you know, it’s been for a long time, but I guess COVID really accelerated a move to much more digital working. So the listener kind of used the example of keeping track of things when you can’t see physical files. So everything being, you know, digital data, both, you know, tricky in terms of you keeping track of stuff, but also making it easier for people to keep track of you. And, you know, there’s a big emphasis on data collection. So that’s one part, but also, you know, a move to, again, accelerated by COVID, you know, hot desking, you know, online working, hybrid working. And I wonder what your thoughts are on how that contributes to ADHDers experiences of the workplace?

Floriana Reinikis (30:59)

I think that’s a brilliant comment and question from your listener and I agree with you that actually it’s pre-COVID. COVID just accelerated things and I remember during COVID I was already in my independent practice, so I had already left the NHS. So if I think of me in the NHS, I remember the time when we were introduced into the idea of smart working. And before that we were introduced to open offices. I’ve always had, I was lucky I suppose, I always had an office for myself and then all of sudden I had to be in an open office. So open office, smart working, online working. I loved my paper diary, and then all of a sudden I had to keep an online diary. So all of these things, remember even on myself as an NHS clinician at the time, pre-COVID, was already like, oh my God, how am I going to manage? But I have to think about it as actually there were pros and cons in the end. So for example, I found that smart working, so having a computer that I could use at home, meant even more difficulties with boundaries and even more I need to compensate because I’ve not been able to do all the things I had to do compared to my very organised colleague who managed to do everything, you know like all your emails or your paperwork or your reports, and I was like so actually having a computer to take home meant not having time for me for my family. I remember sitting in my dining room and working on it while the children were kind of playing around and saying, you know, can you please be quiet? So that definitely I felt was a problem if we were not able to set boundaries. But also expectations, because then the expectation is that you can do, maybe is self-expectations, I don’t know, the ADHDers may have, I’m going to do more, I’m going to work more, I don’t know. But that’s the kind of cons, I believe. The pros about smart working, I felt was the ability then to be allowed with some difficulties at the beginning, I think now with COVID things have been accepted, being allowed to work from home. So some flexibility in where I work. But again as ADHDers we need to be very careful because the environment where we work will inevitably make us more or less distracted, more or less focused. So being able to say I’m working from home but I’m going to work in an area of my house that is not definitely my bedroom like many people did during COVID because they didn’t have enough rooms at home, or I can work in my bed. ADHDers don’t do well with that because they get immediately sidetracked doing other things. So you can see flexibility, great, but then you have to self-manage and that’s the problem with ADHD, self-management. Once you have started, you know, self-managing that flexibility, I think smart working could work. Also, I think could work as, I remember often I had to travel between sites which created some problems again in terms of managing time. How long is it going to take me from this place to this place? Okay. And that was also part of smart working. And if you’re not good at managing thinking, I may find traffic at this time of the day, you arrive late and then you become panicky, anxious. But it means that you come to a desk that’s less cluttered. Let’s be honest. I remember having my own office and thinking, I’m just going to leave stuff here. You know, obviously not confidential stuff, not files, but my own bits and pieces. And clutter is not helpful for ADHDers. So there are pros and cons. But then other things like open offices, I loved the social part of it because as ADHDers we like that, we like being with people, we are chatty, we like the interactions, but to the detriment of then working and staying focused. Or overstimulatory – an open environment for me is often full of too many stimulation, people talking on the phone, I can’t focus on writing a report if my colleague is having a conversation and that’s not because I am curious what they’re talking about, it’s just I cannot filter so easily. So I know other people have talked to me about an open office being really hard to be in, not having enough previously when you think okay I really want to do this work, I really need to do it now but then being like a magnet as soon as there is a noise, as soon as someone comes in through the door you get immediately distracted and what is the problem? Refocusing. It’s just so hard for ADHDers to refocus. So open offices, I’ve never been in favour of open offices. So I think there are lots of cons there apart from the social side of it, which is also good. I think we need that. The other problem, for example, is out of sight, out of mind. So everything online. So I remember the time when we went on to these systems, Rio and all this system. I was like, oh my god, I’m not sure where things are, how I’m going to search for them. Well, I remember going into a filing cabinet, taking the file out and chronologically things were there. So I quite like, and I think still today, I find whenever I need to do something important, I will have a physical thing. I always talk to my ADHDer clients and say what works for you? And many of them say actually I need to see to remember. So that’s something that could be a problem when you have everything online and it’s not immediately there and also you don’t remember what you may have read the day before and you have to reopen your file and blah blah. But on the other side I find that possibly online calendar, online files could be also helpful if you are someone who tends to… let’s say an online calendar. I remember having this beautiful diary, let’s be honest many of us like our diaries and I used to buy every year a new diary, I used to love them. You know they gave it to you in the NHS, now I want that really nice fancy one because I liked it. But the problem was often writing at the same time two appointments because one had cancelled and then I had forgotten to remove it and I was thinking my goodness, or booking, double booking and then your secretary calls you and say there are two people waiting for you, I think oh my god I didn’t delete it, I forgot to delete it. Well online diaries, very difficult to do that. Now I love my online diary. So there are pros and cons. I suppose I always say to ADHDers is routines and structures are so important for us because I don’t want to rely on my brain or my mind to remember things, to do things, I need to have something external. So it’s really how we use them for our benefit. But there are definitely pros and cons for both. I remember as an NHS clinician, I used to go often to A&E to do assessment of individuals that were suicidal. And oh my goodness, I found it so difficult because the busyness of A&E with so much noise, so many things happening, people coming in, I had to always ask, can we have a quieter place? Because not only for the privacy of the person, it was also for me. I didn’t have this knowledge I have of myself now. So I think that’s what we tend to become able to self-advocate when we understand ourself as ADHDers, an environment that is conducive and supportive of our differences rather than against us.

Paula Redmond (40:03)

I was just wondering whether you think any other sort of things that people might be useful to think about in terms of what they could ask for in a workplace to help support them to prevent burnout?

Floriana Reinikis (40:17)

I think the first step, the importance of a possibly a diagnosis not because we are supporting the idea of labels and that’s a very old kind of a message I remember in the past, we don’t like labels. It’s not about that, I think it’s about this understanding of who you are and therefore stopping many things that before would be more like self-critical thinking, lots of self-critical beliefs but then strategies that were not working. And then the environment around you not knowing how to support you. So I think a diagnosis can be helpful in many ways, personally but also from a work kind of placement or education placement. So when we think about it, having a diagnosis will mean hopefully that you feel comfortable to discuss this with your manager or your employer. I still think there is a lot of stigma that goes with the diagnosis of ADHD and I know many individuals who for a long time don’t talk about it. I mean it took me a year to become open about it because I felt comfortable talking to my clients about, oh I know what you’re talking about, you know, I get it. But it was with my colleagues, with your employers. I mean, at the time of my diagnosis, I didn’t have, but still I had colleagues. And with your peers. Okay, so the first thing is, are you at that stage of having accepted the diagnosis because that I think is the first step. And then the second part is can you discuss this with your employer and then hopefully discuss a way forward. A way forward would be really in how the environment can be adjusted and I know there is a lot of criticism at times from others saying you know why should we adjust the environment to you and not to others. I totally disagree, I think a flexible environment would increase productivity, would increase loyalty, would increase the sense of I like my job. Okay. So I think flexibility should be probably applied more generally, but definitely to neurodivergent and ADHDers. So having a conversation of what works for you, what is it that could work for you? So an open office, actually, most of the time really distracts me and I don’t manage to get anything done. Can we look at another way? Can you work maybe a certain amount of hours a week? So creating even a plan. Okay, we’re not really good with planning. And I always say to my clients, find someone to help you plan and put things in place, rather than trying to do it yourself. Because if you had already tried many times, not working, just you need to change tactic, maybe someone else could help you. I remember sitting with my manager and talking about my diaries. So I was someone who will do exactly that. I will be able to see as many clients as a day, no problem, because I love that part of my job. Absolutely. I adored the idea of being in the session with my clients thinking of what they needed and the support I could provide back to back, often forgetting actually you need a break Floriana. So my manager will come and say this is your lunch time you have a break okay. I just needed someone to give me permission as well, and that’s also this part of your diary has to become admin, which I know you don’t like it, I know you find difficult, but actually when you do it, you do it really well. Okay. But I almost needed someone to help me with that. So I think discussing these things with your manager would be great. What can we do to help you? What can we put in place? Maybe if open offices are not possible because unfortunately there are some situations where, you know, there are no other offices, do you feel comfortable with noise-cancelling? I think it’s become quite fashionable these days. So it’s not really seen as a problem. So I’m hoping that people will feel comfortable to go into work and not to feel like maybe my colleague is thinking I don’t want to interact with them. And if that’s the case, can we have an open conversation with our colleague, which means for me having an environment which is neurodivergent friendly, it’s okay to have noise-cancelling earphones or headphones because I find it easier to concentrate. I also think the other important thing to consider is adjustment in terms of physically what kind of things work for you in an environment. So for example, some of my clients have been able to… I remember this research many, many years ago, even before I was aware of these things as ADHDers, some of my clients starting having standing up desks. So even things like this, think should be discussed and considered. Having a break and being able to go out of your workplace rather than staying in your workplace. I remember how it affected me remaining in my workplace because I felt I could never get out of work. So I was constantly in this agitated state of okay I’m gonna have lunch but I’m gonna be so quick, I’m gonna eat while I am looking at a report. Well if I was feeling comfortable, I almost didn’t feel comfortable because maybe it wasn’t what was happening or maybe it wasn’t what normally we did. If I was allowed to leave the building and it happened at some point, I moved to another building and we were very close to the town centre and people in that building used to take their lunch out. So I decided, oh my God, I’m going to do it. I realised that the ability to come back and refocus was so much better for me. I mean, this was pre-diagnosis for me. So even those kinds of things, again, that’s a kind of really friendly neurodivergent environment that allows people to have, you know, this is kind of, again, flexibility of what works for you. And we know research on productivity, we know that people will feel more able to give the best of themselves when they feel supported, they feel understood, they feel heard, and adjustment has been made around them. And when that is not the case, we see long-term sickness, we see people changing jobs, and I find ADHDers, maybe for other reasons, but it should again be considered, why do ADHDers change so often jobs? Could it be impulsivity? That could be impulsivity as I’m not happy here, I don’t feel supported, so I’m going to move to another job, thinking that by moving somewhere else things will change. So yeah, quite a lot to consider. I feel there is a much more open dialogue and discussion on organisations that value these things. Whether they do happen, that’s another issue. And I’m sure there are some systems that are still very rigid. So it’s exactly the opposite of what we’re saying, the flexibility against a system that’s rigid. You come to work, nine to five, this is your desk, and you don’t move, you just kind of go from one room to another, or things like that. It’s the ability for managers to think a bit beyond what culturally we have been used to. I suppose the other important thing to keep in mind is that another part of the research, maybe not specifically on ADHD, but in general on neurodivergent conditions and burnout, is that we know that the right support, the right therapeutic coaching, support for whatever the person needs, the workplace adjustments and support, possibly anything as also medication. We know that that will prevent possibly burnout or speed up the recovery. So I think it’s really crucial that organisation managers, systems understand that it’s not the person. Yes, the person may engage in a personal therapeutic journey, but when the mismatch between the environment and the person happens, so the rigidity of the environment, that’s where things go wrong. And we know the opposite is true when things are there to support the individual, even the ADHD differences are less problematic. They still exist, but the person just feels more fulfilled, feels more able to work, feels more able to be themselves, which is another important thing. And maybe even their masking, coping strategies kind of get a bit less intense and they can be dropped. So definitely a lot of work on how others can support.

Paula Redmond (51:06)

And I think that you’re right, that message around workplaces really needing to actively engage with this stuff is, you know, good for work place wellbeing, but it also makes sense for productivity and retention and sickness levels. You know, there’s just such a clear business case for know, workplaces to really actively engage with this. And I’m always just shocked and horrified that it doesn’t happen, which is, you know, a big driver for this podcast, let’s think, let’s talk about this stuff. And these issues, I think that we’ve been talking about today are relevant to anybody in the workplace, but I guess for people who have, you know, who have ADHD, face, you know, particular challenges that are not you know, it’s not, you know, the kind of accommodations and, you know, adjustments that you’re talking about are not like rocket science, you know, they don’t require huge restructuring or huge funding to put in place. You know, it’s quite straightforward, I think, you know, to just allow people to, be able to advocate for, you know, the kind of environment that allows them to flourish and you know, I don’t think it’s the huge barrier that, you know, it often feels like it is for workplaces can be quite, you know, defended against this stuff.

Floriana Reinikis (52:34)

I think because, even surely from a financial point of view, which is obviously something that the organisation system has to keep in mind. So they may think of financially what it would mean to make this adjustment. I have never seen anything written and I’m sure there’s probably something, but surely if you can prevent burnout and you can therefore prevent sickness, that will cost much less than, you know, supporting someone who is off sick for a long time. Okay. And will support and prevent, sorry, will prevent also the possible, while likely development of mental health problems or physical problems which comes with burnout ,which also would put even more strain on resources and financial commitment. I think it shouldn’t be too complicated. So I don’t know why sometimes this seems to be such a big problem that we encounter still in workplaces. But hopefully this conversation that you and I are having today are becoming much more what happens, the conversation that everyone has openly, frankly, and therefore becomes easier to accept that yes, we need to change something.

