Those looking into what assessment of Autism Spectrum Disorder (ASD) involves and anyone working or researching in this field are likely to come across people referring to ‘the ADOS’. This is an acronym that is short for ‘Autism Diagnostic Observation Schedule’, which is basically an assessment tool that is used by clinicians and researchers to help identify whether someone meets criteria for a diagnosis of ASD, or is presenting with features of ASD. It has been referred to as one of the ‘gold standard’ ASD assessment tools and was originally created by autism experts Catherine Lord, Michael Rutter, Pamela Di Lavore and Susan Risi in 1989. A revised second edition (ADOS-2) with an additional Toddler Module was released in 2012. The ADOS is available for appropriately qualified practitioners (e.g. clinical or educational psychologist, speech and language therapist, occupational therapist, specialist nurse, psychiatrist, paediatrician, etc) to purchase through Pearson Clinical or Hogrefe in the UK (WPS in the US; MHS in Canada) costing around £2000 for the complete kit and around £6 per administration booklet.

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The complete ADOS-2 kit showing materials used; Image courtesy of pearsonclinical.co.uk

The ADOS is NOT a ‘test’ for ASD, as some people mistakenly believe. An assessment that seeks to conclude whether someone meets criteria for a diagnosis of ASD should not rely on an ADOS alone. This is because the ADOS is an observational tool that focuses on observations of a person’s presentation, behaviour and social responses during a set time period (usually how long it takes to complete the activities – around 40-60 minutes). This means that it is merely a ‘snapshot’ of the individual’s behaviour and presentation and what you see during the ADOS assessment may or may not be representative of what the individual is like in most circumstances in their daily life. For this reason, it is essential to put observations from an ADOS assessment into the context of the person’s everyday life, likes, dislikes, particular areas of difficulty and the experiences they have had to date. It is also important to establish (perhaps with a discussion with someone who knows the person well afterwards), whether what is seen in an ADOS assessment session is typical of how that person would generally react and respond. It is not always possible to gauge this though.

The ADOS should be one part of a comprehensive assessment if the question being asked is whether the person meets criteria for a diagnosis of ASD. Other important information that should form part of a holistic assessment would include information from those that know the individual well regarding their functioning in different contexts (e.g. home, school/college/work, socially etc). This helps build up a picture of all aspects of their life and the particular areas of strength and need for an individual.

When assessing for ASD, there is a focus on the person’s social interaction, language and communication, cognitive flexibility (including routines, repetitive behaviours, obsessions, imagination, play) and also sensory issues. This is because these are areas where we see a pattern of atypical (different) functioning in ASD, compared to individuals who do not have ASD. Furthermore, ASD is a developmental disorder, meaning that it affects a person’s development in a number of areas from an early age and we typically see signs that an individual’s development is following a different trajectory (path or pattern) from infancy, although this is not always identified at this stage as differences from typical development can be very subtle.

In order to meet diagnostic criteria for a diagnosis of ASD, the individual must have displayed signs of atypical development in the areas of social interaction, language and communication, play, rigidity or sensory issues prior to the age of 3. For this reason, a comprehensive ASD assessment will involve gaining a detailed developmental history from a parent, other caregiver or someone else who is very familiar with the person’s development from birth (e.g. a grandparent). It is common that differences in a child’s development may not have been initially identified as a concern at the time, as they may not have been felt to be atypical (e.g. if this is a first child), may have been attributed to the child’s personality, or may have been explained away as something else. It is also often the case that when going through a developmental history with a family, they become aware of other differences in the individual’s development that they may not have perhaps noticed at the time but recognise in hindsight when asked about specific areas in detail as part of an ASD assessment.

So, back to the ADOS. The ADOS is an observational assessment tool; it involves direct observation of the individual being assessed, as opposed to information given by other people. This usually means the person being assessed either attending a clinic for a pre-arranged appointment, or someone trained in using the ADOS coming out to visit the individual being assessed at home, school or another appropriate place.

The ADOS tends to involve two practitioners undertaking the assessment, although it can be done with just one. Some practitioners prefer having a colleague present as a ‘second pair of eyes’ to observe anything they may have missed whilst they are administering the assessment and it can also be helpful for someone else to take notes to aid rating/scoring the observations afterwards. However, others prefer to administer and take notes themselves and in any case there may not be another practitioner available to do this.

For this reason, some practitioners will video the ADOS assessment so that they can play back the video and look for any observations that they may have missed. This is also common practice in research, where a second (or even third) person will also look at the ADOS assessment footage in order to make sure the observations are valid and reliable. In order to administer the ADOS, you need to have completed approved ADOS training. This is typically an intensive 5 day course delivered by an accredited trainer and usually those who receive training already have significant experience and knowledge in ASD.

In the latest version of the ADOS, the second edition (ADOS-2) published in 2012, there are five different ADOS ‘modules’, each containing a set of semi-structured tasks, activities and discussion topics, that map onto different developmental stages. These tasks and activities are designed to elicit the types of behaviours, interactions and responses that we assess when considering an ASD diagnosis, taking into account what we would expect at different stages of development.

The Toddler module is based on tasks suitable for children aged 12-30 months of age who may not yet be consistently using phrase speech. Module 1 is for children aged 31 months and older who may not be consistently using phrase speech. Module 2 is for children of any age who may be using phrase speech but who are not verbally fluent. Module 3 is for children who are verbally fluent and young adolescents. Module 4 is for verbally fluent older adolescents and adults. It is important to use the module relevant to the individual’s developmental stage in terms of their expressive language ability and understanding, which may not necessarily be the module indicated by their chronological age (e.g. for those with a learning/intellectual disability or a language disorder).

Module 1 and the Toddler module are both primarily play-based and include the examiner seeing if the child responds to their name and other attempts to gain their attention and elicit interactions. Module 2 is a mixture of the play based activities in Module 1 and the more conversational discussion in Module 3. Module 3 is based on both play and structured activities and also conversational discussion, similar to Module 4 but with a more child-focused stance. The tasks include construction of a puzzle, demonstrating an everyday task using actions and gestures, describing pictures, narrating a picture story book, creating a scenario using toy figures, creating a story using random objects, reciting a story from picture cards and discussing social relationships, school, careers, future plans and emotions. There is also the opportunity for free play during a scheduled break, as well as general chat to get to know the individual and a chance for them to ask any questions and say how they found the assessment. Module 4 is similar to Module 3, but is less play-focused and based more on chat and discussion.

Immediately following the assessment, the observations of the individual and how they responded and approached the different tasks needs to be ‘scored’ or rated using the ADOS scoring schedule. This is a framework where specific aspects of the individual’s social interaction, language and communication, repetitive and stereotyped behaviours, and sensory issues are given a numerical rating according to whether the person displayed typical responses and behaviours, or whether they presented as atypical or having difficulty in the specific behaviours rated that fall under these domains, and where appropriate, the degree of difference/difficulty.

