Hi! I’m Dr Lucy Maddox from Bath University (UK). I’m a clinical psychologist researching compassionate care and things that can get in the way. I have a new book out called A Year To Change Your Mind, about how psychology can help with everyday life

Do ever feel like your just putting a plaster over a bigger problem as many nurses are probably compassion fatigued because they're underpaid/overworked in the least funded area of the NHS?

Great question. Think this absolutely is a risk of interventions which only target individual staff members. The one I am designing is intended to be a multi-level intervention – so to target both staff members with things they can do that might help, and also to try to tackle some of the more systemic problems, via influence on managers and creative thinking about how to overcome massive workloads and tricky rota-ing issues etc. It doesn’t help with the chronic underfunding of the NHS and undervaluing of the nursing profession. I’m really hoping that the current strikes will prompt some engagement from the government and the possibility of some solutions to that.

Similar situation going on in children's residential homes. We're often working with teens who have just left hospital or secure units but chronic underfunding and lack of appropriately trained/ competent staff combined with ludicrous red tape and unrealistic expectations means all to often they end up going back.

Therapeutically parenting traumatised children and teens is challenging and compassion fatigue is a very real issue that definitely needs greater awareness and intervention. It is, however, something that needs to take place alongside a complete overhaul of health and social care services. My fear is that what sounds like it has great potential would be used to allow complacency with the current standards which are seeing vulnerable people failed on an alarming scale.

ETA wrote this without seeing Dr Lucy had responded. It's great to hear you've acknowledged wider issues and the need for systematic change!

I think that is a real risk which is important to try to guard against. My worry with waiting until there has been a complete overhaul though, as you say, is we may be waiting a while, and if there are some interventions which we know have value, both for staff individually, and at a more team focussed or wider system focussed level, then should we wait or is it good to offer what we can whilst still shouting about the problems in the wider system?

Is modern life good for our state of mind? Should we look to revolutionise work, play, education etc?

Wow fab thing to think about. I think it depends on which aspects of modern life and how we are using those aspects. Some things I think are definitely not helpful, for example exam culture for children and young people. Others are more nuanced, for example social media can be both positive and negative depending on how it’s used.

Hi everyone! It's Lucy! Good to be here! Thanks for your questions. I’ll get stuck in!

Hi Dr. Maddox,

What implications or crossover might your research have with general caregiver burnout?

For example, could your intervention also be utilized to help spouses who also act as caregivers to their loved one to avoid burnout?

Fab question. I think probably a lot of the same mechanisms are at work, but the context is quite different so would affect how an intervention could be delivered and what would feel acceptable. It’s a huge issue in caregiving in general though. Lots of work done with foster carers too.

What are your views/knowledge on microdosing psychedelics to treat psychological disorders?

This is a very interesting new area of research. I don't know enough about it but good people to read/listen to include Suzi Gage who has a fab podcast on all things drugs: https://play.acast.com/s/saywhytodrugs and Val Curren who does really interesting research in this area: https://www.ucl.ac.uk/pals/people/valerie-curran

You know how I know you're an actual professional clinical psychologist?

You admit something isn't your area of expertise.

Take notes Jordan Peterson, you don't have to pretend to be an expert on everything.

Thank you for taking your time to speak to us!

Ah thank you!

I think compassionate staff are more able to do their job when supported by compassionate management and commissioners. Shouldn't any compassion intervention be applied systematically through the service? Else you risk a "compassion gap", already present ( imo) between patient facing staff and their non-patient facing management structures.

This reminds me of the resilience training for front line staff. I worry that this scapegoated staff capacity, rather than address unreasonable expectations by their managers and commissioners.

Tldr: Don't mistake a symptom for the disease.

I couldn't agree more! I've got increasingly interested in organisational and systemic elements of compassion fatigue and compassionate care in general. I did a masters in organisational psychology recently and I'm hoping to be able to pull together knowledge about individual level interventions for staff with more organisational level interventional components which tackle work conditions. It's a bit of a tall ask but that's the plan!