Paula Redmond (54:06)

Floriana, I wonder for anybody listening who either has a diagnosis of ADHD or who suspects they might, what advice you might have for them to help them prevent or respond to burnout?

Floriana Reinikis (54:22)

Okay that’s a very important question. Okay the first step for me is awareness, self-awareness because you may be in a stage of burnout when you’re not yet realizing. We know from the phases of burnout that have been described that some of them you’re still in this kind of drive to do things, to achieve, you feel also quite satisfied but it’s starting to become difficult. Becoming self aware is the first step. So asking yourself what is different? Is my attention, my focus, my memory, my organisation, my hyperfocus, my emotional regulation, my feelings, are they more or less the way they have always been? Being an ADHDer or there is an intensification of them? So if there is something you start thinking, something is not right with me, then you may want to start considering, could it be burnout? So self-awareness. And I suppose the next step would be, who could I talk to? I suppose it could be someone you trust and you feel comfortable, but it could also be then a professional if that needs to go a bit further whether you’re not getting anywhere and people may actually know, family and friends I think most of the time want to do the best for you and they may say you know maybe you just need to try a bit harder and maybe you need just maybe to have a holiday, take a few days off, and maybe you already try these things and if it’s still not working, I will then request maybe a conversation with someone, someone like you who specializes in burnout or a GP. But other things you think are very important you could do even before that is, for example, when burnout kicks in, we said about this kind of detachment and disconnection from life. I will say to my clients who are in that kind of phase, I actually would like you to make an effort and I know it’s going to be a very difficult effort, but an effort to even book just a coffee once a week with your friend and go out and meet, I don’t know in a coffee shop somewhere, and just talk about anything that comes to mind. Or having some time with your partner out of the house but almost regularly because I find that the more they don’t do these things the less they will be in contact with others and we as human beings we need others. So re-establish some connection. The other thing is be realistic in what is possible to achieve and accept it. Sometimes less is better rather than constantly being on, I want to do this this and this and that everything else, less is better. If you can manage your hyperfocus, so if you start realizing your hyperfocus has become so intense and you pass the whole day without leaving your room or your bedroom, your office, because it could be someone who is becoming so work-holic, they don’t leave, okay, put reminders for yourself. Work with someone in your family and your friends and say, can you help me out? Can you come and knock on my door or give me a ring and accept it as the offer of, I need to stop it, because it’s definitely not helpful. So, put some external reminders that are great for ADHD as well. Also you need to increase that, work with someone, body doubling, get someone to help you to say, we’re gonna go for a walk now. That’s the other important thing I would like to reiterate. Some self-care. Self-care is another alarming bell. If you realise that actually, even as an ADHDer, you’ve always had quite good self-care and that’s not happening, ask yourself what’s going on. So start maybe on purpose having some self-care. self-care means a lot of things, means not only looking after yourself, putting some nice clothes on in the morning, having a shower, whatever it is that is your self-care, but also means going for a walk, get some fresh air, whatever the weather, whether it shines or rains, I always say to people that will increase your dopamine, will make you feel better, will make you feel more able to come back and focus but also will relax you. So these little things. Sleep, keep an eye on your sleep. ADHDers are very renowned for difficulties with sleep. As your sleep becomes worse, so you’re so exhausted during the day but still you can’t sleep, when before actually you could at some point fall asleep. Okay, that’s another alarming bell. Maybe discuss with your GPs or anything that you can do because lack of sleep will just increase problems and have some regular meals as well. You know, look after yourself even in the very basic way. These are basic but they’re so crucial. I suppose the last thing I would like to say from a clinical psychology point of view is what can you do to help your nervous system, who is so at the moment kind of overwhelmed, to go into a state of slightly, gradually, because it’s not going to happen over a night or over a week or a month, if you’re in burnout, it’s going to take time. But what can you do to help your nervous system? And obviously all the things I spoke about will already help your nervous system. But is there any way to help you with things we know work for ADHDers like mindfulness? And I always say to my ADHDers who look at me like, I hate mindfulness, I always say, yeah, I get it, but you don’t need to sit still, you don’t need to do a very, what I call the classical mindfulness. We can do a very informal, and your informal could be go out and just feel the rain on your skin, or listening just the sound of the birds around you while you’re walking. Just mindful of how you’re walking in a different way or a different kind of place or just enjoying a cup of tea outside in your garden and just kind of very slowly having it and thinking about it and smelling it. These are exercises I think ADHDers find easier to implement because they don’t need to stop their mind which is obviously quite a difficult thing to do and we don’t want that, it’s never going to happen to anyone anyway, but you can do it as suits you and it’s more practical and feels more realistic. So these little things could become really part of your daily life and could be very helpful.

Paula Redmond (01:02:05)

Yeah, and I often think about things like, this idea of active rest. So being able to, I mean, for me, that is knitting. You know, something that, you know, you’re keeping yourself, you know, physically active, you know, tapping into a creative part of your brain, but at the same time, it’s soothing the nervous system. So I always like to have those conversations around, you know, creative pursuits that, both help with connection, you know, it’s the opposite of burnout to be able to connect to something alive and creative, but also just so good for our nervous system.

Floriana Reinikis (01:02:45)

Yeah, I like, I love that. I call them with my clients restorative breaks. And I always say restorative breaks is not about you going on your phone or going to another hyperfocus. Okay. It’s actually moving your body in some ways, whether you are knitting or I had this question, I remember with my children often when they were little, how do you know mom needs to take a break from something, maybe because she’s feeling a certain way? And I was so pleasantly surprised when they said, you go out in the garden. Okay, because that’s my way of being active, using my body to calm my mind and just being in touch and maybe doing some work in the garden, trying to pull the weeds. Actually, that is so helpful and my nervous system, I always send to my clients what is it that could be an equivalent? Okay you may not be a gardener, I’m not a gardener, I just like being in the garden, you need but what is it for you? And that’s a restorative break, yeah. So that’s the kind of things we really would advocate for. They don’t need to be a lot a long holiday, at the end of the day we, most of us don’t go on holiday every two months. No, it’s not possible. But you can do these daily things to restore your nervous system.

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Full transcript below

This conversation explores the personal journeys of 3 NHS clincians diagnosed with ADHD as adults, focusing on their experiences with diagnosis, the impact on their lives, and the challenges they have faced in academic and professional settings. The discussion highlights the complexities of self-disclosure, advocacy, and the need for greater awareness and understanding of ADHD, particularly in women. They reflect on the misconceptions surrounding ADHD and the evolving narrative in society, emphasising the need for a more compassionate and informed approach to neurodivergence.

Speakers’ recommended resources:

Scattered Minds by Gabor Mate

Dirty Laundry by Richard and Roxanne Pink

Ted Talk by Salif Mahamane called “ADHD sucks, but not really“

ADHD Chatter Podcast

Amazing Marvin productivity app

I’d love to connect with you so do come and find me on LinkedIn or at my website and do check out the ACP-UK and everything it has to offer.

Follow and subscribe so you don’t miss an episode!

Transcript

Paula Redmond (00:37)

For this episode, I wanted to speak with NHS clinicians who themselves have a diagnosis of ADHD and to hear about their relationship to ADHD and how this interacts with their professional roles and identities. I’m really grateful to the three people who volunteered to take part and for their openness and generosity in sharing their stories. I think this is probably my favorite episode of the podcast so far, and I’m sure you’ll get a lot from it.

The three people who join me are clinical psychologist Dr MW, Dr JT, an intensive care consultant, and Dr CD, another clinical psychologist. We’ll hear from Millie first as she explains how she came to be assessed for ADHD.

MW (01:29)

So I was actually working as an assistant psychologist in a assessment and diagnosis service for children for autism and ADHD, and prior to that, I’d never really thought about ADHD at all to apply to myself. And then I think I started to notice with some of the clients I was working with who had ADHD, I’d be thinking, yeah, but I do that, like that’s very normal, you know, that’s the way people’s brains work, isn’t it? You know, and things like that. Just noticing lots of similarities. And then I never really pursued it myself actually, I was applying for the doctorate. So I was doing my application, and one of the psychiatrists was supporting me with that, and we were discussing it, and I think he kind of probably, on reflection quite bravely, kind of said to me like, you know, I noticed this and I’ve noticed these things, and he highlighted a few things about in meetings, and I think I kind of moved my face quite a lot, like visual kind of movement and activity. And he said also around the difference, I suppose, with my presentation at work versus my ability to kind of write about that in this application form. And he kind of said, have you ever thought about ADHD? And I think I was quite taken aback and initially quite like, shocked and a bit annoyed and thought, how dare they? Yeah, it made me feel, I don’t know, it made me feel quite shocked by it. But then I think on the drive home, I kept thinking about it and if anything it was just lots of things that were making sense. And I think prior to that point I hadn’t really understood the differences in women as well and some of those differences because I hadn’t learned too much about it before that job. And then the more and more I thought about it I think it was making me more frustrated because I was thinking I think he’s right. Actually I think that is, that does apply to me and obviously then I was looking at things and very kindly, he kind of said, you know, think about it, and if you wanted to, I would support you, you know, to kind of access a private diagnosis, because I think I agree, I don’t think I would meet, maybe it would take me a very long time to get it, let’s say, through the NHS in terms of this idea of you’re quite functioning, you’re quite academic, it perhaps isn’t causing you distress in a typical sort of way. But I suppose throughout my life, it definitely has, especially in the kind of emotional regulation realm. So I did pursue a kind of private diagnosis. And yeah, I got a diagnosis of inattentive subtype, which fits quite well for me, I think. And then since then, it’s yeah, it’s just been very useful. I did trial kind of medication briefly, but I didn’t particularly get on very well with it. I don’t think I really wanted to pursue it up into a therapeutic dose. And also I think because I’d got to 24, 25, I’d done uni, I’d done a masters by that point, I’d already had to develop quite a lot of strategies to manage my ADHD. I think the main impact it was having for me was kind of, yeah, that emotional reactivity, some of the inattentiveness, more in relationships and more in things like that outside of work maybe. And I’d kind of given myself quite a lot of structure in work. But for me, just having the diagnosis itself helped a lot in understanding me, how my brain works. I think my sister gave a reflection as well that it was really helpful for her just understanding it as well in that context. And then since then, I mean, I’ve always kind of known, think my parents probably both have quite a lot of traits of it as well. So kind of reflecting on that. So yeah, so it’s been really quite useful, and think even just sharing it with my family and stuff for them, I think it’s been quite helpful as well.

Paula Redmond (05:31)

And that process of kind of having a new or different lens through which you might have looked back on things in the past with a different understanding, did that kind of, was that part of it for you that you understood maybe past experiences differently with that diagnosis in mind?

MW (05:58)

Yeah, I think it’s hard almost now to think about it without having that in mind, you know, because it’s been quite a while. But yeah, definitely. Especially when I was younger, especially at school, quite typical, you know, I was described as like, oh she’s very able, but she just distracts everybody and talks to everybody. And I remember I used to think, God, I can literally talk to everyone. And the teachers would put me next to like the most quiet, most academic person, and I would somehow manage to distract them as well, just chatting or whatever. And also just to be honest, it really just made me reflect on how I coped with it strategies wise. Like, I’ve always been very energetic and active and done a lot of physical things. And I remember since reading studies about how apparently, kind of an hour of cardiovascular physical activity can have similar effects on the brain as ADHD medication. And I was easily doing that. I used to play football, you know, and also I’ve on reflection, have noticed periods in my life when I can’t do that – traits or symptoms or whatever you want to call them of ADHD being much more difficult to manage.

Paula Redmond (07:10)

Okay, so when you’ve not been able to do that exercise, you’ve noticed an impact?

MW (07:15)

Yeah. I think for me the emotional kind of liability and changeability and feeling those really intense emotions, obviously as I’ve got older that’s been slightly more easy to manage and especially with a diagnosis and understanding myself but, but yeah, there were stages in my life where I think I kind of was very desperate to know like what’s wrong with me. Like other people don’t seem to have this or feel it as intensely. And obviously that can be a real pro. I like to think about stuff, you know, I’m now on reflection and looking at other people’s brains or how they respond to stuff, more neurotypical people, I think we, or myself, I think I feel the positives massively as well, those real highs of emotion. But the downside of that is you feel the kind of crashing lows. And something I think my partner observed is that kind of recency effect where if I can kind of just feel whatever I’m feeling right now and that feels like it’s going to be forever, you know, you have less of that ability to think, yeah, but I didn’t feel like that last week, you know, and without some of that insight of why that might be and things like that, that was really tough to manage. And also I think obviously over different stages of my life, impulsivity has been a big one, like risk taking behaviors being very impulsive, especially as a teenager, which now having that lens on it is really quite useful. But at the time, I didn’t have that. So yeah.

Paula Redmond (08:44)

Is there, have you been able to be more kind of compassionate towards yourself or your past self with the knowledge of ADHD?