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An ADOS-2 Toddler Module record form; Image courtesy of wspublish.com

Once all of the behaviours, responses and observations in the ADOS scoring framework have been rated or ‘scored’, an algorithm is used to convert the individual’s score to a ‘comparison score’. This is based on lots of data gathered by the people who developed the test and allows the assessor to work out whether the behaviours and responses they saw during the ADOS assessment correspond with a ‘high’ level of ASD features and thus a high probability of meeting criteria for a diagnosis of ASD, or a ‘low’ level of ASD features and a low probability of meeting diagnostic criteria. Comparison scores range from 0-10, with 10 representing ‘highly likely’ and 0 representing ‘highly unlikely’. The pattern of the scores in the different domains assessed is also relevant.

It is important to remember that an ADOS comparison score in itself should not used in isolation to make a diagnosis and that an individual may present differently in their ADOS assessment to how they would present generally in their everyday life, due to it being an unusual situation with new people that typically takes place in an unfamiliar setting. This is why it is crucial for those assessing the individual to be experienced and skilled in working with people on the Autism spectrum and also to have gathered information from a range of sources as part of a holistic assessment to build a picture of the individual and how they function in all aspects of their life. It is useful to have also directly observed the individual in a different setting, preferably one where they are more comfortable (e.g. in school).

In addition to the quantitative (numerical) comparison score, the ADOS also generates very useful qualitative (descriptive, rather than numerical) information about the person’s functioning in the areas of their social interaction, language and communication, cognitive flexibility and sensory issues and this can be just as important, if not more important, data for those undertaking the assessment.

For further information on what constitutes a high quality ASD assessment for children and adolescents aged under 19 in the UK, the National Institute of Health and Care Excellence (NICE), have produced NICE Guideline CG128, which is based on a systematic review of available evidence and also covers recognition and referral.

Similar guidance from NICE for adult ASD assessment can be found in NICE Guideline CG142 that covers diagnosis and management of ASD.

In terms of questions I have been asked by families, individuals being assessed and other professionals, I will try and answer a few here…

Who will be present during the ADOS assessment? 

Many parents ask this and it is a very valid question, as it can be useful to explain to the individual being assessed who will be there in the room in order to prepare them for what to expect during the assessment. The answer to this will depend on the practitioners undertaking the assessment and this can be a good question to phone up and ask prior to the ADOS assessment, or at the beginning of the session when the practitioner explains what will happen.

For younger children, it is important for a parent or other caregiver to be present so that the child feels reassured and at ease. The parent or caregiver may also be asked to assist with the assessment, usually simply involving speaking to or interacting with their child in a specific way requested by the practitioner.

For older children who are able to tolerate being separated from their parents or caregivers, they are generally asked if they would mind completing the ADOS assessment whilst their parent or caregiver remains nearby in the waiting room (or equivalent). This is simply because they may look to their parent or caregiver to answer for them, may behave differently with them present or may become embarrassed due to the nature of the questions asked (e.g. ‘does anyone in your family annoy or irritate you?’). However, if the child would prefer that a parent or caregiver remain in the room, this can be discussed.

Adults generally complete the ADOS unaccompanied, but there may be one or two practitioners present.

The ADOS is essentially an autism test though isn’t it?

No, it is a semi-structured set of tasks, activities and interactions that aims to elicit behaviours and skills that are associated with ASD, as the observational component of a wider assessment. The actual assessment session is play-based for younger children and for those who are older, is focused more on a chat to get to know the person and what they think about things and there are no ‘right or wrong answers’. Individuals who are assessed using the ADOS may worry about being ‘tested’ or evaluated if it is referred to as a test or exam, many of those assessed actually enjoy it!

Can you do the ADOS again / more than once?

ADOS assessments can be repeated, although if there has only been a short space of time since the individual last did it, they are likely to respond in a similar way. There needs to be a clear rationale for undertaking a further ADOS, such as if the individual’s presentation has changed significantly in one of the areas the ADOS assesses and the question has been asked regarding whether they still meet criteria for a diagnosis of ASD. For example, it may be unclear following a comprehensive ASD assessment that includes an ADOS whether a child meets criteria for a diagnosis of ASD and the assessment team may decide to review the child and re-assess them in a further 12 months in order to gather further information and monitor the child’s development. In this sort of situation, the ADOS can be readministered.

If the ADOS suggests ASD, that means a diagnosis can be given right?

Not necessarily, a decision about whether someone meets criteria for a diagnosis of ASD should never be taken based on the results of an ADOS in isolation. Individuals with other conditions or difficulties can present similarly to ASD (e.g. learning/intellectual disability, attachment issues, selective mutism, significant anxiety) and would thus be likely to achieve an ADOS score suggestive of ASD, therefore it is important to interpret the observations in the context of background information and a full developmental history. It is not uncommon for someone to have an ADOS score highly suggestive of ASD, but their developmental history and information from other sources regarding their functioning contradict this because there is another explanation underlying their presentation. This highlights the need for somebody skilled and experienced in assessing ASD who also knows about other similarly presenting difficulties to look at the ‘whole picture’ as part of a comprehensive assessment.

As always, if you have any comments, questions or want to discuss anything I’ve talked about – feel free to respond below!

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Image courtesy of raising children.net.au

I thought I’d write this post as I often see families of children and young people coming for an autism assessment who may not have any idea what to expect. I realise that this can make it seem much scarier and it also makes it harder for parents and carers to prepare the child in advance regarding what is going to happen.

I also think that it is useful for other professionals and people in the child’s wider world to understand what the process is likely to involve, and also what it probably wont involve. This enables others who support the family (including professionals asking for an autism assessment) to give realistic expectations of the process.

Just to clarify, when I refer to autism assessment, I am using ‘autism’ to include the whole autistic spectrum – both those individuals who may have more severe difficulties and those for whom their difficulties may be more subtle or who have many skills and strengths in addition to their social communication difficulties, those who we might think of as having ‘Asperger syndrome’. However, Asperger syndrome is no longer a diagnosis included in the Diagnostic and Statistical Manual for Mental Disorders (DSM), that most clinicians use. I will write a separate blog post on this issue and you can read more about the changes in the new edition of the DSM that area relevant to autism in this useful article by the National Autistic Society.

So, the beginning of the process usually starts with those closest to the individual. You may have noticed that your child appear different to others their age in terms of their behaviour, play or communication. You may have sought advice from a health visitor, speech and language therapist, paediatrician or other medical doctor in relation to your concerns. If you haven’t, or concerns have been raised by someone else who knows your child (e.g. their teacher or nursery staff), the first port of call would be to arrange to get your child seen by a paediatrician. In the UK, this is a medical doctor who specialises in working with children and young people and who has specific training in child development and children’s medical conditions. If you are already seeing another health professional such as a health visitor, ask for them to refer your child to a paediatrician. Alternatively, you can go and see your GP to explain your concerns and ask for them to refer your child to the paediatrician.

For those of you who have already seen a paediatrician, you will know that they will generally undertake a brief assessment of your child’s overall health and development. This tends to include weighing and measuring their height and the circumference of your child’s head. They will also usually physically examine your child and listen to their heart and breathing. They usually ask about the pregnancy, birth and labour and your child’s early development, as well as exploring your current concerns. It is very helpful if you can clearly describe your observations that concern you and be prepared to give examples to help the paediatrician develop a picture of the nature of the difficulties. As with any appointment or meeting, it can be helpful to prepare a list beforehand of the things that you want to discuss so that you can ensure you mention everything that you wanted to.