Yes! Couldn't agree more. I got very interested in the organisational aspects of compassion fatigue. I ended up doing a masters in organisational psychology and thinking about how some of these ideas about workplace conditions might influence staff ability to provide compassionate care. I'm in the very early stages now of a 5 year project but the aim is to develop a multi-level intervention, not something which is just for staff, but which also involves managers and possibly commissioners.

That's great to hear! I personally feel that the lack of compassion starts at Whitehall and rolls down the hill, ending with a HCA on a 12hr shift, getting yelled at, who then passes the hurt onto the patient.

I'll always remember how one of the Winterbourne view HCAs who was convicted, was voted "most caring" at school, had lots of St John's ambulance experience, wanted to go into nursing. She probably didn't start out abusive, but got there in stages.

What might those stages be? ( Maybe lack of service direction / exhaustion /boredom / suggestiblity?)

It would seem more efficient to start as close to thr top of the pyramid as you can reach (less NHSE /ICB senior leaders to reach, than front line staff).

That's an amazing image of it rolling down the hill. The pressures being passed on feels very true. I think there's also the bit about how people who have been traumatised respond to a system around them and how the trauma influences the system too. It's so complex. Important to recognise anyone could be involved in this as a dilemma though, as you say.

There was an article in The Psychologist magazine this week (the British Psychological Society mag) which summarised a book called Hospitals in Trouble by John Martin. I haven't read the book but the authors said certain quite practical aspects of ward location and culture influenced whether care became poor. The factors included ward location, personal and professional isolation of staff and lack of training opportunities. Obviously this is no excuse for abusive practice but I did think it was interesting to think about what factors could act as roadblocks to make abuse less likely.

Thank for your perspective on intervention efficiency - that's a very helpful thing for me to think about.

Whoops! Thought this had disappeared so answered it twice!

Hi Dr Maddox! I found out very recently I have been dissociating for large spells of my life as a defence mechanism from when I used to get in trouble at school. Have you read or heard anything about future improvements to the assessment of mental health for children/young adults?

I feel I’ve missed out on lots of my life and that my memories aren’t my own because I was left to create negative coping mechanisms. It would be great to hear of any plans to prevent this happening as much for people because it can have major impacts on their adult relationships & career.

Hi! Firstly, I am really sorry that you've had this experience. I hope you've got good support around you now. It's really difficult to feel like you've missed out on a lot. I hope you have found someone to talk to about the negative coping mechanisms you mention too - to help with finding and practising alternatives.

In terms of improvements to assessment of mental health in children now - it depends which country you are in as to what is available, but in the UK there is a new initiative to bring mental health workers into schools with a new type of worker (educational mental health practitioners). Historically sometimes clinical psychologists or counsellors were embedded in schools but funding for this dwindled and the new EMHPs are a response to try to get to students earlier if they are having problems. It has only just started so it's too soon to say how it's going but I think the idea of getting in early is a good one. There are also some fab research projects looking at early intervention, for example CUES: https://cues-ed.co.uk/what-we-do/

Thanks for the questions all! I'll pop back on on Tuesday for half an hour at 10Am (GMT) in case there are any more.

Wishing you all well over this festive bit and into the new year.

Just wrote an absolute essay and then saw this 😂

Sorry! Will try to find your question!

Can you tell us about one of your best clinical moments? About one of your worst?

Wow that's a tricky one! It's a lovely question actually because it makes me realise that there are so many very special moments. It's always great to feel like therapy has made a difference to someone's life, but even the moments when things are not going so well can feel important, especially if the person is able to tell you that they feel bored or like things aren't helping. It feels like there is a genuine connection and then you can try to do something differently. Many special moments happened when I worked on an adolescent ward in London where I also felt very connected to the team and to my supervisor, as well as to the young people I was working with.