MW (08:53)

Yeah, definitely. Yeah, definitely compassionate and also maybe a little bit kind of sad that I didn’t maybe have some of that understanding at those times and how things might have been easier. I think it really helped the time I got it because I got it probably about a year or two before starting the doctorate. So that was quite helpful. It also made me reflect on how I’ve coped academically in terms of knowing kind of how I have to manage work and things like that in comparison to my friends at university and things like, you know, looking at yourselves and your learning styles. So I’m much more visual and verbal and take things on. Like my room at uni used to be covered in posters of things I had to try and remember. And also my working memory is quite good. So kind of relying on that instead of maybe, you know, in long lectures, I’d switch off or things like that. So yeah, it has allowed me to be a bit more compassionate to myself. I think it does make me a bit sad that it did take that long and maybe just a lack of understanding of what ADHD looks like when it’s not a kind of typical presentation. Yeah.

Paula Redmond (10:10)

Because you talked about kind of that sense of being really high functioning, not having maybe high levels of distress or real kind of struggles that may have masked some of those, the things that were more difficult for you.

MW (10:32)

I think just to clarify as well, like I suppose external struggles, like a lot of it is obviously that internal difficulty and the internal inattentiveness that I think a lot of people with ADHD work really hard to kind of mask, which takes a lot of obviously energy and resource. And I think I really dislike that term, high functioning or low functioning or that sort of level because I think that was what I think has been missing is almost this idea that if you can do well academically or you can do those things, then it’s not that. And I think I remember having a kind of disability kind of student assessment kind of thing to get some support in the student services, and they kind of said about it being a learning difficulty was the language that they used. And I kind of clarified and just said, you know, it’s a neurodevelopmental condition. And I understand that for some people it can be that level of, you know, it impacts their learning that dramatically. And I remember also once in that AP job, when I was actually going through the process of getting the diagnosis assessment myself, I went to do a school observation and a teacher kind of said to me, oh, so can, somebody have ADHD and still be like intelligent and smart? And I almost had to stop my mouth from like falling open. And I was like, yeah, and kind of just tried to provide some kind of psycho education about that. But I think that can be a pervasive kind of narrative about it. And then I think that can block people getting diagnosis, you know, in terms of, oh but you’ve been able to get to this or access this or…

Paula Redmond (12:12)

And Millie, what was it like doing your doctorate training? And I’m wondering about, yeah, that experience, whether you talked about your diagnosis in that process?

MW (12:24)

Yeah, I think it kind of relates actually to a previous question you said about the lens and can you be more compassionate to yourself? I think I always just had this view of myself as well throughout school, that I wasn’t academic, that I wasn’t able to do those things. I think I had quite a view of myself that that wasn’t where my strengths lay. So I never went to, I never thought I’d go to uni, I thought I’d just go into work and it wasn’t actually until I found psychology that I was like, oh this is how my brain works anyway, so this could be easy to go to uni. If it was another subject, I mean, certain things like maths and things like that, I really struggled with. I liked things like English. And so I think that had always been my view of myself. And then I think over time, with lots of support, I started to think maybe I could do that in this, in these contexts. And so I think that stayed with me as well, not being an academic sort of person. So then, applying to get on the doctorate I remember thinking like, my God, how am going to do a PhD? I know I have to do a thesis at the end of it. I’m never going to be able to do that amount of work and attend for that amount of time and concentrate. So I think at the stage in my life and career where it came, I’d already had to develop a lot of ways to manage deadlines, work, remembering things. You know, I’m the sort of person where if I don’t do it straight away, I won’t do it. I’ll forget about it. So in terms of organisation, that has to be kind of key. But in terms of on the doctorate, I had a bit of a journey with it myself. I think at the start, I felt quite strongly, you know, why should I need to tell them? It doesn’t affect my ability to do the course or the job or I don’t think I need to tell placement supervisors. I think there was a worry that it might be kind of stigmatized or the way you might be treated about it. And I think I just got used to just people’s such varying levels of awareness that you’re then kind of opening yourself up to that when you tell them. So the first couple of placements, I mean, I did tell the university from the beginning, I think I tried to be proactive in thinking if I need some extensions, getting that student support plan in place, just to try and manage in case to see how I get on, because obviously there’s that daunting, you don’t know how you’re going to do. And actually, I’d never apart from one time, which was due to kind of family emergency circumstances as well, I didn’t need to use it at all. But it was nice to have it there. It was nice to have that as a backup. I think what I felt disappointed about is a lot of the parts of the plan that are put in place with the student support services never came into reality. Like lecturers were supposed to send you things in advance so that you would have time to read it and it wasn’t all on your, you know, your concentration in the lecture and that never happened, certain things, which is a bit sad, you kind of just have to make do, I suppose, with that. And then I think over the time, I started to test that out and did tell placement supervisors and they kind of said, yeah, that would have been really helpful to know just as having an awareness. And so then over time, I did feel more comfortable to say in that initial meeting, you know, this is, I have ADHD and this is how I feel it kind of affects me, not really much in placement. have lots of ways to manage it, but this could be the area that it might come up or where you might observe. And I think it was a bit of a mixed bag. Some people were great and really understanding and really asked great questions like what would be helpful for me to support you with that and just kind of then did it. And then I think in other ones, it was a bit less supportive where I told them at the start of a placement, you know for me, I said it might come up in, you know, attending to numbers, especially like in cognitive assessments or things like that. I could have read something 12, 20 times and I still might miss it or I still might make an error, or like words in a report. It’s not because I haven’t proofread something, it’s that I’ve read it and my brain hasn’t, you know, paid attention to those bits. So in terms of then at the end of a placement, you know, not feeling marked down for that, like, she could take more care and attention or she could do this, you know, that would be feel, and I think that there’s a real leftover from school almost like I can’t make a mistake on that either because it means a lot more maybe for me. And then I think I had a bit of a difficult experience where then even though I discussed that with them, even though they said, yeah, and I think in terms of applying it to a client or a young person, they would have really got it. But then when it came to it, when it did happen, they were quite, you know, oh I don’t think you really paid attention to this, I don’t think you maybe checked it. And I was like, this is kind of what I was on about when I when I started. So yeah, so it was a bit of a mixed bag. But I also think in lots of ways, I find it can be a real asset clinically. And I think I noticed that on training, like reflecting, when you’re having to work with more than one person in the room, I think one of my friends on the course fed back that when we’re doing like systemic work with a family, you’re having to attend to like multiple people, and you’re having to hold in your mind like they’ve said this and they’ve said that, and then I’m going to come back to you, and she was like, you just seem to be able to do that so much easier than I can. Like I’m finding that quite overloading. So certain things, I think it was quite helpful. So there’s definitely the kind of positives for me clinically and the drawbacks, I suppose, as well.

Paula Redmond (17:57)

And what about in your work now, post-qualification? What are the things that you found helpful or unhelpful in your work now?

MW (18:10)

I think it’s pretty similar, to be honest. I was upfront with it as well, qualifying-wise in my first job qualifying. I think, to be honest, I probably don’t ask for much. I probably don’t ask for many amendments or adaptations. And I think I’ve found that really helpful reading about it, being in forums or hearing from people what they do ask adaptation-wise for work. That’s been quite helpful. Yeah, I think I just kind of have been quite upfront, you know, this is the way that it would help for me. You know, I’ve said to work if I need to write a big long report or focus on one task for a long time, I find that easier to do it at home, not in a really busy office with loads of other distractions. And, and I find, I do find shared office spaces, hot deskings, what that set up really quite difficult because if someone’s on a phone call I’m paying attention to that, I’m not listening to what I’m doing or I’m trying to do both and so and they were quite supportive you know if I need to use a separate room or an office or if I you know, and I can I think to be honest my job as a clinical psychologist I find it really does lend itself well, I like that it’s changeable, I like that you know because my worst nightmare would be sat in the same room at the same desk doing the same task for nine hours a day or seven and a half hours a day or whatever, I would just lose my mind. So the changeability that one day you might be driving somewhere with a session and then, and I just manage it. Like, I wouldn’t do a whole day doing a task. I have to kind of mix it up a bit or make it work for me. And I think because it’s quite flexible at this level, it works, that works quite well.

Paula Redmond (19:55)

Yeah, yeah, great. Thanks, Millie. I’m going to come to you now, Jo. And just maybe to start with, you could introduce yourself, tell us what your job role is?

JT (20:10)

So my name is Jo and I am a medical doctor and I’m currently working in pediatric intensive care. My background is in anesthetics and intensive care. That’s what I’ve done my training in.

Paula Redmond (20:28)

Great, and just to start with, any kind of thoughts, reflections, questions for Millie, from what you heard her say? Anything that resonates with you or, yeah?

JT (20:40)

Yeah, thank you, Milly, for sharing your kind of diagnosis and journey really through ADHD. It was wonderful to hear and certainly lots of similarities that I can pick up on with my journey as well. I think it’s amazing that you had someone at the beginning. You’d said your psychiatrist supervisor who really identified those issues. And I think very few people have that. Maybe more and more so there is awareness and people are picking up on these things. But I think it’s amazing that you were led to the diagnosis via someone who identified it. Were there any emotions or anger potentially against that person? Shock maybe to say there’s nothing wrong with me and then as you gradually learned about it you came to accept, but I can imagine you might have been a bit taken aback and quite startled about that to begin with. So just wondered if you could tell us a bit more about that?

MW (21:55)

Yeah, yeah, definitely. I think because of how I view it now, as you say, I’m very, I feel very lucky and privileged that that was the case. And also, I think, to be honest, it’s only because he had specialised in that for a really long time with, with young people, adolescents and adults that I think he picked that up. But yeah, initially, I felt very angry. I kind of thought like, what an abuse of a powerful position to kind of say that. Because it is quite hard when you’re like a band for assistant psychologists and this is kind of quite a senior member of the team. And, and so I think at the end, they were the first ones. And I remember ringing up my sister and being like, can you believe this? This is what they’ve said and la la la. And yeah, I think that is part of the stigma, suppose, isn’t it? Is that feeling of the, hang on, there’s nothing wrong with me. And, and that isn’t the case, almost wanting to fight against it. But then I think the more and more I thought about it, I think that was what was frustrating me was I was like, oh my God, I actually think that is 100% accurate. And then also feeling a bit annoyed and frustrated and angry that it took till that age of my life for somebody to sort of suggest that, I think. And I think reflecting that I think for women especially, it’s often a lot more like, it must be a mental health thing. Because I’ve done that to myself, kind of going through mental health diagnoses and thinking, does this make sense of what’s wrong with me? In inverted kind of commas or quotation marks. So yeah, they were definitely all the emotions. And then I think I did feel, following that, really grateful in terms of they provided that private assessment and diagnosis for me for free, which obviously I would never have been able to afford. And I would have waited for years on an NHS waiting list. And as they were highlighting, might not even then have met it due to somebody’s understanding about it as well. So yeah, in terms of the support they provided, then there was lot of feeling grateful and pleased that they were brave enough to raise it to a kind of work colleague.

JT (24:00)

And have you found as you’ve been, you’ve obviously had a journey for quite a number of years, during the course of the journey have you seen a shift in people’s attitudes that you’re able to now unmask yourself and actually be more free with the diagnosis around others? Or not?

MW (24:20)

Yes, yes and no. Yes and no. I think yes, just definitely since then and my understanding of it, I was incredibly like unaware. But I think also that comes from the teaching that we had on it as well, like as somebody who’d done a psychology undergraduate and like nothing essentially. And the way that it was taught was quite skewed and what you hear in the media, you know, I think even my own understanding of it as well was, was quite ignorant. So I think definitely yes, in the sense of, especially around ADHD in women, girls, there has been a shift. I’d say the no is that there is still quite a lot of misunderstanding kind of stigma, not being able to integrate it. And I think that’s what I experienced maybe on training, being able to understand it in one sort of presentation, but not being able to integrate it for a mental health professional that you work with and who also presents in different ways. I think that integration part is still kind of missing.

JT (25:24)

Yeah, and also, I mean, I think it must be really hard to focus on doing a thesis, particularly. I mean, I’ve struggled with those times of my life when I’ve had to, you know, stick to your own deadlines, use self motivation. That’s incredibly difficult, whereas I’m sure it’s easier for you, as you said, in practice, having your kind of varied job plan, no two days are the same and you enjoy that. So yeah, I think it’s amazing you obviously shared some strategies that you might have had during the course of that. But I can imagine that would have been quite a difficult time of your life and, you know, a space and place where you would have come to terms with the demons of ADHD, so to speak. Yeah.

MW (26:17)

Yeah, yeah, definitely. Just to say as well, I did have some very supportive research supervisors, which were great. Like, do you want me to check in when you’ve made these deadlines for yourself, like almost externally managing that for me, which was really great. And also I think my partner probably observed things that he hadn’t observed before where it was like, gosh, you’re very ADHD today, you know, because of all the things that I was kind of thinking about. So yeah.

JT (26:46)

And I think it’s that external validation that we can so often rely on and having someone to check in and really sort of crack the whip on deadlines and making sure that you’re sticking to them is so important. Did you find you had an ability to really hyper-focus at times, which is something I tended to do when I was doing similar and to the exclusion of everything else in your life, including eating, personal hygiene, those sort of moments, which I know can be quite typical of those with ADHD. Yeah.