The paediatrician may see you again for a review appointment to gather further information, or they may refer your child to other health professionals who can directly assess aspects of your child’s development that you are concerned about in more detail. A speech and language therapist may become involved to gain a better picture of your child’s language development and communication skills. A physiotherapist or occupational therapist may assess their motor (movement) skills and practical abilities (e.g. dressing, using cutlery, holding a pencil).

If there are still concerns that your child is presenting with particular difficulties that are suggestive of an autistic spectrum disorder, the health professionals involved usually ask a specialist who is knowledgable and experienced in working with autistic spectrum disorders and other social communication difficulties to see your child for further assessment. Who this will be depends on the local arrangements in your area for this type of assessments. In the UK, there should be a local autism spectrum disorder ‘assessment pathway’ in every area. This sets out who exactly does these assessments where you live, how you can access them (e.g. referral from your paediatrician) and what steps are involved.

Generally, a specialist multidisciplinary team (a team made of up professionals from different backgrounds, who have different roles and expertise) will be responsible for ASD assessments. It is suggested in the UK NICE guidelines (these are guidelines for best practice, based on available evidence) on recognition referral and diagnosis of autism in under 19s that children and young people are assessed by a multidisciplinary team that includes a medical doctor or psychiatrist (a medical doctor who has specialised in mental health), a psychologist (this may be a clinical psychologist and/or an educational psychologist), speech and language therapist, occupational therapist, specialist nurses, and other practitioners who are experienced and knowledgable about ASD. It is worth noting that not all local areas have a team of these professionals specialising in ASD and it may be just one or two professionals who do this kind of work in addition to their other work as they have an interest in this area.

It is not typical for all of these professionals to be involved all at the same time in your child’s ASD assessment, although if your child has complex needs then they may be. Professionals may work together as part of a team on a day to day basis and be based in the same place, or may work as a ‘virtual team’ where they are not physically located together and are based across different departments and locations. Some teams are based within community paediatric (children’s health) services, whilst others are based in child and adolescent mental health services (CAMHS). This depends on your local setup.

When it comes to the actual autism assessment, there is usually a long waiting list due to a high demand for this type of assessment and limited resources to meet this demand. I have worked in several different specialist autism teams in different NHS trusts across the country and it is a similar picture with waiting lists across the UK. Typically, you can expect to wait anywhere between 6-12 months for an autism assessment. You may be seen sooner for an ‘initial assessment’ with the service if they have never worked with you or your child before, but there is generally a long wait for the actual autism assessment.

It is common for you (and sometimes your child’s school) to be sent out questionnaires to fill in prior to the autism assessment appointment(s). This gives the team useful information about your child and their difficulties so that they can plan how they will do the assessment. You may also need to ‘opt in’ to the assessment in some places – this is where you confirm that you still want an appointment and there is usually an expectation that you will return something or contact the team to confirm this. If there has been a long wait between your child being referred for an autism assessment and them coming to the top of the waiting list, the team may contact you to check that you still want to be seen in case the situation has changed. Some teams will contact you to offer short-notice appointments (e.g. if someone else has cancelled theirs), so it is a good idea to remember to contact the team if your contact details change (e.g. if you move house or change your mobile number).

Most teams will send out an information leaflet giving you some details about the team, where the appointment will take place and what it might involve. If you aren’t provided with this information, it can be helpful to phone up and ask any questions you may have, such as whether your child needs to come along to the first appointment or just parents/carers, how long it will last, who they will see, and anything else you might be wondering, such as whether they have free car parking.

At the first appointment, you should meet the main person or people who will be co-ordinating your child’s ASD assessment. They should introduce themselves so that you are clear about what their names and roles are and how to contact them if you need to. They should also explain at this point exactly what the assessment will involve and check that you understand this and agree to go ahead. If your child is 16 or over, your child will need to understand and give consent for the assessment to go ahead.

Different teams do the assessment differently – everything may be completed over a single longer appointment that both yourself and your child attend; or multiple appointments may be scheduled and/or they may ask permission for your child to be observed in the school setting. There is no set way to do an autism assessment and so different teams do it differently according to their staff resources and local demand. It would be much easier if there was a simple blood test for autism, but at the moment there isn’t and assessment involves gathering detailed information about your child’s development, functioning and behaviour. It is crucial that you understand exactly what the team assessing your child plan to do, how long this will take and when you will receive feedback on the outcome.

It is common practice for two professionals from different disciplines to conduct the assessment. This may be a paediatrician and a speech and language therapist, or a speech and language therapist and a clinical psychologist, or a psychiatrist and a specialist nurse, or another combination. The important thing is their knowledge and experience of ASD and that they are bringing slightly different expertise and viewpoints. Generally, it is not that the doctor or any other member of the team is more senior or experienced in ASD, as team members tend to have a similar level of specialist knowledge and experience. However, they will bring specific skills from their professional background too. So, as well their specialist knowledge and skills in autism, medical doctors and nurses specialise in physical health, psychologists specialise in cognitive and other psychometric assessment as well as other areas, speech and language therapists specialise in language and communication, and occupational therapists specialise in everyday skills and sensory issues.

Typically, an assessment will involve the following:

Direct observation of your child – including their communication and interaction skills and their play (or creative skills if they are older). This may be done informally, or using a formal assessment tool called the Autism Diagnostic Observation Schedule (ADOS)

Parent interview – the clinician(s) will ask you about current difficulties and concerns, as well as a developmental history that explore when they met their milestones and aspects of their development (it may be useful to dig out their ‘red book’). Again, this may be done using a formal assessment tool. There are a few available to clinicians, including the Autism Diagnostic Interview – Revised (ADI-R), the Developmental Dimensional and Diagnostic Interview (3Di), and the Diagnostic Interview for Social and Communication Disorders (DISCO).

Information from school – this may be gained via a questionnaire sent to school or a telephone conversation with a member of staff, and/or direct observation of your child in their school setting

Additional assessments, depending on the particular issues your child has and the availability of resources, may include:

Speech, language and communication assessment – by a speech and language therapist

Cognitive functioning (intellectual ability) assessment – by a clinical or educational psychologist

 ‘Theory of mind’ skills assessment  – this is the ability to think about and understand others’ thoughts, feelings, emotions and behaviours

Emotion recognition and understanding assessment – both in terms of their own and others’ emotions

Everyday living skills (adaptive functioning) assessment – further detailed assessment of specific skills such as dressing, cutlery use and holding pencil may be completed by an occupational therapist

Sensory profile assessment – this looks at whether your child seeks out or avoids particular sounds, sights, smells, tastes, textures or sensations.

Mental wellbeing assessment – a clinical psychologist may assess your child’s emotional functioning, self-esteem and overall wellbeing.

Behaviour assessment – if your child is engaging in problematic behaviours these will be explored in more detail to understand their function and think about what need the behaviour is meeting

There are lots of different assessment tools available to health professionals, so even those within the same team may prefer slightly different methods.