Worst moments... I once got sent home from work because my clinical registration had lapsed without me knowing due to an admin error. It was awful! I had to be escorted from the building and I felt like a criminal! It's obviously very important to make sure that professionals are properly registered so it was absolutely the right thing to do, but it was horrible!

How do you respond if someone tells you things aren't going well? Are therapists taught how to do this? Does the response affect therapy going forward?

Thank the person for letting me know and problem solve together what would be helpful going forward. It's really helpful to have feedback!

how to change a bad/negative inner-voice? Please and thank you

Such an important thing to think about. We spend a lot of time with ourselves and if we're having a go the whole time it can have a negative effect. One question I find useful is to ask yourself what you would say to a good friend. We're often much meaner to ourselves than to someone else we love.

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This book by Mary Welford is a good one too: https://www.amazon.co.uk/Compassionate-Mind-Approach-Building-Self-Confidence/dp/1780330324/ref=asc_df_1780330324/?tag=googshopuk-21&linkCode=df0&hvadid=310805565966&hvpos=&hvnetw=g&hvrand=18171044736043241899&hvpone=&hvptwo=&hvqmt=&hvdev=c&hvdvcmdl=&hvlocint=&hvlocphy=9045631&hvtargid=pla-537293131368&psc=1&th=1&psc=1

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And in the new book I just have out one of the chapters is all about speaking to ourselves more kindly (April's chapter). This is on sale at only 99p for a few days if you want the e-book. https://www.amazon.co.uk/Year-Change-Your-Mind-Therapy-ebook/dp/B0B4BTF8RH/ref=tmm\_kin\_swatch\_0?\_encoding=UTF8&qid=1671200145&sr=1-1

Is it available in the US?

Not yet but hopefully soon! This article has some of the ideas from the December chapter in https://www.bps.org.uk/psychologist/coping-christmas

Ah! Just seen there are a couple of questions I haven't been able to answer. I will pop back on Tuesday. Sorry to have to go now.

What psychological disorder fascinates you the most?

Which is the most difficult to treat?

I think of most psychological diagnoses as on a spectrum with more common experiences, and I suppose I feel fascinated by the relationships with the people who I see rather than thinking about an illness in particular. Having said that I’ve worked a lot in wards with teenagers, and worked with some young people who are experiencing psychosis, and I think that’s one areas which is open to misunderstanding, with people seeing it as something dangerous or totally “other”, when again it is actually a spectrum of experience that we all lie on somewhere. All of us can experience paranoia and lots of people have beliefs that others don’t necessarily share. The difference is when it affects someone’s life negatively.

Hi Dr Lucy, thanks for the interesting AMA! Obviously CBT has dominated as a model for quite a while, but IMO has some issues. Do you think there should be a push for prioritising Compassion Focused Therapy as first port of call over CBT? Also a second question regarding your career overall. Do you have any tips for an aspiring Clinical Psychologist? I'm just about to complete my psychology undergraduate degree but am feeling so overwhelmed as to what to do next. AP positions are limited in my country, would you have any recommendations for getting non AP clinical experience? Thanks so much!

Hi! I'm a big fan of compassion focussed therapy but I don't think the evidence base is there to suggest it should be prioritised over CBT. I think it's important to be guided by what the evidence says is most effective, and for a lot of problems that is CBT at the moment. It doesn't mean that won't change as more studies are done with other modalities though. I also think patient choice is important - giving people the information about what the research says helps, but also telling them what the different therapies are like so they can be involved in the decision making. One of the reasons I made the podcast Let's Talk About CBT was to demystify the different types of therapies which are based on cognitive behavioural principles. There's an episode on CFT in there too! https://letstalkaboutcbt.libsyn.com

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With clinical psychology - if AP positions are hard to find you might have more luck with a research assistant post on a study which has clinical components. Voluntary work can also help if you are able to do a bit of that on the side (e.g. things like phone lines often provide training). Good luck!