MW (27:29)

Yeah, definitely. I think just generally being interested, I chose a topic purposefully that I really cared about, you know, for that reason, as you say, to be able to hyper focus on it. But yeah, there are times where you think, God, I really need to go to the toilet, like to do a wee, because I haven’t done that for ages. I’ve been sat here typing or furiously trying to concentrate and monopolize on this energy. And I think also some of that permission came with getting a diagnosis that otherwise I used to just sit there and just be like, why can’t I do it and get into this spiral of like, why can’t I focus? But some of that reflection on right today, I’m just finding it too difficult, so need to go away and do something else. And then maybe tomorrow I’ll have some of that hyper-focus or more of that ability to concentrate. Because otherwise I used to just, yeah, like, know, flagellate yourself and think like, I’m not doing it. This is terrible. You know, so I think that, that helped.

JT (28:21)

Yeah, absolutely.

Paula Redmond (28:22)

Jo, I’m gonna jump in, I’m gonna jump in, because I feel like we could talk forever. But I want to kind of come to you, Jo, and just wanting to hear about your journey to diagnosis and what that’s been like for you?

JT (28:38)

Yes, so my journey to diagnosis, I think was really based around just gradual awareness of ADHD symptoms. It was about 10 years ago that I pursued and received the diagnosis via a private psychiatrist. And it was really just the penny sort of dropping around things that I’d read. I also had a friend who had realized she was autistic and she started becoming very vocal about that on social media platforms. And suddenly this whole world of neurodiversity gradually started opening up, but it was certainly well before the current kind of atmosphere around neurodiversity and the amount of information that was on display. So I feel it was preceding the current climate of everyone has ADHD, that’s the cool thing to be. So it was well before that. Not a lot of people knew about that. I just, the more that I read, the more I said, wow, this is exactly what I have. Prior to that, I’d really thought that I had something you know mentally, I was mentally ill or I had anxiety was one of the biggest features in my life and all those kind of running rushing thoughts, your brain never feeling quiet. There was a time when I thought I had post-traumatic stress disorder after having the loss of a friend and colleague in very difficult circumstances while I was on an expedition as a medic. So I thought some of the symptoms were related to that. There was a time when I really thought I was having early dementia due to, you know, at times poor working memory. I did trial some SSRIs for a bit and, you know, it was a very bewildering time. And then as I gained access to more and more information, I thought I need to pursue this. And I got very excited about that. And then I looked up for someone with a special interest in ADHD in adults and managed to quite easily get an appointment. I went for one appointment and my second appointment he asked for me to bring my partner at the time who really just agreed with my own observations but provided some verification. And then it was at that point he said, let’s you know, let’s try all some stimulant medication, which similar to Millie, I also didn’t get on with too well. I just didn’t feel that it helped me in the ways that I wanted. And, and certainly at work, I’ve always been able to focus quite well without the use of any medication, whereas I feel it’s a lot more external to work that I might struggle and that’s usually when you’re not on medication.

Paula Redmond (31:56)

What was it like to get that diagnosis, to hear that?

JT (32:00)

I think for me it was just, I had pursued it myself, so it was very validating of what I thought. I think if it had come from someone externally, I would have, like I said to Millie, that yeah, I would have struggled with that and thought, how dare you? But because I had taken on that responsibility to pursue it, I really, I was quite happy with that. And then I, you know, I told family members and not really any close friends for a number of years and many friends don’t still know about it, but as people have become more aware I felt more confident to disclose that and of course you know, also friends that say that absolutely cannot be true, you’re high-functioning you’re academic you did well at school. And then it was reflecting on the times when it was difficult for me and certainly at the transition points through life and as you become more of an adult, figuring out that things are hard and maintaining control of all aspects of your life becomes increasingly harder, whereas school is a very structured environment and that made sense. And I think now, you know, with at that time of diagnosis and telling my parents, they were like, wow, I sent them, I sent them literature about it and they said, okay, well gosh, yeah, you’ve always had a messy room. This makes sense. There’s a reason for these things, it’s not just you being lazy or messy, there is actually a way that your brain works that is different to other people. And yeah, certainly on the most part, I think people have been very receptive and I felt certainly, I think validated is the best word that I can use. And also I’m just grateful that I managed to get that help privately, whereas now I think these days that would be very hard. There’s certainly long waiting lists and people struggle to achieve that, although I would like to pursue some more formal testing, especially, you’d said you were inattentive type ADHD, you know, just to kind of clarify things better and also to figure out if there’s any other associated, you know, not disabilities… 

Paula Redmond (34:37)

Co-occurring stuff.

JT (34:38)

Yeah, concurring things and comorbidities, which certainly, you know, anxiety can be a comorbidity and it can muddy the waters. So I think that would be helpful.

Paula Redmond (34:49)

And what’s it like, Jo, because I guess, you know, thinking, I guess, you know, Millie and Clark and I are all clinical psychologists, so, you there’s a particular kind of world that we occupy and, you know, being a medic in a different take, I wonder how, what’s your sense of, you know, whether you’ve disclosed personally or just generally discussions with colleagues, how is ADHD perceived in your context?

JT (35:19)

Yeah, I would say that we are not quite at the level we should be in terms of, well, certainly the specialties that I work in. There are a lot of clinicians that I know of via social media, Facebook groups, and speaking to them personally that do have neurodiversity, either autism or ADHD. There’s a high rate of this in the medical profession. But yet I think you know, our supervisors at work, those involved in education don’t have a massive understanding of this yet. Despite the fact that there is now a lot more neurodiversity training, I think it’s still incredibly difficult for people to recognize this when someone is struggling, particularly during postgraduate training in medicine. And I think there’s a huge amount of work that can be done. And certainly I can spot a lot of people with neurodiversity, I feel, from a bit of a long way off, or have a bit of a hunch about it. And I think there’s a lot of people struggling out there. And, you know, personally, I felt brave enough to really unmask a diagnosis in the workplace, because that’s an area where I feel it’s my safe space, where I have control, where I excel for the most part, and I would rather keep that as my space, safe space almost, is what you could say, where things make sense to me and where I can function well. And as I said, it’s more outside work where things can fall apart, which I think was previously unrecognized, was all about work and school and if you do okay there, then nothing’s wrong. But what about the rest of stuff that we need to do as an adult. And all those other extra tasks that we have to pursue. It’s not just, you know, doing the fun stuff as I’m sure you’re all well aware of as psychologists, you know, actually interacting with clients and patients and doing things and talking to people is great for us with ADHD, but it may be all the other behind the scenes paperwork, documentation, writing letters, writing reports that can be extremely hard for those of us with ADHD. And that’s where things are troublesome.

Paula Redmond (37:52)

Yeah. Yeah. So I do quite a lot of work with junior doctors, inverted commas, who, with exam support, so maybe, you know, struggling with their exams and, have, have kind of sessions to support them around that. And I’m always struck by the kind of unbelievable expectations that are placed on people to manage, you know, crazy kind of shift work, huge demands at work and study for these exams, which always seem rigged against people. And often at a stage where maybe also people are really navigating adulting and wanting to be or becoming new parents and just like the executive function load is immense. I really have so much admiration for medics surviving this time. And if you add in some kind of executive function challenges to that, it’s a lot.

JT (39:04)

Absolutely, yeah. And I think the key thing is, you know, doing something that you find inspiring and meaningful will help towards that, but it can be hugely destructive to your emotional wellbeing when you fail. And these exams are very, you know, rigorous and they require a lot of hard work. And certainly if you fall down, you can really become despondent very quickly. And as you said, there’s not a lot of awareness of the impact of neurodiversity, although I would say that is now becoming more commonplace to do a neurodiversity assessment when people are struggling with exams, as you said, via exam support. But that’s one of the issues. I never struggled with exams. And so therefore, once again, you’re not looked at in the same light as struggling. But that said, I can hyper-focus, I can study and cram in quite extraordinary ways, but that may well then be to the exclusion of many other important aspects of my life, be that health, be that relationships, be that exercise, and it can be destructive to so many other aspects of your life.

Paula Redmond (40:25)

And I guess Jo, I mean, just to let people know we’ve known each other since primary school, so I kind of have a sense, and I guess for me, I am always absolutely in awe of how much life you live. I have such a boring life compared to you. You fit more into a week than I do into a decade! And I feel like you’ve had this capacity to make work really work for you in that you found a way to, I think, you know, really navigate work so that it really works to your strengths in terms of, you know, variety and novelty and opportunities to, you know, go to, I mean, you know, I know one week, I have to always ask where you are, because one week you’re doing mercy missions to Ukraine, the next you might be planning a trip to Antarctica, you know, then you’re off, you know, on holiday. I’m like, what? I mean, does that, does that kind of fit your feeling of your work life?

JT (41:44)

Yeah, I mean, I would say I’ve definitely chosen specialties that are within the acute care side of medicine, which definitely appeals more to my brain and has a potential for constant dopamine release. And so, yeah, no two days are the same. I think people do struggle with having a rota that’s not, you know, Monday to Friday, but those of us with ADHD often do better with, you know, shift patterns. I do a lot of nights. I don’t mind those as much as other people. I actually flourish more in those environments and certainly with a lot of activity, a busy day. You know, in my day, I’m exposed to a lot of things and going out on them, retrieve, medical retrieval, dealing with a lot of information on the unit, a lot of activity, stressful situations. And it’s in those times of crisis that those of us with ADHD really start to actually excel. So I think I’ve chosen work to suit me. And yes, and then in terms of even outside work, I definitely have a passion for pursuing almost work-related things outside of my actual working day and week. And as you’ve said, it’s a lot of global health medicine that I enjoy, teaching others in countries around the world. And that’s really my passion and almost my hobby outside of work. And so it keeps things interesting. You obviously have to devote a lot of your own side time to doing those things. And then that could certainly come at the expense of just being organised, washing the dishes and doing your laundry and getting on top of your finances and doing life admin that can certainly suffer. And I know none of us, neurotypicals included, don’t like to do those things, and that will usually be the response from those people. But we really struggle with all of that management. But yes, I think with having a lot of stimulation and a lot of things to achieve that once again feeds my brain and I can organise my life and my time well because I’m stimulated by what I’m doing. And I feel that those things that I’m doing are meaningful and that really, really helps with your time management. Because if it’s something you want to achieve, you will go the extra mile to make it work. Whereas I think some people might just give up and say, this is too much to be done, I’m like this is achievable, we can do this! So yeah, it’s picking what you love, I think.

Paula Redmond (45:15)

Yeah, brilliant. Thank you, Jo. Clark, I’m going to come to you. And again, maybe if you could just introduce yourself and your work role and then any kind of responses to what Jo was talking about.

CD (45:32)

I’m Clark Davidson. I am a clinical psychologist, as you mentioned, by professional background. I currently have a role as a head of psychology psychotherapy for an adult mental health directorate, as well as a busy private practice as well. As part of that, I also do a fair bit of ADHD, autism assessment, post-diagnostic support with adolescents and adults, and I provide leadership to a neurodevelopmental team as part of one of the aspects of my NHS role. So thinking about neuroatypicality assessment and support, I think is, yeah, has become increasingly a kind of passion, I think, really. In terms of reflections on Joe, I’ve got a lot of reflections, I think, on a lot of things that have been spoken about, both in terms of points of difference as well as points of resonance in my own personal experience. I think it was interesting kind of Joe picking up on anger at the suggestion of having a diagnosis potentially. I think I’ve had kind of more anger and frustration, more generally post diagnosis actually, and thinking about others reactions to, you know, that as a label, as a diagnosis. And that is something that I have a conversation with patients about really, is that it’s very unpredictable, I think, in terms of what you’re going to get on the receiving end of that, you know, in terms of, you know, a good, bad, ugly or mixed response really, with this kind of sense of an awareness of you being different, people will change in response to that. And if you’re making changes post diagnosis, people will respond to that as well. And it can be mixed, I think. I think that the kind of thoughts in and around some of the stigma that surrounds ADHD as a diagnosis I think is also interesting and I think post diagnosis have ended up pushing more into kind of advocacy I think and kind of fighting for, you know, people who I think are at risk of being shown contempt or marginalisation. I think within the profession of clinical psychology, I think there’s some very powerful other voices there that would oppose the existence of the diagnosis itself and can be, I think, quite attacking in and around that at times, which I found difficult actually that the profession in which I sit doesn’t necessarily universally accept or accommodate it. Other reflections that I’ve had? I think it’s interesting that we’ve all had a different route into diagnosis other than the standard NHS referral and assessment. And it makes me think about the affordability of the diagnosis to some extent, you know, that some people are just going to, you know, kind of opt out because the kind of wait otherwise is too long or they can’t afford it. And certainly if I was coming to diagnosis at an earlier time in my life as a question mark, I’m not sure I would have pursued it, you know, or been able to from a financial point of view. So I was diagnosed two years ago in my forties and I think it was some of the best money I spent, but it was a costly enterprise, both the assessment, but then also I ended up going further and in the medication route, which in and of itself is significantly expensive in order to titrate up to the most effective dose. Yeah, which I think is kind of interesting in and of itself. I think in terms of support from others as well, which is something that’s been raised, I think my own journey both pre-diagnosis, which has been most of my life, and post has felt really just trying to manage and function in isolation as best as possible, actually. I’m not sure I’ve necessarily felt a huge amount of being with others in the journey necessarily. It’s you know, it’s taken a lot of work to manage these traits in the way that I do. And I’ve only realized post diagnosis just how much energy that has taken and effort and work to put that stuff together. I would say I’m probably the, or one of the most efficient, you know, people within my work kind of life. You know, that does come at a cost, I think, you know, and part of the advantage post diagnosis, I think is about, still alone, probably, but kind of being able to kind of reconsider just how much energy that needs to take. I think that that was a big advantage post diagnosis, which has helped I think. Some people have been supportive, but I think that there’s something just generally in my experience of working, I mean, maybe this is just work life generally, but certainly working in healthcare, working in the NHS, I think most of the time there’s an attitude of you just get on with it regardless of…

JT (51:27)

That’s true. Yeah, yeah.