All of these assessments are to enable to clinicians to get to know your child and their individual areas of strength and difficulty and to build up a detailed picture of their functioning. As a clinical psychologist, I see this process as putting together different pieces in a jigsaw to build up an overall picture of your child. We call this a ‘formulation’  in clinical psychology, where we develop a picture of the presenting issues, what may have led to them, and what may be making them worse or better. This helps us think about a plan for what will help (we call this an ‘intervention’).

Once all the different parts of the assessment have been completed, which is a process that may be done over one long appointment or over several appointments over a period of time, the findings should be fed back to you so that you understand the outcome and conclusions of the assessment and what will happen next. It is good practice to also summarise all the information gathered as well as the assessment outcome and conclusions, in a written assessment report. You should get a copy of this and it also typically gets sent to your GP so that it can be added to your child’s main medical record, and also to the person who referred your child for assessment. There may be other people  already involved with your child such as an educational psychologist, who you may wish to share a copy of the report with.

I also recommend to parents that they arrange a meeting with the Special Educational Needs Co-ordinator (or ‘SENCO’) at their child’s school to sit down and go through the report and what this might mean in terms of how they understand any issues that are apparent in school. It is also important in order to discuss any extra support that your child may need in school as a result of their difficulties or anything that they may need doing differently. It might be that the school feels that they will find it difficult to meet your child’s specific needs within the existing resources and staff they have and they may suggest you apply for an Education Health and Care (EHC) Plan, which is what has replaced what was formerly known as a statement of special educational needs. I will talk more about these in a future post.

The team that assess your child may be able to offer you further advice or support, either through another appointment with you or workshops/groups that they run for parents. If your child’s difficulties weren’t thought to warrant a diagnosis of ASD, they may point you in the direction of another service or team that may be better able to support you with your child’s difficulties. I plan to write another post on the various things that present similarly to ASD.

Sadly, in the UK, many areas are limited in what they can offer in terms of support following a diagnosis of ASD in the NHS. However, there is often a specialist autism team in local education services that can help support school and families of children and young people with ASD. There are also lots of local parent organisations that often offer a number of resources and supports for children with ASD and their families. It can also be useful to get in touch with parent organisations for support from others who have been through similar experiences with the emotional aspects of having a child with ASD and coming to terms with the diagnosis.

Every local council also has a ‘local offer’ from the local authority of services for parents of children with additional needs and it is worth googling the ‘local offer’ for your area to find out what you may be entitled to. There is usually a local ‘parent partnership’ (now often known as Information Advice and Support, or ‘IAS’) organisation included by the council as part of this local offer that provides parents with advice on things like EHC plans, Disability Living Allowance (DLA) and local supports and resources available for children with additional needs and their families.

I plan to write a separate post in the near future on the ‘aftermath’ of a diagnosis, which will cover issues such as whether to tell your child, who else you should tell and the emotional experience of your child being diagnosed with a lifelong development disorder.

Finally, I get asked quite a lot about whether you can pay to have an autism assessment done privately if you want your child to be seen sooner than they would be via NHS services. If you are willing to pay or are covered by health insurance, there are local independent practitioners offering these in most areas of the UK.

I myself offer an autism assessment service for children, young people and adults in the Greater Manchester area and beyond by negotiation. I offer evening and weekend appointments for assessment, as well as home visits. It is really important that you ensure that you are dealing with a credible professional who is recognised by their relevant professional body (General Medical Council for medical doctors; Health and Care Professions Council for educational or clinical psychologists, speech and language therapists and occupational therapists) and has the appropriate qualifications and insurances for their practice.

I hope this post has been useful and please do post any comments or questions and I’ll do my best to answer.

This is just a short post as I felt compelled to share my thoughts in light of the recent news of Robin Williams’ sad death and also wider discussions I’ve been involved with very recently in relation to the stigma of mental health issues.

Sometimes we experience such horrible thoughts and feelings that they overwhelm us and it feels like there’s no way to make them stop or feel ok again. I’ve been there and so have many more people than we realise. Despite what people show to the outside world, we are all facing our own struggles and demons. We need to all take responsibility for talking more about our wellbeing and for being brave enough to let people in. I can guarantee no matter how you feel, you are important and have people who care about you. It should not be perceived a sign of weakness/failure/not coping to say I’m not ok and I need some help. We must change our attitudes about mental health.

It is especially true for those of us who work in mental health, which is where you’d think you’d find more acceptance and less stigma. Surely it’s more worrying if people working in mental health are just carrying on and trying to cope and hide things…? As we tell the people we work with – this rarely works and it is true for professionals working in this area too. We are no different. We’re all human at the end of the day and it is our capacity to feel and think and be moved by our experiences that sets us apart from other species.

It’s ok to not be ok, but it’s not ok that people suffer in silence. Mental health issues can kill.

tumblr_krtoi9hUhI1qz4teko1_400Photo credit: http://eastcoastgirl.tumblr.com/

I was recently asked what a psychologist working in a paediatric setting does and what their job is like on a day to day basis, so I thought I’d share my experiences of working in paediatric psychology.

Firstly, paediatrics is a branch of medicine specialising in the care of children and young people (it is spelled ‘pediatrics’ in the US). A paediatric psychologist therefore usually works with children and young people with a medical condition and/or physical symptoms that are directly impacting on their wellbeing or mental health.

Paediatric psychologists are usually a clinical psychologist by training, although there are some health psychologists working in paediatric settings, in addition to paediatric clinical neuropsychologists who have undertaken further training to specialise in brain functions in children and young people. Paediatric psychologists also work with children, young people and families who are finding it difficult to cope with a physical health condition, whether this is in terms of managing the required treatment or adjusting more broadly to life with a medical condition and the impact of this on them and their family. Paediatric psychologists are usually based in acute medical settings such as children’s hospitals and specialist children’s services, as a lot of their work will involve being part of a multidisciplinary team (MDT) involved in the young person’s care.

The psychologist may advise the MDT on the impact of a treatment or a medical procedure on a young person’s emotional wellbeing or provide advice on how to engage the child or young person. In addition to providing ad hoc (‘on the spot’) advice and guidance on issues relating to the young person’s emotions and behaviour, paediatric psychologists also encourage and support colleagues to consider the impact of psychological factors (e.g. emotional and behavioural) on medical care. They may offer  formal training and support to develop the psychological knowledge and skills of their colleagues in medical settings. For example, this comprehensive resource produced by NHS Education Scotland was developed by a clinical psychologist to support staff in specialist children’s services to think and work in a psychologically informed way.

In common with psychologists working in other medical settings (a field known as clinical health psychology when working with adults), paediatric psychologists may provide clinical supervision (in an individual or group format) to colleagues employing psychological interventions or wishing to develop their psychological knowledge and skills. These are often what we call ‘low intensity’ psychological interventions that can be undertaken by staff under the guidance of a psychologist, but are not so complex as to require specialist and comprehensive training in the theory and practice of psychology for their delivery.

Doctors, nurses, occupational therapists and other professionals can have a central role in providing psychoeducation and supporting children and young people with low intensity psychological interventions, under the guidance of psychologists. This makes their practice more psychological which potentially ‘nips problems in the bud’ and also increases the capacity of paediatric psychology services as psychologists can then focus on the more severe/complex cases.