Hi Lucy, I’m an RMN working in a community adult access team, I have experience in female and male forensics, community affective disorders and CAMHS inpatients. I have a bit of a passion for trauma informed care probably to the point that I think almost all mental health diagnoses stem from a form of PTSD. For me the barriers to compassionate care at the moment come mainly from staffing and burnout related issues. It’s hard to give patients your best when the staff team are spread so thinly. In CAMHS I found patients attitude towards each other made things difficult as well as the attitude of their parents, I think the complaint culture we have gotten into plays a big part in this as well, as we are scared to do our jobs in some ways due to fear of litigation if something goes wrong. I think being able to recognise when staff are burned out and rotating them for a while would be great but rarely happens, especially if you work somewhere like a PICU where it’s hard to recruit to. Do you think that the staffing problems we have now, such as a heavy reliance on agency staff, mean that patients are not getting good, compassionate care and continuity in their care?

Aha I found your question! Thank you for writing this. I'm so sorry that things are so hard at the moment. It feels like things have always been difficult but in recent years have really bene stretched so so thin. I do think that staffing problems contribute to barriers to care. That's not to say that some agency staff aren't brilliant, but I think it's harder to have the same sense of continuity and team cohesion. It's also so stressful for the senior nurses managing the rota and trying to fill shifts. I do also think there is hope though because retention of staff is better in some wards than others, so I think we can learn from what is working in some places as well as from the research.

I’d love your thoughts on CPTSD. I suffer from this and for some reason it’s still very taboo to speak about it generally.

What are some helpful tips to help overcome this issue? If there are any.

Hello!

I'm really sorry to hear you have complex post traumatic stress disorder. That's so difficult to live with. I would really recommend seeking some professional help with it if you can - if you are in the UK your GP is usually first point of access or you can self refer to some Improving Access to Psychological Therapies services. If the waitlists are too long then private therapists often often sliding scales of fees. It's important to get someone who has training and experience in dealing with CPTSD. If it is related to childhood experiences then this book is also a good resource - although not a substitute for individual therapy https://www.amazon.co.uk/Overcoming-Childhood-Trauma-Helen-Kennerley/dp/1841190810

Best of luck with it.

Since you mention an intriguing phrase - compassion fatigue - how do we handle or deal with friends/colleagues/relatives who are only too happy to go on and on about their stuff without letting you talk about your own stuff?

I think most would know people like these in their life and would agree that it's not always feasible to just "cut things off" with them.

This sounds tricky... And christmas is a time when we often find ourselves stuck in repeating patterns in relationships with people we have known for a long time. One thing that can sometimes help is thinking about what you can do differently to shift the dynamic slightly. Can you make a conscious effort to talk more about your own stuff and not wait to be asked? The results might be surprising!

How much of social media do you believe has affected people negatively as in increase of depression?

The picture here is very interesting and researcher Amy Orben has done some fab work in this area: https://www.amyorben.com

It depends on how we use social media. If we use it to compare ourselves negatively to others and to isolate ourselves then it's unhelpful. If we seek out accounts which are affirming and social links which help us feel connected then it can be helpful.

We need to be careful though, I think, as some dilemmas which occur online e.g. sharing personal photos with wide groups of people, can have devastating effects on young people

What are you thoughts on the Power Threat Meaning Framework? What changes would you like to see in the mental health field?

Wowser this is a big'un!

Main changes I would like to see in the mental health field relate to adequate funding. There has been so much talk of "parity of esteem" between mental and physical healthcare but I would like to see "parity of funding" and also proper investment in social care and third sector services. I'd also love our knowledge of staff wellbeing and the impact on compassionate care to advance so that we can more effectively help both patients and staff.

Do you make a distinction between compassion and empathy?

For instance, compassion is an awareness of suffering and a heartfelt wish to alleviate it; while empathy is to feel as another person feels?