CD (51:28)

…you know, the pressures of the job or what’s going on in your life. You know, I think that there’s a kind of, you know, kind of…

JT (51:36)

As long as you get the work done, I don’t think people are that… stigma or not, as if you’re getting the work done, just crack on and carry on.

CD (51:43)

I think this is it, isn’t it? Indeed. ADHD would just be one of those things that is noted maybe, paid attention to for a second and then it’s well get on with the work anyway, you know, it’s so I think that is difficult I think. You know, it does feel like there is this kind of cultural, you know, just kind of message around yes, that’s fine, but it can’t impact on your work.

JT (52:10)

I think the newer generation, there’s a lot more awareness of these differences and the older generation might look down on these sort of snowflakes and say just get on with the job. But I think things will change and I think that more and more people will demand adjustments to their work as they do now for family life and for other difficulties that people have there. Things will change.

CD (52:39)

I think that’s my hope. I think things have, I think there’s a lot of work to be done in this regard and I think it does take those of us that are passionate about it to advocate for people’s, to have adaptations to their work lives in a whole range of different ways. And it feels like that needs constant root, constant reminding in order to kind of help the kind of work system to be able to support staff. It needs a constant reminder. I don’t think it comes naturally necessarily. So yeah, it’s, but no, indeed, I think that my hope would be that there will be a kind of ongoing journey in that regard as there have been with other things.

Paula Redmond (53:23)

I just wanted to kind of jump in and ask you about what led you to seek diagnosis at that point in your life?

CD (53:34)

So there was someone who I was supporting to get their own diagnosis and I was recommended a private psychiatrist by the medical lead of the time that I work with. And then there was a question put back to me whilst supporting this person through their measures and those kinds of things in terms of actually, does this stuff not apply to you? And my initial reaction was no, no. I mean, you know, I’ve been able to function, you know, coming back to that word again, you know, I’ve kind of, you know, gone through the educational steps and I manage a lot in my work life, etc. And so that was my immediate reaction. You know, I can, you know, I think that it’s humbling to some extent if you’re doing assessment of others and you’re missing out on an assessment of yourself in that way. But then once I did start to consider it in a kind of different light, different perspective, I just thought, how did I not see this before? I mean, it’s just blatantly obvious, and life makes so much more sense looking at it through this lens than kind of otherwise. And then that led me through that journey really. You know, like I say, in some ways it is surprising, but I just wasn’t very attentive to this in me, really, I think is the reality. So that’s what kind of led me down that path really. And I think I kind of took it as I tried to kind of do generally with healthcare, healthcare is rubbish at being a kind of science driven enterprise, I think in the main, but I think that’s how I like to go into it. It was a kind of science based ‘test this hypothesis’ you know, and continue that process of test and learn, will this medication do something for me? You know, are there other things that might help with this? You know, I mean, what is ADHD? It’s, it’s a concept, talking to a collection of traits, but I think there’s a number of different pathways to people ending up in the position where they have this as, you know, a significant part of their neuro development I would suggest is kind of where my thinking has kind of taken me latterly. And so that is the kind of spirit in which I went into it with really was let’s just test this hypothesis out. And I think it’s the best idea of the moment probably for me.

Paula Redmond (56:11)

And what, has that led to any change in how you relate to work and how you are in work, structure work?

CD (56:21)

Yeah. I mean, yes, I think there’s a noticing these traits and being frustrated with yourself around these traits. Oh for God’s sake, you know, I’ve still not taken the bin out or I’ve been to the fridge 18 times when I could have just got it all out of the fridge, you know, in the first place, that kind of thing. It also made me reflect on just what I had done and what I’d built, I guess, really, in terms of strategies and approach to functioning, you know, and actually, as I say, kind of reviewing that and thinking, actually, can I make this work better for myself? So actually, I think I had put a lot in place, but I think it was taking a lot of energy and some of it wasn’t needed. You know, I think it kind of moved into this kind of ultra control kind of state, so actually easing up on some of that where it wasn’t really functioning in the way it was intended, I think was helpful. The kind of medication in and of itself, I think was helpful in that as well. So I was titrated to the maximum dose of eventually of dexamphetamine. And I think just on first taking it, I noticed a significant difference in terms of attention, concentration, focus. I was a lot more aware of how fatigued I was, whereas I just would just carry on, blast through regardless, you know, I can easily work 50, 60 hours a week, you know, and just relentlessly kind of driven in that way through hyperfixation and the ability to just keep going until I drop. But the kind of medication actually made that harder, made me more aware of how fatigued I was. So that then helped me, I think, to kind of slow down and pause, make different decisions and just be a lot more relaxed about it all. I felt, you know, I had courses of psychological intervention before around different issues, you know, and kind of thinking about some of the comorbidities that have been mentioned by Jo and Millie, you know, anxiety issues and kind of other things. But I just felt like there was just this napalming of a baseline of shame-based anxiety that I didn’t even know was there. And I would have never, I don’t think, got to the point of getting that same outcome in terms of a napalm of it without the medication actually, because I’d tried. I think it then helped me to work on it in other non-medical ways as well. But I, you know, and I think there are other routes to that other than medication, actually. I don’t think it’s an essential, but it helped to facilitate that in a more kind of quick, ready way, and then enabled me to kind of go backwards, kind of think, OK, well, actually, how do I now kind of work on this in a different way? So that was huge. It did open the door, though, actually, to me then reflecting back on my life and just actually being aware of another comorbidity in terms of complex PTSD, just a life lived of a lot of threat and danger and risk and, you know, kind of events that I just kind of laughed off or shoved in a box, all of a sudden, I think I was in a much better position to actually look at those new, suffer those in a different way, actually. And then, you know, then there was another task actually to be, to kind of work through that as a kind of second emerging issue, which was interesting. And I guess these things along the way impacted in terms of work being difficult to juggle alongside that journey, whilst also finding that work was able to, I was able to make myself work better for myself and that impacted usefully in work. I think clinically it kind of made me think more and differently about ADHD and other neurodevelopmental conditions. I think it pushed me a little bit more into working with that client population. And like I say, kind of advocating for and thinking about the kind of post-diagnostic support, the kind of various avenues that kind of lead to the manifestation of these traits and therefore opening an idea around what could help with that. know, so things like physical health. You know, I always ask questions now in an assessment about physical health. I’m always interested in seeing whether somebody’s had a work up of bloods, you know, and the amount of people who have then gone on to get treated for quite significant physical health issues that wouldn’t have been if I’d not asked those questions, they’d not sort out, you know, some investigation through the GP, you know, that have helped them people with the, with kind of some of the resolution of those traits, even if they do still have that kind of core concept diagnosis, I think has been quite significant and eye-opening. So it’s helped in a whole range of ways, I think, actually personally, in terms of my own work life and approach. Although it’s quite easy to then fill the time you save with more work. You know, I would put that in, there’s that risk.

Paula Redmond (1:01:55)

I was thinking it sounds like it’s opened up doors for you in terms of your own personal kind of healing and discovery and way of, you kind of this interplay between your personal and professional life that has been enriched.

CD (1:02:11)

Indeed, indeed. And I think without that kind of carrying of shame, it means that there’s a lot less shame-based offence. The kind of striving to please, the kind of masking your true self, the kind of constantly seeking that praise but not knowing what to do with it and dismissing it when you get it. The kind of awareness of contempt for others who aren’t able to kind of hyperfixate in the same way as well as contempt for myself, you know, and playing up to some of that, you know, because at least I’m in control of how embarrassing I am, et cetera, et cetera, I think has all really, really helped, definitely.

Paula Redmond (1:02:59)

Really powerful. Thank you, Clark. I wonder if Millie, you have any responses or reflections to what Clark said?

MW (1:03:12)

Yeah, thank you. Thanks for sharing, Clark. It was really interesting. I mean, I think I have loads. As you see, I was nodding a lot. I think there are a number of points where you succinctly described my experience much better than I think I did as well. I think the point you said about in the NHS, that feeling of you’re kind of sharing with somebody and it’s like a great, okay, but just get on with it and don’t let it impact anything, that is exactly what I think I was trying to share in my experiences as well. And also I think I was observing that going first, I think I had some anxiety that people might be thinking, oh no, that’s nothing like my experience, so was nice, really nice for me hearing from Jo and Clark, there was loads of overlap and lots of things that you’d said. I think I kind of really agreed with your point, Clark, about the affordability of a diagnosis and who that’s available to from an affordability perspective, but also from just an understanding, having even that on your radar, you know, because I think when I was at school, and I’ve really noticed that because my one of my best friends is a teacher at my old secondary school and it’s now a specialist in neurodiversity and support and it was not even raised on anyone’s radar when I was there, you know. I think, yeah, that’s really crucial. And also often I’m, you know, reflecting on who is more likely to meet a different type of diagnosis versus ADHD, you know. I also was really pleased to hear that you’re kind of, you know, a leadership and provide consultation to a neurodevelopmental team and you’re part of that leadership team for them. I think that’s great. I was wondering, it’s a question of whether you’re open with your own diagnosis in that role and whether people are aware of that or..?

CD (1:04:58)

I am, yes, both with colleagues, but also patients, I’ll bring it in. It feels like there’s always, you know, a kind of balance in terms of self-disclosure and whether it’s more for you rather than the patient, obviously. But I find that actually self-disclosure around a neurodevelopmental condition is helpful. I think it’s useful as an icebreaker. Sometimes it’s useful to actually provide some kind of a kind of model in terms of kind of what that kind of journey looks like. There’s a normalization kind of aspect as well as a de-stigmatizing aspect of that as well. I think the idea that there’s a task to survive being neurotypical in a neurotypical dominated world is something that’s able to be spoken a bit more if you’re owning your own kind of experience of kind of some of the battles that you’ve had with that. You think, you know, that actually this isn’t, I don’t think inherently a disability, because I, you know, I wouldn’t be in the job I am now, wouldn’t have had the success as a career without ADHD, without what we call ADHD, I’m highly convinced of that. But society itself and elements within, I think, can be disabling and can disadvantage, and I think making that distinction is also useful with self-disclosure to have those conversations. Some people feel like it’s a sentence that they don’t want actually, even if they’re pursuing the diagnosis. I think it helps with that.

MW (1:06:37)

I think the fact you said modeling as well, I’d written that down. I didn’t want to forget any of my reflections for all of your points, but I just think I agreed with what you were saying, like that advocacy and that modeling of it is really important. You know, being able to see somebody in those positions with that diagnosis, you know, a doctor, a medical professional, a head of service, like a lead role, things like that, I think is really important to kind of challenging some of those views. And I think I really connected with what you both said about anxiety. I think again, you summarized it really well, Clark, that shame. I think that was pointed out to me, that ongoing shame from masking or from mistakes being highlighted. But I think I remember thinking when I was working with a young person with ADHD, it’s almost like we have the ability to be anxious about a million things at once. Whereas maybe somebody more neurotypical might just focus on one thing, whereas it’s like you can do it on hyper speed, almost like a hyper fixation or focus on anxiety, and I think that really then feeds into that self-criticism. And I think it connected for me with what you said, Jo, about always being busy. I’m definitely like that too. But I think it’s took me a long time to try and manage ways to learn to switch off, to be able to calm yourself. Because that was just not in my ability. I would just be nonstop busy. And as you said, it’s exhausting. Whether it’s with work or whether it’s with a social thing, but it was almost like a fear that if I stop, then I’m just gonna go into her overthink and over anxious, and so I think, yeah, hearing that from both of yourselves was quite, was validating in that sense. I was also just struck by what we’ve all mentioned about this recent narrative of, oh everybody has ADHD. And I think it can be used as a bit of a stick to kind of beat people with, and I’ve definitely come up against that more recently, you know, with the panorama and, and it’s this idea of like, oh yeah, everyone has that, it’s so popular nowadays and la la la. But then I just think it’s so interesting based on all of our experiences, how actually difficult it is to access and that not being people’s experience, but in the media, it being perpetuated as almost like, everyone gets given a diagnosis, everybody’s put on medication immediately, when actually what we’re highlighting is that if anything it’s often really missed. And I think I often have, I’m going to say discussions, sometimes it can be more arguments or debates, but with with people in this field as you were saying Clark you know in the field, in the profession of clinical psychology in terms of kind of and in teaching, my sister’s a teacher, she often has this discussion now with people. But almost like this idea, I would love for it to get to a place in our world where we don’t need a label, we don’t need a diagnosis, we don’t need to go through an assessment and people just accept that people’s brains work differently. You know, I’d love for that to be the case, but unfortunately it isn’t. And unfortunately our schools and things and work systems are set up where people need to get that. So I think we can’t have it, you know, both ways, a bit like being like, do we even need to diagnose that anymore, everyone’s got it? And it’s like, well, unfortunately, yes, because in order to access support or even understanding or even awareness that is unfortunately the way our systems are.