This model of service delivery is called ‘stepped care’ and is based on similar principles to the model adopted in mental health services (e.g. in IAPT services). In a nutshell, stepped care involves provision of different levels of intervention that can be matched to a person’s level and complexity of need. Upskilling and supporting non-psychology colleagues in psychological interventions means that these can be delivered more widely, thus increasing access to such input and making use of the skills and experience of other professionals.

With regard to what is involved in the role of paediatric psychologist on a day to day basis, working in paediatric psychology is different from working in child and adolescent mental health services (often abbreviated to ‘CAMHS’)  because the majority of paediatric psychology services see children and young people who have behavioural or emotional difficulties that directly result from or are linked to their physical health. This includes anxiety, low mood, eating issues, anger, adjustment problems, general coping problems or obsessions/compulsions that arise as a result of having a particular condition and it having particular effects.

CAMHS, on the other hand, see children and young people who have behavioural or emotional / mental health issues where their physical health is not the main causal or maintaining factor in their presenting difficulties. In some areas, there isn’t a local paediatric psychology service, so in this scenario CAMHS may see children and young people who would otherwise be seen by paediatric psychology.

Something that seems to vary a lot in different areas where paediatric psychology services and CAMHS are both present is who will see young people with medically unexplained symptoms (also referred to as ‘functional’ symptoms). In some areas this particular area of work is done by CAMHS as it can be seen more as a mental health issue, although there’s lots of different opinions on this. In the paediatric psychology service I worked in for a year, as long as the child was under the care of a consultant at the children’s hospital where the service was based, we would accept referrals for young people who were experiencing physical symptoms that had been investigated (or were in the process of being investigated) where no organic cause had yet been identified.

The focus of this work was slightly different and was more on coping with and managing the physical symptoms and any associated presenting problems, such as tiredness, lack of energy, pain, sleep problems and lack of (or over-activity). Here is a presentation I gave as part of some training I delivered a few years ago with a colleague about working with functional symptoms in CAMHS that gives an overview of some of the things to consider in this type of work and how you might support the young person.

The other main issue that paediatric psychologists work with is when children and young people’s behaviour is impacting on their medical condition or physical health, or their adherence to treatment. Psychologists in paediatric services also help children and young people prepare for medical procedures, as a large body of research has shown that increasing understanding of conditions, procedures and treatments helps people feel more in control of their health (referred to as an internal locus of control) and predicts better outcomes in terms of their physical health and psychological functioning.
In addition to direct work with the children and young people themselves (which may be on an individual or group basis), psychologists in paediatric services may also support parents/carers, siblings or other family members who are involved with the child. Paediatric clinical psychology (and clinical health psychology more broadly) is very much focused on supporting the systems around the person so they can develop a better understanding of the young person’s needs and provide a better standard of care and support to the person.
If you are interested in finding out more about working specifically with children who have very complex and chronic physical health issues, I  recommend taking a look at the resources produced by the Managed Clinical Network for Children with Exceptional Healthcare Needs, especially the videos “How does it feel?” that includes parents’ and professionals’ feelings about the emotional impact of tube feeding, and “How do you want me to talk to you?” about health professionals’ communication with young people with little or no verbal language. There are lots of other useful resources, including free workshop materials, available on the MCN CEN website.

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I had a recent experience with a patient who I’d been seeing individually for some months for psychological therapy where we said our goodbyes and she gave me a hug and a kiss on the cheek. I was really touched by this relatively simple gesture and it seemed to be particularly significant as we had spent almost a year of therapy sessions sat across from each other with a gulf of space between us. With my therapeutic work with adults (over the past year this has mainly been older adults and people with physical health issues who have sought therapy), I see a big part of my role as a therapist as creating a space were a person can experience healthy vulnerability – where they can safely be themselves without judgement and share thoughts and feelings that are troubling them or that they might elsewhere feel unable to reveal. As therapists working with adults, we use non-verbal communication such as the tone of our voice, pauses, silences, eye gaze and facial expression during therapy in a myriad of ways to facilitate this – to show that we are listening, that we understand, that we empathise.

However, I started thinking after the experience I described above, about how most psychologists working therapeutically with adults often avoid physical contact with patients. Throughout the majority of my training as a clinical psychologist, I got the impression that we should avoid physical contact with our patients, as this was deemed too close, too personal. I can see this point of view to an extent, as some people do not like physical contact and it makes them feel uncomfortable and of course unsolicited touch even in the most innocent sense can feel invasive to our personal space. It can give an impression of dominance and power (Gallace, 2010) and of course, touch can be inappropriate or perceived as so. I find it is sad that due to very real risks that it is obviously important to acknowledge and manage, all forms of touch have now become oversexualised. I suspect it is for this former reason in our increasingly litigious society that psychologists, as well as other professionals in caring roles such as teachers, simply refrain from touch or physical contact as they see it as a minefield best avoided.

Nevertheless, physical touch is one of our first senses that we develop as infants, allowing connection with others and the outside world. Most of us begin to experience love and security through the medium of touch as babies and tactile stimulation has been recognised as crucial to the development and maintenance of regulation of both physiological and psychological processes, including pain and emotion (Field, 2010). Although we generally perceive ‘touch’ as one unitary sense, it is thought to constitute information blended from a number of different kinds of somatosensory receptors in the skin and the rest of the body (Gallace, 2010). Interpersonal touch is recognised as having an important role in wellbeing (Field, 2001) and even the briefest touch from another can elicit a strong emotional response (Gallace, 2010). Indeed, Tiffany Field, a prominent researcher in this area, believes that many people today suffer from ‘touch hunger’ – a dearth of tactile stimulation. Interestingly, there are cultural variations in interpersonal touching behaviour, with research indicating that people from the UK and certain areas of northern Europe and Asia touch each other much less than their counterparts in France, Italy and South America (Jourard, 1966). Furthermore, touching behaviour is influenced by the gender, age and other characteristics of both parties (Gallace, 2010).

This brings me on to my next observation. I have spent the past four years working with children with intellectual disabilities and developmental disabilities and their families and I have noticed that I use touch very differently in this area of my work. In my own experience, children are more likely to touch others, both peers the same age and adults around them. Perhaps this is because the societal norms in the UK mean that it is generally more acceptable and often encouraged or elicited by adults, or because children are still developing socially and learning the social nuances of what you ‘can’ and ‘can’t’ do when with others. Most children seem to find touch comforting and reassuring and as a psychologist, I believe this is developmentally appropriate. However, I’m not necessarily sure touch becomes inappopriate or any less needed when we reach adulthood.

Touch can be especially important for people with an intellectual disability or developmental disorder (e.g. autism), as there is considerable evidence that the processing of sensory information is disrupted in these individuals (e.g. Tomchek & Dunn, 2007). This can result in ‘oversensitivity’ (hypersensitivity) and ‘undersensitivity’ (hyposensitivity) to different sensory stimuli and as a result of this, the avoidance or seeking of certain sensory experiences. Due to the explicit recognition of the importance of thinking about sensory processing when working with people with a intellectual or developmental disabilities, the power and importance of touch seems more readily recognised in my work as a psychologist with this population. Consequently, I feel that touch is less ‘taboo’ in this type of work than it can be in the settings where I undertake therapeutic work with adults with mental health issues.