I ask because I think the distinction might be important. Extended periods of feeling what others feel can lead to empathy fatigue (checking out and shutting down), but extended periods of wishing to help alleviate suffering don't seem to lead to compassion fatigue.

What do you think?

This is a really great point. I think they are different too. Some people have made a similar argument to yours: https://www.researchgate.net/publication/336746147_Contesting_the_term_%27compassion_fatigue%27_Integrating_findings_from_social_neuroscience_and_self-care_research

I think we maybe don't know quite enough about the subtleties of the differences yet, but this is something I'm trying to get my head around at the moment.

What is your #1 advice for management of mental health? What is a daily activity that helps the most and what daily activity does the worst for getting optimal mental health?

Ooh fab question.

I would say that things vary for individuals - there's no one thing, but things that tend to help daily are (obvious but still helpful): trying to move your body, eating well and sleeping enough (if possible!), trying to treat yourself with kindness like you would a good friend, trying to spot things you enjoy and things you feel proud of throughout the day.

Things that are usually unhelpful: too much of any one thing - e.g. too much isolation or too much busyness, not enough rest (even if it's tiny micro rests in the day), beating yourself up about things, ruminating on things that have already happened or worrying too much about things that are out of your control.

It's obviously easier said than done to make changes to these things, but they are worth considering in my opinion! There are more ideas in my most recent book which is only 99p on kindle for a few days: https://www.amazon.co.uk/Year-Change-Your-Mind-Therapy-ebook/dp/B0B4BTF8RH/ref=tmm\_kin\_swatch\_0?\_encoding=UTF8&qid=&sr=

Any way to buy your book in the US?

Not yet but hopefully soon! Article here is based on some of the chapter on December: https://www.bps.org.uk/psychologist/coping-christmas

Hello! I'm afraid I have to go now. Thanks so much for all the questions - I answered as many as I could - if I didn't get to yours have a look through the others - it might be answered there.

Wishing you all a good festive period. Here's an article on coping with christmas in case it's helpful: https://www.bps.org.uk/psychologist/coping-christmas

Can you post any third party reviews of the book?

Some are quoted on the amazon page: https://www.amazon.co.uk/Year-Change-Your-Mind-Therapy/dp/1838959092

Very happily for me it was one of Apple books' best books of December and also one of the Independent's best books of December.

Hello! I'm back for half an hour now to answer a few more queries!

Hi Lucy, thanks for taking the time to do this! From an aspiring clinical psychologist currently working in a CAHMS inpatient service for teenagers, I have a few questions - please feel free to answer whichever you feel like.

1. Your intervention sounds really interesting! I also hold an interest in compassionate care and compassion-focused therapy. What will your intervention comprise of, and how are you planning on evaluating it? Do you have any papers published or registered for this yet? I'm keen to have a read!
2. How do you approach self-practice and self-reflection if at all (i.e. outside of teamwork reflective practice and supervision)? Do you take a freeform approach or utilise a framework? Do you write, record, or just think? Has this changed from the early days in your professional development?
3. If you could choose one book (other than your own) to recommend to someone entering the field, what would it be? This can be as loosely or as closely related to the profession as you like.

Thanks in advance! :)

Hello! I'm nearly out of time again but here's a paper I published recently: https://pubmed.ncbi.nlm.nih.gov/35915459/

And self-reflection is hugely important. I use a mix of things - supervision and writing and peer supervision. I probably use self reflection and peer supervision more as time goes on but it's still really important to have regular supervision from someone who is just doing this for you - we can all have unconscious biases and can benefit from someone helping us to spot them and improve our practice.

ooh and the book - I'd recommend Yalom - Love's Executioner. It's quite psychodynamic in model which is not what I use but it's brilliantly written and I like the way he acknowledges his mistakes.

Will the book be available in the US?

Hopefully at some point but it isn't yet

Do you use mindfulness or metra meditation?

I use mindfulness, both myself in my personal life and professionally with other people. It's not for everyone but I find it very useful.