JT (1:09:57)

And I think I know myself and Paula, we were talking about this the other day, just the way the world is also changing so much in terms of the age of information, obviously now the age of AI, but just that kind of access to information, which I think on the most part is excellent in terms of ADHD awareness, but also we run the risk certainly of being sort of overstimulated and having so much more information that we need to process and deal with every minute of our lives. And that can really also be something really difficult to work with for those of us who have brains that function in this way. There’s just so much overload.

CD (1:10:46)

I think you’re right and some of the patients who I will work with, what they’re looking for actually is for somebody to signpost and direct and to slim down for that journey because it is quite unwieldy if you’re trying to navigate that yourself I think. You know we’re professionals so obviously maybe we’ve got an advantage in terms of you know kind of how we do that, but a lot of other people won’t have that. I think it’s interesting that, you know, I was in a trust-wide meeting with the medical lead for ADHD and her citing her concerns about just how many people are coming through for referral and the questioning of, you know, are we getting this right in terms of a diagnostic concept? Are we, you know, kind of actually at the forefront of where the evidence is with this in terms of assessment, et cetera? And so I do think that there’s a balance there. I think there’s a lot of poor assessment practices out there, particularly in the private sector. And I think that has an impact in terms of the ongoing legitimacy of this as a useful diagnosis, which I think is helpful to hold in mind. But you know, there’s also a kind of legacy that you would expect to be dealt with. I mean, you know, I was born in 1981 and I can’t recall a child in my school having a diagnosis of ADHD. It wasn’t thought about, the school system didn’t really, wasn’t really geared up to kind of work for me. I had to try and make myself work as best as I could and failed and struggled in different respects along the way. As was mental health, not particularly a thing, you know, people having diagnosable mental health conditions in the 80s. So I think there’s the legacy of that in terms of people that have gone through, you know, their childhood and their adulthood and that not been there even thought of as a thing, you know, to catch up on, which is why there’s a lot of adults out there that are seeking diagnosis now. And I think actually even within the kind of current school system, there is a reluctance and I think to highlight these things and to put people forward for. Partly because it’s so difficult as a child to get a diagnosis, even though there is much more awareness of this. So I think inevitably you’re going to see high numbers of referrals. You would expect that, you know. Yeah, I think there’s a balance and I think that’s why you know there is this need for this kind of ongoing science, this science-based approach you know and kind of practice-based as well as evidence-based you know, approaches to continuing to develop where we go in terms of our understanding of this thing.

Paula Redmond (1:13:50)

Thank you all. I’m going to sadly bring this to a close, but it’s been so wonderful to hear your personal stories and your professional insights into this. So thank you so much.

The post Being a healthcare professional with ADHD: sharing experiences and insights appeared first on Dr Paula Redmond, Clinical Psychologist.

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Full transcript below

Paula speaks with Clinical Psychologist Dr Lauren Breese about some of the complexities, controversies and opportunities around ADHD diagnosis, particularly in relation to work.

The conversation includes:

• what ADHD is and how it might impact people in the workplace
• gender differences in ADHD presentation
• thoughts on workplace adaptations
• controversies and misunderstandings about ADHD
• the importance of a rigorous assessment process
• benefits of seeking an ADHD assessment
• navigating conversations about ADHD with empathy and curiosity

About the speaker:

Dr Lauren Breese is a Clinical Psychologist and founder of ‘and Psychology‘ (an assessment and therapy service for neurodivergent adults) and ‘The Neurodiversity Practice‘ (a service supporting ND parents, as well as workplaces and mental health practitioners to embrace neuroinclusivity.

Instagram:

@_andpsychology_

@‌theneurodiversitypractice

Linked In:

www.linkedin.com/in/drlaurenbreese

www.linkedin.com/company/theneurodiversitypractice/

Lauren’s recommended resources:

Podcasts:

• The ADHD Women’s Wellbeing podcast
• The Hidden 20%
• ADHD Chatter
• The Neurodivergent Woman

YouTube:

• How to ADHD – Jessica McCabe

Books:

• How to thrive with Adult ADHD – Dr James Kustow
• We have a free recommended booklist for ND parents to download here: https://www.theneurodiversitypractice.com/book-list
• Download our free neuroinclusion at work checklist to share with employers: https://www.theneurodiversitypractice.com/business

I’d love to connect with you so do come and find me on LinkedIn or at my website and do check out the ACP-UK and everything it has to offer.

Follow and subscribe so you don’t miss an episode!

Transcript

Paula Redmond (00.38)

In this first episode, I spoke with clinical psychologist, Dr Lauren Brees, to explore some of the complexities, controversies and opportunities around diagnosis. Our discussion includes common misconceptions about ADHD diagnosis, gender differences and presentation, how ADHD may impact people at work, navigating conversations about ADHD and more. I began by asking Lauren to introduce herself.

Lauren Breese (01:12)

I’m Dr Lauren Breese, a clinical psychologist specialising in working with neurodivergent people. I’ve worked in neurodevelopmental services in the NHS for over 14 years. And in that time, I had the opportunity to work with neurodivergent people across the life span. So I started working in cams with children and families and then I moved over to working with adults at the national specialist autism and ADHD psychological therapy team. And I’ve also set up two new clinical services as clinical lead for neurodivergent adults, and I’ve taught at universities and conferences all about neurodiversity. Now, though, I predominantly work privately and I founded two companies, the first one is And Psychology, and that’s a service where I assess for autism and ADHD and provide therapy for neurodivergent adults. And also The Neurodiversity Practice, and there we provide more systemic support for the neurodivergent community. That means things like our online community called the Neurodivergent Parent Space and workplace and professional training to support the implementation of a neuroinclusive culture across different settings. 

Paula Redmond (02:35)

Yeah, brilliant. Thank you, Lauren. So we’re talking today specifically about ADHD. And I wonder if we could start with just a question about what is ADHD and thinking specifically about the context of work and I guess a second part to that question about how having ADHD can impact someone’s relationship to work, how might it show up and what kind of impact might it have in someone’s working life. But yeah, maybe let’s start with what is ADHD?

Lauren Breese (03:14)

So yeah, ADHD, it stands for Attention Deficit Hyperactivity Disorder, which unfortunately is quite a misleading name, because what we find is actually people who have ADHD don’t tend to necessarily have an attention deficit. They might have an abundance of attention actually and find it hard to regulate that. So they might find it very easy to attend to some things, but find it very difficult to attend to others. So more broadly, it’s a neurodevelopmental condition that is characterised by difficulties with self-regulation. So thinking about attentional regulation, emotional regulation, and also executive functioning difficulties or differences. So executive functioning is, you know, I always think of it like the little conductor in front of your, in your frontal lobe, in the front of your mind that’s helping you with organising tasks, planning, starting tasks, stopping tasks, kind of time management, things like that. And I suppose for a diagnosis of ADHD, we’re looking in two main areas. We’ve got hyperactivity and impulsivity, as well as difficulties with attention or inattention. And usually people might assume that hyperactivity might look like running around or, you know, an image of a little boy, a child, like running everywhere. It actually can be more subtle than that. So it can be kind of more internalised presentations, like racing thoughts, finding it hard to feel settled or being constantly on the go but that might look like pacing in the workplace for example or doodling. So yeah, we’ve got these two main areas which can be kind of represented by lots and lots of different characteristics and a combination of these. What we’re looking also for if somebody’s diagnosed with ADHD is actually that they are having an impact on that person in the sense that it’s really making it hard for that person in numerous areas of their life with relationships or at work, you know, in kind of multiple situations. That they’ve had those characteristics or differences since childhood, they might present differently or have presented differently in childhood, or people might have learned to suppress them. And we also need to be careful as well that they’re not characterised by other conditions, other mental health difficulties or other physical health difficulties. So yes, that’s kind of broadly what is ADHD.

Paula Redmond (06:07)

Yeah, great. And yeah, that question about when we’re thinking about people in the workplace. What kind of things do you commonly find with the people that you work with when they’re talking about the impact on themselves in work?

Lauren Breese (06:23)

Yeah, absolutely. It can be hugely debilitating. And I always find that it’s kind of two factors. Firstly, the characteristics of ADHD themselves can be very debilitating. So if you struggle to plan ahead or if you struggle to start tasks, tasks at work become quite overwhelming. Then, you know, time management, attending meetings on time, prioritising tasks, having a to-do list that can feel extremely overwhelming and finding it hard to work through it to a deadline. All of these things make being at work or in a traditional working environment very, very difficult. Also kind of schooling. But on the secondary level, I would say that you’ve obviously got these kind of practical things that people do struggle with that then make working hard. But often when I work with people, they have struggled with these things throughout their life. And as a result of that had very negative feedback. So there’s kind of an idea that children with ADHD might hear 10 negative things to every one positive thing in the day. I mean, I think that was potentially, I don’t know if this has been a research study, I think it’s more a professor who said it, but it’s a good guess around kind of people experiencing these negative critical comments around could you not just try harder? Why can’t you do it and that person can do it? You you’re always, you’re always doing that. You’re never able to complete a task. And so then what can happen is then. people can internalise this criticism and it becomes self-criticism. And what I see really commonly is on a practical sense, people being asked questions, for example, at work or being asked to answer something in a meeting. And then the processing speed or executive functioning, it potentially feels like they’re being put on the spot and there’s a well, they’ve had all of those previous experiences of being criticised and not necessarily being able to answer very quickly or had negative feedback on how they have responded. And this just sends them into that flight, fight or freeze mode. They’re in the threat mode. And then their mind goes blank. And it’s kind of a very, very difficult situation to be in because they can’t think straight. They’re very stressed. They do have potential like… or the difficulties that they have with the executive functioning and processing speed. But you’ve also got this extra layer of then criticism which then makes that worse. So, yeah, this is something I commonly find for people that I see in clinical practice, this kind of double warning of your ADHD symptoms and the kind of flight, fight or threat mode that they find themselves in in workplace scenarios. So that’s kind of very tricky. And I think just on a different note, I often see people might have changed jobs quite often. They might have kind of had lots of different experiences of work. People might tend to thrive in a different type of environment that’s maybe less traditional of a workplace.

Paula Redmond (10:06)

Maybe say more about that Lauren if you can. What are your observations around that?

Lauren Breese (10:11)

So, yeah, often we find that maybe a traditional, well, I think for people with ADHD, they can thrive with adaptations to their work environment. And these need to be put into place and to be thought about to kind of make sure a workplace is neuro-inclusive in its culture, but also its practices. So things like, you know, on a practical level, we know that people with ADHD sleep can be poorer and their sleep cycles actually can be different or kind of later onset of sleep. And so actually it really follows then that a nine to five schedule might not work for somebody with, you know, and, you know, other reasons on top of sleep, but that’s just one example. So it might be that outsourcing tasks that are potentially difficult for somebody like having a PA or having somebody to help organise a diary is just a really simple solution to something that somebody finds difficult. And so what I tend to find is I work often with people who have maybe left a traditional workplace and created their own workplace. Maybe they’re an entrepreneur or they created a space where they can thrive, they can be creative and they have the flexibility to outsource the tasks that they might find hard. And that can be very helpful for somebody with ADHD, but obviously it’s not always possible for somebody to kind of go and create their own business. So this is why we’re needing the kind of workplace adaptations to, and actually they tend to suit everybody. It’s kind of making workplaces more inclusive, which is incredibly important.

Paula Redmond (11:58)

Great. And as you’re talking, Lauren, was just thinking about what I’ve been really aware of in my own work, for example, in the NHS, but I hear this in other industries, fields as well, is that with the kind of move to more digital recording and more kind of data driven work practices, that there’s a much greater emphasis on the kind of ticking the boxes and filling in the forms and these kind of practices that help with data collection and much less emphasis on quality of work, you know, thinking particularly about healthcare, that what people get monitored on and assessed on and appraised on is, have you filled in all the right forms and ticked all the right boxes and, you know, is everything up to date on the computer system? Not, you know, how, are you doing in your work? You know, what is the quality of, of care that you’re providing the quality of interactions? And I guess I’m just thinking how, I mean, that’s challenging for everyone. But I think, you know, I’m imagining that if you have ADHD you might really struggle with those more, you know, administrative aspects of the work, how depleting, demoralising that might be in terms of the kind of work environments we now find ourselves in that emphasise that part so much more.