Indeed, touch is used as both an augment to communication and as a therapeutic intervention in itself for children with developmental and intellectual disabilities. For example, intensive interaction is an intervention for those with autism and/or severe or profound intellectual disability that aims to facilitate communication and encourage positive interactions. I have found the use of intensive interaction with children with profound and multiple disabilities (a particular group of interest to me) an incredibly moving and rewarding experience, it really is something to enter the world of another who cannot readily enter yours as they do not have the communicative abilities. I have also found it incredibly liberating to communicate with another person at the fundamental level of touch, basic sounds and expressions and it really gets you thinking about the purpose of why we communicate at all.

Therefore, it seems somewhat bizarre to me when I think about it that we do not use touch more as therapists and psychologists, beyond its use with young children or those with developmental or intellectual disabilities. The issue is clearly a complex one, but surely we should be thinking about how touch might be used carefully and effectively where appropriate, rather than avoiding it all together?

If you’re interested, this article discusses issues specific to the dilemma of touch in therapy.

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I have two weeks left of being a trainee clinical psychologist and a doctoral student, after 10 years at university. I’m finding myself both excited and apprehensive about this impending transition to post-doctoral life as a clinical psychologist, especially as it feels a bit like the proverbial cotton wool has been unwrapped from around me and the safety net of my status as a student is being whipped away.

My situation is slightly unusual, however, as I’ve never been a full-time, university based postgrad and have either studied part-time at a distance from my institution or as part of professional training where you’re mostly on placement in the NHS with blocks of study time at the university, usually once a month at most. So, for me this transition seems to have happened more gradually, as I have spent less and less time at the university and essentially feel like I’ve been working in a job. The fact that I have increasingly become more autonomous in my job and have been working to a Band 7 NHS KSF job profile for the past two years (the same as a newly qualified clinical psychologist who has followed the standard 3 year doctoral route) has made this change to qualified status much more gradual and hopefully smooth. It makes me wonder what it is like for the majority of trainee practitioner psychologists who follow the standard 3 year doctoral route, which seems like it would be much more intense and a bit of a shock to the system to suddenly go from trainee to qualified ‘overnight’.

From my own network of friends and colleagues who have recently completed PhDs, it seems that many people go on to work in the department where they were a postgraduate. They may have already been working in a teaching, lecturing or demonstrator post but I do wonder about how people manage the increase in teaching and lecturing hours, responsibility for writing and assessing course material, and the supervision of students. How this role transitions is managed by employers, managers, mentors and supervisors of new post-docs really seems to vary from place to place from speaking to people.

These musings, combined with me experiencing withdrawal symptoms following my departure from PsyPAG, got me thinking about developing some sort of peer support network for psychologists early on in their careers (post-docs and also newly qualified practitioner psychologists) that would be akin to a ‘grown up’ version of PsyPAG! So, with a little help from my friends (sorry, too cheesy I know…), that’s what I’ve set up: the Early Career Psychologist Network. The idea is that the ECPsych Network will provide a central hub where people early on in their post-postgrad careers can find news and information about funding opportunities, jobs, grants, awards, bursaries and also find out about skill and career development and share issues that affect people at this particular stage and hopefully get some advice and support.

So far we’ve set up an ECPsych Twitter feed and a Facebook page so that people can connect and follow our information feeds. We also have a website that is in development and we’re in the process of formulating a blog that will probably feature guest authors, in addition to hopefully hosting a regular #ECPsych Twitter chat slot and arranging some events to network in person.

Do you have any ideas of how we might use this network to support those early on in their career as an academic / practitioner psychologist?

What would have helped you?

What do you need that you’re not getting?

Please do get in touch with any ideas or feedback or if you want to get involved, we look forward to hearing from you!

Image courtesy of six0six design

I realise it has been a long while since I last posted here, despite many a good intention and several ideas for blog posts (which I will be following up in the coming months – I won’t let myself off the hook that easily!). In the mean time I’ve completed all my academic work for my doctorate in addition to passing the clinical components. I have also co-organised the Blogging for Postgraduates workshop at the PsyPAG conference, stepped down from PsyPAG and handed over to a new Chair, secured myself a qualified clinical psychologist post with a neurodevelopmental disorders service down in England, and also found myself a new flat to rent down there. Phew, busy times. I had a holiday or two and did some non-psychology stuff in amongst all that. Hence the absence from this blog!

Now that I’ve finished my doctorate, I’ve had a little time to reflect on all sorts, including my own career development and journey so far and within this, my experiences to date of blogging and what others with varied levels of blogging experience have shared with me. These reflections will be the subject of this post.

I first started blogging almost a year ago now in October 2012 after having considered it for some years. This was basically because I think about a lot of stuff and like to share my thoughts in case they may be of any use to others and also to hear what other people think too. Blogging seems to be a great way of showcasing your own ideas and thoughts on a subject to a potentially wide audience in a way that discussions within our own personal and professional spheres may not allow so broadly. I really like the idea of this and try to expose myself to as many different perspectives and viewpoints as possible, as I think that this is the way we learn and develop (I’m a Vygotskian at heart!). Sure, we can go so far by discussing things with our supervisors / managers / colleagues, in the teams we work and / or research in, with peers in our field and even at multidisciplinary conferences. However, blogging and social media open our worlds even further to people and viewpoints we may never otherwise encounter. I love that and indeed have made connections with some highly valued friends, colleagues and collaborators because of this who I would not otherwise have known (you know who you are!).

I also think creating content is a great way to reflect on something and construct a tangible record of your thoughts, observations and perhaps most importantly, bring together a record of existing resources on that subject. So for me personally, my blog has functioned a little bit like an online ‘scrapbook’ where I can put down information before it goes out of my head! I enjoy reading blogs such as The Introspector, The Thesis Whisperer, and The Cyber Psyche (plus too many others to mention, check out who I follow on here) in order to further my own knowledge in areas such as mental health, therapeutic approaches, academia and psychology in the online sphere. Along with using Twitter as a microblogging platform, these blogs help me stay up to date with current research and resources and also provide the impetus to reflect on specific topics or phenomena. Therefore, part of the function of my own blog posts thus far has been to provide information and signpost to resources, as well as generating thoughts and reflections from my readers.

However, as I look over the content of my blog posts over the past year, I have realised that they seem to have mostly featured reflections on the process of studying as a doctoral student and training as a clinical psychologist. In addition, I have covered specific topics such as, for example coping with being a caregiver to someone with an illness or disability. Feedback on my blog has overall been positive, but I have been told that it lacks a coherent focus, which I fully agree with. When I think about what makes a good blog, a clear focus is one of the criteria that comes to mind, and thus part of the development of this blog will be the task of clarifying my aims and remit and remaining within these. It is likely that my focus will evolve to centre more upon my area of work and research interest – psychological aspects of caring for a significant other who has a disability or illness. However, I still need to work this out.

As you may or may not know, my forays into blogging were part of a joint exploration with my friend and former PsyPAG colleague Emma Davies, who has been writing an excellent blog herself on alcohol research, psychology, teaching and other things. As well as learning about ourselves and reflecting on our own experiences of blogging so far, we are really interested in what others working and/or studying psychology have experienced as bloggers or blog readers. We’d like to know more about why you blog, and why you don’t? What sorts of blogs do you read? Plus a number of other questions.