Hi!

I am looking to go into Clinical Psychology, I am doing an Undergraduate degree in Psychology. Do you have any advice? I am attempting to gain as much clinical experience as possible!

Research jobs in clinical settings can be good, support worker posts, charity roles, voluntary work (e.g. Childline or Samaritans). There are lots of ways to get experience and see if you like the role. Talk to clinical psychologists if you can too to get a sense of what the role is like and also what other roles are around. Good luck!

Hey Dr Maddox! Thank you for doing this AMA :) this is going to be a little personal, and trigger warning for those with trauma.

I've had a lot of experience recently with my partner going through multiple UK NHS services for their undiagnosed chronic pain and severe PTSD from childhood trauma they're still working through. They find the physical pain can lead to suicidal thoughts.

Each time they're suffering and a doctor speaks to them, my partner is extremely adverse to being honest about their suicidal thoughts as it leads to them being put in mental institutions that they feel have been unsafe and triggering while their physical condition goes untreated. As their partner and carer, I can understand their incredible reluctance to continue engaging with professionals who can help them, as my partner feels they do not truly understand or listen to their troubles.

My question is this; what can be done and what changes need to be put in place to overcome this block between doctor and patient, and what can we as individuals do who have suffered what we feel is a lack of compassionate care in the system?

Hi!

Firstly I am really sorry, that your partner had these experiences and that you have both had to manage difficulties with the healthcare systems in response.

I think there is no easy answer to this one, and unfortunately the risk assessment questions which are needed from a clinical point of view can feel like they get in the way sometimes. They are the best tool we have and it's important to try to assess risk but they're not a very good one.

In terms of what can be done in response to a lack of compassion - I think it depends on your level of energy partly. You could write to an individual clinician to give feedback, or it's always possible to complain - in the UK the Patient Advisory and Liaison Service is independent and can manage complaints about the service you have been involved with. Making a complaint means it gets put on record and the clinicians involved will get that feedback, which hopefully will help improve the service. However it depends on whether you feel that this would be helpful for you as well - if you feel like you have the time and inclination to put a complaint together. I'm not saying this to put you off at all - just to acknowledge that this can sometimes feel like an extra burden.

Whatever you decide, I really hope you find some support which is helpful for both your partner and you.

Hi Dr. Maddox,

Just in case you see this when you're back online, I thought it'd be interesting to get your insight on this:

For those of us who might use psychologists, is there any specific certification we can check for therapists claiming to deal with specific issues?

I was recently seeing a psychologist for something that she claimed to have expertise in, and the more sessions I did, the more it became clear she was definitely not trained in dealing with them.

Is there some way to check this in case I decide to go back into it?

Hi! Such a good question. It's very confusing I think to find this sort of information out clearly. Clinical Psychologists should be registered with the Health and Care Professions Council (HCPC) but this doesn't tell you about specialisms. You can ask them though - have you had special training in this, do you have any accreditation, what is your experience? For example CBT therapists are often accredited with the British Association for Behavioural and Cognitive Psychotherapies. I'm really sorry you had this experience though - it's not good. I hope you were able to give feedback. If they are a clinical psychologist you can also complain to the HCPC, or through the NHS service if it was through one of those. Best of luck and hope you find a therapist who is more helpful.

Is it hard to become a clinical psychologist and does it require a big knowledge of math? I want to become one but math really isn't my strong suit.

Edit: Why was I downvoted???

It has some stats involved but you get taught that. Don't let it put you off!

Sometimes the brain does extreme things to protect us (although with nasty side-effects), for example in DID/MPD or PTSD. However in schizophrenia it's hard to see that there's any protective benefit at all. Am I missing anything? Is there any utility to it? And is it a natural response to any stimuli?

Thanks in advance

Not necessarily the case for everyone but sometimes strong unusual thoughts might be protective against things in reality which feel very hard to manage.