Lauren Breese (13:31)

Absolutely. I think that’s such a good point, And it’s frustrating. It’s, you know, I think you’re right. It’s the prioritisation of the completion of all the forms. Just you’re reminding me of, know, have you asked this question? Have you asked about something that may not be clinically related actually to what you’re working on? And I think, you know, one strength of somebody with ADHD is that they potentially can be quite creative in their thinking and are able to think diversely or outside of the box and may have lots and lots of different ideas. And there isn’t an assessment for that, there isn’t a kind of you’re doing a good job because you’ve actually come up with this idea about how to do things differently. Actually what we’re praised for is doing things exactly the same way and in this way and to tick this box and to be having it completed and yeah it is I imagine very challenging.

Paula Redmond (14:41)

Yeah, and people that I’ve worked with, who’ve been suffering from burnout, and that’s been a kind of a common theme for people either who are starting to kind of think about an ADHD diagnosis or who have one that, you know, the kind of burden of often duplicating work over and over, and never feeling like you can catch up, never feeling like you can do a good enough job because of this emphasis on those kind of tasks. It’s really difficult.

Lauren Breese (15:23)

And keeping things in mind and kind of that working memory and visual working memory which we know people with ADHD struggle with, and I think this also it’s reflected as well in I think the path of later diagnosed people. So what we might find is people struggle with all of those, well they struggle with these things in childhood, but they have either had the environment to help support them or they have learned ways that they can tick the boxes despite it perhaps being quite debilitating. And then as we get older, so, especially for women, if we’re thinking of our reproductive life cycle, our hormones fluctuate across the month, but also across puberty, after pregnancy, perimenopause and menopause. And what that means is at times, at key times we have a reduction in oestrogen, which also reduces dopamine, which is indicated in ADHD and other hormones. So we have this physical change, but also what coincides with that are lifestyle factors that add to the mental load, which, so we’re thinking about the extra burden of potentially childcare or planning for more than just one person, thinking about potentially being carers for the older generation. And this doesn’t just affect women, it also affects men, but we’re also seeing the combination of hormonal changes. And so what can happen is the demand outweighs the capacity. So where we have coped previously, there’s too much now to cope with in terms of the mental load and the checklists and the previous coping strategies haven’t worked necessarily or are no longer working, and we can then lead to this cycle of burnout. So yes, all of the admin tasks at work, but as well as all of these other things on top of the hormonal difficulties is, in my opinion, why we’re kind of seeing these later in life diagnoses, particularly for women. Yeah, when the kind of demand exceeds the capacity.

Paula Redmond (17:55)

And one of the other things that I was thinking about and that I’ve noticed more, I suppose, in my personal life than professional life, is there are people who for whom work is maybe a particular domain where they really thrive and the difficulties actually don’t show up in work that it might be, you know, the one domain where they’re able to really perform and really kind of meet their potential. But everything else is a struggle. And I guess that can be quite challenging when it comes to kind of understanding, thinking about a diagnosis or that being seen or thought about in work when it maybe doesn’t show up there.

Lauren Breese (18:45)

Yes, yeah, I think that that can be a huge challenge and I think, yes, you’re right in that ADHD can show up differently in different environments, so, which is why it’s so important to adapt the environment where possible to support somebody. But if somebody with ADHD finds something incredibly rewarding, for example, potentially quite novel or they’re able to really engage in it, then they, exactly as you said, could thrive. And we see this often as well at school when the structure is right and that it’s very validating, very rewarding, people can achieve. But it’s when those things, so either people can get into then a cycle of then potential hyper-focus and burnout where it’s very enjoyable to have that sense of achievement and that I’m doing well and kind of being able to do it. And then they might do that a lot, and then that’s exhausting. We can’t maintain ourselves at that level. We need time for rest. We need time for soothing. We can’t always be in drive, strive or throat mode. And so it can tend to kind of go into a boom and bust cycle in that sense where some people might end up being exhausted and then at home where they might feel more able to be in that soothe mode then that’s very challenging to maintain that kind of high level that they are achieving elsewhere. And I suppose, yeah, it’s helping somebody to find a balance between those, I suppose, ways of being because all are important, but how is somebody going to be able to thrive in all of the areas that are important to them? Because they might be, they might want to have more of a balance within that at home or at work.

Paula Redmond (21:04)

Yeah. We’ve talked a little bit about women and, and how things might affect women differently. And I wonder if you could say a little bit more about that, about how ADHD might present differently for girls and women and why that might be?

Lauren Breese (21:22)

Yeah, definitely. So we’re not very good at picking up on ADHD in girls and women. Traditionally, it’s been seen or kind of more recognised in boys. It’s interesting, there’s kind of research to show that more boys than girls have ADHD, but actually by the time puberty hits, that equals out a little bit which lends weight also to this idea that there are hormonal implications related to this. Generally, girls and women tend to be more inattentive than hyperactive, or their hyperactivity might present in a more internalised way. So, racing thoughts, more kind of subtle ways of fidgeting, doodling, I think I mentioned that earlier, but less so than kind of running around that you might see in kind of more of a boy presentation.

Paula Redmond (22:29)

And I guess I suppose that is part of why women and girls are under-diagnosed because their presentation doesn’t necessarily fit so easily with the diagnostic criteria.

Lauren Breese (22:47)

I think that’s it. So I think that the kind of research tend to, you know, tends to be skewed in that way and that we don’t, we don’t know necessarily what ADHD might look like in girls and women and that it tends to be based on a more of a boy male presentation. And I think this is why, yeah, we’re less good at picking it up. And in fact, I think what can be more likely to happen for girls and women is that they are misdiagnosed with another mental health difficulty like anxiety, depression, UPD, bipolar disorder. And this happens frequently. So, you know, women that I have heard from who have had a later diagnosis of ADHD, they might go to the GP and mental health difficulties are potentially the first thing that somebody is kind of thinking about, you know, more so than if a male went, this is from my clinical experience yeah, it’s this kind of diagnostic overshadowing that happens frequently for women. So we know that things like PMDD is more common for people with ADHD and kind of menstrual pain, but also like other physical health difficulties, like inflammatory conditions. And, you know, these then tend to overshadow an ADHD diagnosis. So what, you know, is helpful advice, I think, is to keep an open mind at that assessment stage. You know, we’re really, it’s incredibly important to be doing differential diagnosis with ADHD, but it needs to be on the table from the beginning as part of the discussion to be ruled in or out. And I think that it hasn’t been so the case for women.

Paula Redmond (24:39)

Yeah. And I guess there’s also something about masking and social expectations that might play a role in these different presentations. And I guess something about, you know, the internalisation of some of these symptoms that might happen more for women than for men.

Lauren Breese (24:59)

Yeah, I think so. I think it’s what do people expect of, of even play, you know, from an early age of playing for children. And is that running around the playground and being able to engage in sports, for example, or is that kind of sitting quietly and nicely and doing imaginative play. And it’s very gendered from the beginning. I think it’s potentially those narratives around being quiet and being good and being, you know, not shouting out, not being able to express your individual opinion, which I guess without being stereotypical can be internalised as being a good girl. And so you’re kind of suppressing from the beginning that urge to shout out or the kind of traditional hyperactive impulsivity that we might see for somebody with ADHD. You’re learning to suppress that for fear of negative connotations or not being encouraged to be yourself in that sense. So yeah, I find a lot of women tend to have had this experience.

Paula Redmond (26:14)

Yes. And I guess it’s also fair to say that this can be, you know, it’s a very topical conversation, you know, ADHD is around in the news a lot. And there are, I suppose, some controversies in the field around, and even in within clinical psychology around the diagnosis itself, around, you know, the kind of expansiveness of diagnosis and need. And I guess I’m aware of when I, you know, tell people that I’m offering ADHD assessments, it’s really interesting how people respond to that and I tend to get three types of responses, and I wanted to talk to you about those. So the three responses I tend to get are: Is that even a real thing? Like, is this not just an excuse for people being lazy or immature? The second is how come every second person now has ADHD, you know, everyone I know has it. This sort of idea of this sort of, you know, hugely increased prevalence and like how meaningful is this as a diagnosis if everybody’s got it. And the third one is, you know, this you know, Oh yeah I’ve got this friend who, you know, does this fidgeting thing, definitely ADHD. This sort of…

Lauren Breese (27:40)

I hear those too, yeah.

Paula Redmond (27:44)

So maybe if we start with the first one, this kind of question, like, is this a real thing? Does it exist or is it just an excuse? What would you say to that?

Lauren Breese (27:54)

Yes, what would I say? Yeah, it’s a shame because it’s a common, it comes up a lot. And I suppose it’s a shame for the people who experience ADHD, who have ADHD. It can feel very invalidating of somebody’s experience because if you have ADHD and if you know people with ADHD, it can be hugely debilitating. And there is a lot of information about, you know, we want to be neuro-affirmative and we want to see strengths as well as challenges. But in being neuro-affirmative, we can’t deny the challenges. You know, neuro-affirmative doesn’t just mean being relentlessly positive about something. So, I think that this is extremely challenging because it potentially invalidates some of the difficulties and real differences that people experience. I think what I would say as well is there has been hundreds of thousands of research studies on ADHD. And these say that ADHD is a neurodevelopmental condition. And so it’s interesting as to why we are questioning this in a potentially a similar way to some of the conversations we had about autism, know, years and years ago around, you know, very long time ago, autism is related to refrigerator mothers, which we know is not true. But we now seem to have accepted autism as being a neurodevelopmental condition, but ADHD, I feel like we’re still catching up. And, you know, there are neuroimaging studies of structural differences and functional differences in the brains of people with ADHD, particularly in the regions involved in impulse control, attention, executive functioning. And we also know from thousands of research studies is that there’s around a 80% heritability rate, which is about the same as height actually. So if you’ve accepted that, you know, if my mum’s tall, then I might be tall. But actually what we’re seeing is if your child has ADHD, your parents may also quite likely have ADHD. And yes, there are other risk factors involved, but there are even kind of new studies, you know, trying to think about the genetic expression of ADHD. And you know, we’re not there yet, there’s probably likely multiple genes involved, but, you know, I would say that there is a lot of evidence for the validity of ADHD and in the same way that, you know, autism and, you know, we would characterise that as neurodevelopmental conditions, we know lot more about how these present and how we need more research, but yeah, that they are real things. And I think questioning that can be quite invalidating for the people who do experience those real challenges.

Paula Redmond (31:09)

Yeah. And what about this, this the second point that I hear a lot, which is, you know, now every second person you come across suddenly has ADHD, and how does that, how do we make sense of that?

Lauren Breese (31:25)

Yeah, it’s so interesting. I was at a conference this year, an ADHD conference, and I think clinicians are also surprised at how interested people have been becoming in ADHD. So what’s interesting is to kind of separate it out a little bit. So what we know is the prevalence of ADHD is around 3% of adults in the UK. About, we know, probably about two million adults remain undiagnosed. So having clinical experience that’s, that you know I think 3% is potentially on the lower side, it may go up to about 6%. So for children it’s a similar percentage, around four to seven percent something like that. And actually the prevalence rates of these diagnoses haven’t changed, but what has changed is more of the incidence rates. So we are seeing more people being diagnosed. So, you know, yes, people are coming for assessment and diagnosis. And I think that’s related to a greater understanding, a greater awareness and communication about ADHD. It’s interesting it kind of coincided with the COVID pandemic in that I think I read something where it was in that year, ADHD was the second most Googled condition on the NHS website, and I think also like the increase in TikTok videos or like online videos about people’s experiences. And also what we’ve got is people working from home, people having a break from the traditional work setting and either seeing that they can thrive actually, or seeing that they really struggled and kind of wanting to learn more about that. And so I think it’s kind of been a, yeah, a bit of a perfect storm in a good way, I think, because it’s, we’ve got more information, more understanding, and people are seeking assessment. But I personally think that this will level off as we catch up, because we, I think we have been underestimating under diagnosing and assessing and we’re just playing catch up. So, you know, women, people of colour are still under-diagnosed, you know, and so I think there will be a point when this kind of levels off and I don’t think the prevalence rates will change. I think we’re just seeing more people coming forward and recognising. I think another thing also is happening for the older, I say older, I categorise myself in that bracket, but people are kind of coming later on and they may have seen their children struggle at school and they have received an assessment and subsequent diagnosis and then they’re starting to think about their own experiences. So this is very common for the people that I see in adulthood, it’s like, oh right, we didn’t have an understanding of that when I was little, but I really struggled with that, and that’s something that I still struggle with. So we’re getting better at recognising it, but we’re still not there yet. Like, even though there has been a huge demand, we’re still kind of underrepresented, I think, in this area. And particularly research needs to catch up too for women and people of colour, or, you know, and generally.

Paula Redmond (34:59)

Yeah, that’s a really helpful distinction between prevalence and incidence. That really kind of makes it clear. Reports on the news every day about, you know, years long waiting lists for people, and it is, yeah, kind of hard to get your head around those numbers. But yeah, that makes a lot of sense.

Lauren Breese (35:19)

Yeah, yeah, there’s a huge increase in demand. And I think people are surprised in the sense that, you know, we haven’t had that before in services. And so we’re trying, you know, services are trying to catch up and design themselves to be able to meet the demand, but we just haven’t had, or services haven’t necessarily had the funding for that. It has been a bit of a surprise, I think.