Therefore, we would like to invite you (whether you write blogs or you just read them, or both) to complete a brief anonymous online survey we’ve put together on this subject (which has received ethical approval from Oxford Brookes University, registration number 130744). We plan to analyse the findings in the coming year and hope to share them as an article in The Psychologist publication, who kindly sponsored our Postgraduate Blogging Workshop that we organised at PsyPAG 2013, along with the excellent BPS Research Digest blog. Thank you in advance and as ever, I invite your thoughts, comments and feedback on this blog too.

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You’d be forgiven for thinking that I have a bit of an obsession with chairs, given the high proportion of chair-related content in my blog posts! This post, however, is in relation to activity of chairing – whether that be chairing a group or organisation or chairing a specific event or session at an event.

I am currently the Chair of an organisation called the Psychology Postgraduate Affairs Group (PsyPAG), which is a national organisation that represents the interests of those studying psychology postgraduate qualifications at higher education institutions across the UK. I have been on the PsyPAG committee for almost 3 years now, having been the clinical psychology representative until I took over last July as Chair.

Being on the PsyPAG committee has been a fantastic experience and something that I originally got involved with having seen that PsyPAG organised some great events such as their annual conference (this year in Lancaster, July 17-19, 2013) and seemed to do a lot for psychology postgrads. I was at a point where I wanted to be more of a part of a community of postgraduate peers, especially researchers. So, I checked out what positions were available on the committee and took the plunge and applied for the clinical psychology representative position and the BPS Scottish Branch representative position. I was unable to attend the AGM at the annual PsyPAG conference (that year in Sheffield) as I was teaching at an Open University residential summer school, so I was asked to send in a paragraph about why I wanted each role and what I could bring to the role that was read out at the AGM (this has now been replaced by a structured application form).

If only one person stands for a position on the PsyPAG committee and there are no oppositions to their application, then that person is co-opted to the committee. This happened for me with the clinical psychology rep role, but someone else pipped me to the post with the Scottish Branch role. In hindsight, this was probably a good thing as I was better placed to fulfil the clinical rep role, I was just very eager so I had applied for both! I was co-opted to the committee that July and got an email to let me know this, as well as introducing me to key contacts from the Division of Clinical Psychology that I needed to link in with and a useful handover email from the previous rep that summarised the work they had done in the role, barriers they’d faced and suggestions for things that I might want to pursue in the role.

I attended my first PsyPAG committee meeting in the November, having received lots of information about how to get there, arrangements for a committee meal afterwards and offering me pre-arranged (budget) accommodation if I required it. I was also sent everything I needed to reclaim my travel costs and had been warmly encouraged to book my train ticket early and to use my student railcard. I arrived at the hosting university feeling very nervous, having never met anyone on the committee, but was welcomed with home made cake and lots of friendly faces including others in the same boat who were attending their first PsyPAG committee meeting. I didn’t end up staying over as the train journey home was only a couple of hours, but I did attend the meal after the meeting, which was a great chance to get to know the committee a bit better – they’re a friendly, sociable bunch at PsyPAG!

From then on, I have thoroughly enjoyed my time as a valued member of a diverse, inspiring and ambitious committee who do an excellent job making sure postgraduates’ voices are heard in UK psychology. PsyPAG also co-ordinate bursaries and awards and organise and host events for fellow postgraduates (see the PsyPAG Twitter feed for regular updates on these). As someone who is not a part of an academic department as I am undertaking clinical training, it has been refreshing to mix with peers who are actively engaged in research and teaching in higher education contexts and this has enabled me to keep up to date with issues in higher education, academia and psychology more widely.

Any PsyPAG event I have been to, particularly the annual conference, has been a welcome break from my studies and clinical practice that has renewed my enthusiasm for psychology and research and allowed me some space and time away from my day to day duties to reflect and gather my thoughts about my work. These events have also been a very useful, constructive forum for discussion with peers both within and beyond my field. This has both built my confidence in my particular area of psychology but also allowed me to make links with other areas of psychology and has highlighted key cross-disciplinary ideas. PsyPAG is also a great networking forum and I have both developed research and professional collaborations with other postgraduates at PsyPAG conferences and also made good friends for life!

I put myself forward for PsyPAG Chair somewhat hesitantly based on the fact that I had been involved in thinking about the organisation’s functions and how we might work better as a committee that fits within a number of other systems. I really enjoy thinking systemically and strategically and thought that it was an exciting time for PsyPAG, so why not get on board and help steer some of these changes. The Chair role has proved to be incredibly rewarding but also challenging at times and has offered me a unique opportunity to develop my leadership skills.

Being chair of an organisation involves a number of key tasks, such as chairing meetings, taking overall responsibility for the direction of the organisation, making sure everyone on the committee has a voice, delegating tasks, problem solving, decision making, representing the organisation to other committees and of course, ensuring that the organisation has a clear vision and aims and that these are being fulfilled. At first, all of this seemed somewhat daunting, but I have had the backing of a very supportive core committee (Vice Chair, Treasurer, Communications Officer, Information Officer) and was made very welcome on the BPS Research Board, who clearly value and respect the input of postgraduates as the future members of the psychology profession.

Prior to becoming Chair of PsyPAG, I had some experience of chairing meetings through my clinical work and had also chaired and judged symposia at PsyPAG annual conferences. I initially chaired symposia that I had convened and organised, as they needed a chair and it made sense as I had selected the presenters and come up with the themes. The main tasks of chairing a session at a conference are to make sure the session starts and ends on time, which also involves monitoring presenters’ timing and keeping them on track. It helps if presenters know from the outset (when their submission is accepted to the conference) how long they have to present and for questions, as this allows them to tailor their presentation accordingly. Arriving early is a good tip, so that you can remind presenters of their time allocations and discuss exactly how you will run the session.

Important things to think about when chairing a conference session are whether you will take questions after each presentation or at the end, how you will respectfully let presenters know if they are running out of time (in a way that is subtle and doesn’t panic them!) and also how to pronounce their name, what institution they are from and what their research area is so that you can introduce them appropriately. In addition to this, I found it useful to introduce the theme of the session and to summarise in one sentence after each talk what were the core messages, which could then be linked to the overall theme and the next talk. I also did a summary of all talks at the end, again to link back to the main theme and to tie everything together. Of course, this depends on how much time you have for the session and is not a necessity.

I’d advise anyone chairing a session to have some questions ready in case the audience are slow to open up when it gets to question time. You may have the opposite problem where you end up with lots of questions and run out of time. You just have to be brutal here and stick to time, I encouraged people with burning questions or who wanted to discuss the subject further to catch the presenters over lunch or at one of the social events. Of course, another important duty is to lead the applause after each speaker and at the end of the session and to thank people for their presentations and questions. You may also be asked to judge a session if there are any prizes up for grabs, but criteria and scoring forms should be provided and if not, you should ask for these.