Paula Redmond (35:43)

Yeah. And the third kind of response I get is this like, Oh yeah, yeah, oh my gosh, my friend’s always late, or, you know, my husband is terrible at, you know, doing the dishes, he must have ADHD. And I guess, yeah, there’s something interesting in that about, you know, this combination of greater awareness of what that might look like but I suppose questions about the complexity of what a diagnostic process looks like, what, you know, what ADHD in its fullness means. And, I suppose sometimes that question of like, you know, what is a kind of trait versus a diagnosable disorder?

Lauren Breese (36:30)

It’s a great question. I think this is the flip side of sharing information on TikTok. Yeah, yes, it’s really helpful to have an increased understanding or awareness, but I think potentially misinformation can be shared. you know, I’ve seen videos of, I have an ADHD diagnosis and I do this thing, and as a clinician, that wouldn’t be something that I would associate with ADHD. But then that gets shared and people resonate with that and then say, well, I do this thing, does that mean I have ADHD? And actually, it’s very difficult because it kind of dilutes what is quite a rigorous assessment process. So to be diagnosed with ADHD, you will have had to have hopefully have undergone quite a rigorous assessment process, especially compared to other, I mean, it’s not a mental health condition, but you know, other mental health conditions, for example. So, you know, I think there’s that part of it, and I can tell you more about the diagnostic process in a second, but there’s also another part of it as well around, I think people, our evidence base hasn’t caught up yet either. So people who have lived experience of ADHD are describing their experiences also. So, so kind of maybe they, for, a really good example is talking about rejection sensitive dysphoria. We don’t have much research on that. We don’t, that’s not part of the diagnostic criteria at the moment. That’s not to say that it won’t be. But it’s a kind of example of how as clinicians, we’re also trying to catch up with people’s experiences and saying, okay, is rejection-sensitive dysphoria a significant characteristic of ADHD in the sense that it could rule in or out ADHD, or is it something that overlaps with other conditions that is also just part of the experience potentially, but it’s not enough to be included in the criteria, for example? So we’re kind of, I think, at that point where we don’t have a lot of research to back up or we’re still kind of a bit behind in that sense. So, but, in terms of the diagnostic process, it includes multiple parts, you know, a kind of general, a general interview with the client about what they’re struggling with, what they’re finding, potentially easier or what they’re finding hard. A more focused interview around specific characteristics related to the diagnostic manual for ADHD, as well as an interview with somebody that knows them really well. Information from childhood, that might include school reports or an informant, developmental history, even looking at reports from professionals or historical reports, as well as your clinician’s observation. So you’ve got multiple kind of triangulated information which is required. You’re also thinking about impact, which is hugely important. So the impact on somebody’s life. And then another huge part of the assessment process is the differential diagnosis, which is hugely important. So ruling out other mental health or physical health conditions. ADHD can look like different things, anxiety, or potentially trauma, PTSD symptoms, or autism. And so a clinician needs to be really skilled at being able to tell apart these different things and amalgamate all of that information from multiple sources to come to a diagnosis. So it’s quite a rigorous process, and yeah, I think I can see why, you know, people might say, I might have ADHD, I do this thing, which I think may come from more knowledge about it, but actually to have a diagnosis, you have to meet a set of stringent criteria which haven’t actually changed. We haven’t got looser with the criteria, which is another thing when we’re thinking about kind of diagnosis broadening, it’s not changed recently. And so, you know, people do have to have training in assessing as well. So it’s not just something that people can come to, you have to have had training in being an assessor. So, yeah, it’s quite an involved in-depth process.

Paula Redmond (41:22)

And I guess there’s, there’s something about the particular context that we find ourselves in at the moment with these long NHS waiting lists, but also, you know, it’s that the guidelines don’t stipulate a particular profession who is able to do the diagnosis. So, there are lots of options out there to seek private assessment. And I guess we’ve also heard kind of horror stories about people having quite inadequate assessments. But I guess as you say, when you, you know, really are clear about what a rigorous thorough assessment takes, that’s not going to be done in 45 minutes or an hour and a one off appointment. And as you say, I guess that’s something that I suppose a profession like clinical psychology is well placed to offer particularly around the differential diagnosis. So I guess that’s really important for people to be thinking about who might be seeking assessment that, you know, checking out.

Lauren Breese (42:25)

I think that’s it. Yeah, checking out people’s experience. People, you know, because I think people are getting interested in it. You want somebody that has had experience of, you know, working in neurodevelopmental conditions, you know, who are able to differentiate between mental health, physical health, and like you say, clinical psychologists are well placed to do that. And I think what I’ve found as well is the skills of a psychologist around formulation are, I very much value in an assessment process. So obviously you have an assessment, there’s no one tool to assess for ADHD. So you’re using lots and lots of information from different sources and potentially different tools to help inform your clinical judgement. But I think, you know, a clinical psychology assessment doesn’t stop there. It offers also, you know, in my practice offering a formulation around understanding somebody’s journey, experiences so far, what might be keeping them stuck, or, you know, what might have contributed to their current difficulties, which some other assessment processes may not take into account. So I think for me, a diagnostic process is more than just a yes or no answer at the end. It provides a clinical understanding or a psychological understanding alongside an answer, which I think particularly adults who may have, I mean, everybody’s different actually. People may just want an answer and want a yes or no diagnosis, but some people want a more in-depth understanding around, and what else? And recommendations related to that. So I think for me personally, that’s what I value in an assessment process. Something that is very neuroaffirming, that can take into account differences within the assessment process so that they can adapt the assessment to somebody’s needs, but also that kind of formulation approach on top of the diagnosis. I find very helpful and I think people find very helpful. I think it’s interesting as part of the assessment process, kind of thinking it’s not just a tick box exercise. A good assessment, it shouldn’t just be a tick box exercise. It should be more of a narrative, kind of thinking more broadly, you know, tell me about a time in the week that you struggle. Tell me about a time in week where you thrive. And so this I feel like characterises a kind of helpful assessment process in that it’s not just, would you say that you’re constantly on the go and driven by a motor, which is kind of one of the diagnostic criteria, for example, where people kind of say, Oh yes, that’s me. So kind of an assessment should be more of a two-way conversation, and a very curious conversation about where people are struggling and may not struggle. And with that information, you come to the clinical judgement or clinical opinion, which is perhaps where a good assessment lies rather than a kind of tick box exercise of the DSM criteria.

Paula Redmond (45:55)

Yeah. And I guess you’ve, you kind of touched on that, but I wanted to ask what you would say are the benefits of seeking an assessment, I guess, particularly for those people who might not be keen on pursuing medication as an option?

Lauren Breese (46:12)

Yeah, absolutely. And so medication isn’t the only option. And I think it’s, I think that having an assessment and subsequent potential diagnosis, it can really help somebody to understand themselves. So often the people whom I’m working with, they might’ve had a lifetime of feeling different, feeling misunderstood, knowing something is different but not able to put their finger on what that is or understand it and that can result in more self-criticism or more kind of downward negative comparisons. And actually being able to have an assessment and an understanding a diagnosis can help to validate somebody’s experiences, that it’s not their fault, it can very much be de-shaming for somebody and help someone to come to a place of acceptance and subsequently thinking about what they need to thrive. And having the language for that is incredibly important. It’s the, you know, it’s in a similar way that having the language for emotions is important. It helps to, to kind of regulate them and, and, you know, having a language for what somebody is struggling with can help somebody feel understood, validated, as well as find other people as part of a community, which we know is beneficial for people’s mental health. And there are also practical things people can access, like access to work grants or reasonable adjustments in line with the Equalities Act, evidence-based resources, so kind of practical things. But also on the kind of flip side, having undiagnosed ADHD can be quite risky actually. And this isn’t for everybody, but it’s associated with unfortunately poorer outcomes of mental health, of socioeconomic outcomes with undiagnosed ADHD. And this isn’t necessarily to say if you don’t have an assessment diagnosed, that is going to happen, but what we know is that it’s helpful to have understanding where there is some to be had so that subsequent support can be put into place and even if that support just looks like you understanding yourself better and being compassionate to yourself, that is helpful. I think because the risks are that people might be, it’s unlikely that somebody is undiagnosed ADHD and might not be struggling with other things like for example, they might be misdiagnosed with another mental health problem, for example, or diagnosed with a mental health difficulty that may be able to be supported if we also had the knowledge that they had ADHD and they would benefit from some adaptations around the therapy that they access, for example. So, I think, yeah, I think there are benefits to having an assessment that aren’t just medication. And I think on a practical note as well, I guess the NICE guidelines recommend, they say like pills and skills. So it’s not just the medication, there are also, I think like I mentioned earlier, maybe practical skills or tools, sorry, that somebody might be able to learn that can be supportive, but also the secondary aspects that may have come from your lifetime of experiencing difference, for example, potentially self criticism can also be addressed. So yeah, I’m quite passionate about kind of somebody kind of understanding themselves fully. But I think sometimes just on the caveat, as a caveat, it’s not always the right time for somebody. So, you know, you have to weigh up the pros and cons for your own circumstances as to whether it feels right and what assessment would bring, what would happen if the outcome was, yes, you have ADHD, what would happen if the outcome was no, you don’t have ADHD. So there’s a lot of thought that I recommend could happen before coming to the assessment. And it’s not always for everyone, but I do think that there are benefits, but there might be downsides for some people in their circumstances, know? So I guess it’s thinking about that for an individual, what makes sense for them.

Paula Redmond (51:07)

And as well as that, if I wonder Lauren if you have any advice for anyone listening who might be recognising some of these things might be resonating with some of the things that we’ve talked about for themselves, any other thoughts or advice?

Lauren Breese (51:23)

Yes, I think take your time, be compassionate to yourself if you can. Just kind of, I think this coming to this understanding tends to be a long process. It’s not just something overnight that you think, oh guess what? You know, I’ve heard, I don’t know how accurate this is, but you know, on average about five years to come to from the point of wondering to the point of assessment. But anyway, five years or not, it’s a long time. think from my clinical experience, it’s a long time that people have been wondering. And I think being gentle with yourself within that process is very important. I think in that sense, potentially asking the question can be helpful because there’s only so much wondering on your own that you can do. And so sometimes it can help to ask the question so that you know what to do next. And that, you know, because often I find also that kind of wondering phase, people might start to then second guess themselves, oh well, everybody struggles with that. So actually having somebody that you trust to help you grapple with this is useful. I think if you are at the process of wanting an assessment, checking out somebody’s expertise and qualifications and experience is incredibly important. There’s lots of misinformation out there, so finding websites that are trustworthy, that are providing evidence-based information is helpful. Thinking about the process of assessment, do you want a yes or no answer? Do you want more of a psychological formulation-informed assessment where you might seek out a clinical psychologist that can help support with that. Yeah, I suppose potentially talking to other people as well, talking to your family about what the impact of a diagnosis might be for you and what you feel that the benefits might be of that or the downsides.

Paula Redmond (53:33)

Thank you. And I guess another question, and this came in from one of our listeners about how to broach a conversation with someone, either a family member or, you know, a colleague who you might think that ADHD might apply. Any thoughts on how you might go about, or if you might go about having that conversation? If you see someone struggling and that this might make sense of that?

Lauren Breese (54:02)

This is really, it’s a very good question and it’s very tricky. I suppose there’s a lot of nuance that might be needed depending on the circumstances. So when we speak to workplaces, you know, The Neurodiversity Practice where we train workplaces and managers and employees, I suppose based on what we’ve said today, you know, for a colleague who may not know the person well, it might not be appropriate to kind of, because of the nuances that are involved in an ADHD assessment, to kind of, you know, having seen something online and they’re disorganised or something to mention it, that it may not be the right setting or you may not know somebody well enough to be able to approach that conversation. However, what we do know is talking about adjustments generally is helpful for employees and colleagues. So thinking about how we all thrive in the workplace and what’s needed. Perhaps, you know, having a checklist of things that some people might help and then, you know, having that for the whole team, not just singling out one person is, I think, a helpful way to go about even, you know, to kind of thinking about helping people to understand their own needs and what they can ask for. And often for managers as well, it’s helpful for that to come from them and the onus to be on them to be providing or asking about adjustments. So approaching it that way can be helpful. If you’re say like a manager or a colleague that you may need to kind of think about how can we support everybody to thrive in this workplace? Does that make sense? And I suppose for a loved one, I suppose these are very helpful conversations to have. Yes, they are sensitive conversations and should be dealt with accordingly with empathy and understanding and curiosity. But I also think being open about communication is is also helpful and maybe sharing things that that person has learned about ADHD and asking for that other person’s perspective on it and just opening the conversation can be useful. I feel like we’re moving away from ADHD and autism and other neurodevelopmental conditions being a taboo. So I think, you know, this it’s not a deficit, it’s a difference in the way people process information. So approaching it as such can be helpful in a really open and a very curious way that doesn’t feel judgmental or blaming or threatening in that sense. So I think that would depend on the relationship and how they’re able to communicate. But whether that’s sharing something or joining together with somebody in curiosity can be helpful.

Paula Redmond (57:25)

Great, well thank you so much Lauren for joining me today.

Lauren Breese (58:23)

Thank you so much Paula, it’s been a real pleasure.

The post ADHD in Adulthood: complexities, challenges and opportunities – with Dr Lauren Breese appeared first on Dr Paula Redmond, Clinical Psychologist.