To sum up, I’d highly recommend taking the opportunity to chair a committee, event or session as you can learn valuable skills and gain leadership experience that you may not otherwise get in other postgraduate roles. It is likely that as you progress though your career, whether you are a psychologist in academia, a clinician, or indeed in many other jobs and fields, you will be expected to develop your leadership skills. Thus, being part of a committee or organisation, especially amongst likeminded peers such as in PsyPAG, can be an excellent opportunity to develop in these areas in a supportive setting. Therefore, I say go forth and chair!

Photo credit: David Bradley

The image to the right looks a little bit like the Venn diagram I attempted prior to writing this post that aimed to visually depict all of roles I identify myself in: researcher, postgraduate student, healthcare practitioner, therapist, advocate, teacher, supervisor, mentor, knowledge transferrer…the list goes on! What this seemingly unproductive exercise highlighted was that it can be tricky when you have many different, sometimes conflicting identities and/or roles. It feels like the image above – a bit messy and overwhelming.

I’ve been juggling these competing demands, in addition to applying for jobs and attending interviews, over the past couple of months and this has meant I haven’t really had time to blog. Well this got me thinking about the old adage of ‘Jack of all trades, master of none’. I have applied for some quite different posts, including lecturer and clinical psychologist. These roles focus on different skillsets, albeit with considerable overlap and many of them involving skills transferrable to the other. However, this makes it a bit confusing and stressful when applying for such posts at the same time, as I’ve found that the whole application and interview process differs.

NHS posts seem to give you very little notice of an interview, which is understandably a necessary consequence arising from practitioners facing increased pressure to squeeze more into their working week, including recruitment. Of the NHS interviews I have attended for clinical psychologist posts, none have required me to prepare a presentation. However, I am aware of peers who have been asked to prepare a presentation. The difference seems to be the level of seniority of the post. I have been led to believe that NHS Boards / Trusts generally do not reimburse expenses, although it depends on the organisation and I’m sure this is judged on a case by case basis. I am by no means trying to swindle money out of the NHS, it’s just that the cost of travelling from Edinburgh to other parts of the UK adds up. NHS clinical psychologist interviews that I’ve had usually comprised a panel of 3 people, including one or two clinical psychologists and at least one other health professional, usually a psychiatrist or nurse. Questions have focused on experiences of assessment, formulation and intervention that are relevant and transferable to the population that the post would be working with, in addition to questions about working as part of a team and wider system.

Based on my limited experience of applying for more academic posts based within higher education institutions, the application format seems much less structured than the proforma you fill in for all NHS posts. Posts I have applied for have asked for the usual details of education, qualifications, and relevant employment, in addition to an up to date CV and covering letter and/or personal statement. Obviously the job descriptions and person specifications also differ, with much more of an emphasis on teaching, knowledge transfer, research impact and income generation. As someone who has never worked in a university and coming from an applied practitioner role in the NHS, these skill areas were somewhat unfamiliar territory. Interviews were very focused on future research plans and potential contributions to the curricula, in addition to how I would add to the looming REF 2014. You tend to get much more notice of interviews and these usually involve a tour or introduction to the department, a presentation (where members of the department are often welcome to attend) and a panel interview. I have been very impressed with the HR departments of universities I have applied to and they usually provide very helpful details about the interview process, what it will involve and provide you at this stage with maps/directions and expenses claim forms. I do appreciate though that universities are probably better resourced than the NHS.

Feedback I’ve received so far has mainly highlighted my enthusiasm and passion for the field I work in (child intellectual disability) and that I show great potential. This is encouraging, but it has made me reflect on what may differentiate me from the people that keep pipping me to the post. It seems to be my reluctance to pledge allegiance either to the clinical ‘camp’ or the research ‘camp’ and I feel like I’m sitting somewhere in between in no man’s land just now. Despite research being a core competency of clinical psychologists’ roles, research and service evaluation seems to be falling victim to the increased pressures on NHS services. Waiting list targets and clinical work are, quite rightly, a priority. However, we must take time to reflect and evaluate our practice and research what works. Otherwise, our efforts may potentially end up becoming inefficient, ineffective and in the worst case scenarios – harmful. However, I realise that I am not yet at the stage of having to manage the demands of service provision in the current NHS and economic climate and my view may be somewhat idealistic.

Returning to my point, my ideal role, balancing research and clinical work does not appear to exist at this moment in time. Furthermore, the fact that I have combined aspects of clinical and research work over my past 5 years of training means that I do not have the same number of high impact publications and international conference proceedings as my colleagues who have followed the more traditional PhD route. I believe that this puts me at a significant disadvantage when applying for research and academic posts, as I don’t have the same depth of knowledge about working in a higher education institution, nor have I had the same opportunities to observe processes such as funding applications and so on.

I am holding out some hope that I will end up in a job combining the two elements, although many people have advised me that it is unlikely that I’ll end up in my first choice of post straight away. This feels somewhat frustrating after 5 years, but I must remember I am very fortunate to have been funded to train as a clinical psychologist and the one thing that this process of applying for jobs has taught me is that I must be patient and keep going! Looking back, each step of the journey has made me reflect and refine my applications and interview performance so perhaps I’m getting closer!

The Thesis Chair
This blog post was inspired by a discussion on Twitter regarding tools people used to help them be more productive during the writing up phase of their doctorate.

The picture shows my ‘Thesis Chair’ – a chair in my living room that ordinarily, I rarely sit in because I much prefer the sofas due to their stretching out capacity. However, I sat in this chair for considerable periods of time last year when I was writing up my doctorate thesis and it became my location of choice for working on my thesis.

I had experimented with a number of locations in my flat (and elsewhere) to see where I was most productive and settled on this chair as it was beside a window with good natural light, right next to a floor lamp for evening lighting and was also next to plug sockets for my laptop. The chair itself was comfortable but allowed me to sit up straight and work, and I must confess that sitting in it made me feel clever and serious! Perhaps because it reminded me a little of the Mastermind chair.

Other people have told me that they have thesis playlists of music that they listen to whilst working to get them into productivity mode, or to inspire or relax them. My friend and PsyPAG colleague Emma Davies was even given a Thesis T-shirt, handed down from someone who had already tread the path to doctorhood. I’ve also heard of people eating certain foods and even engaging in specific routines and rituals that they believe help boost their productivity.

I think the key thing here is that all of these items and activities seem to increase the person’s belief that they are being more productive, thus increasing their self-efficacy and sense of control (also known as locus of control) over what can seem an incredibly daunting, insurmountable task. When we believe that we are being more productive, it can act almost like a placebo effect, where it leads to us actually becoming more productive. Over time, through the process of classical conditioning, this can in turn lead to an association between the productivity ‘cue’ or ‘stimulus’ and the transition into ‘productivity mode’. This is similar to the action of putting on a uniform and entering ‘work mode’ or putting our pyjamas on and entering ‘winding down’ mode.

Anecdotally, such cues and strategies seem to work, although it may be that they simply serve to reinforce the individual’s belief that they are being more productive, whereas their actual productivity may not have changed. It would be really interesting to study this properly, taking into account the influence of other variables (e.g. belief in the particular cue the person is asked to use, global self-effiacy as a trait variable) and measuring different types of productivity outcome (e.g. focus, concentration, time spent working, quality of content generated). Anyone have a few spare weeks and some research resources going begging?! 😉