Time for a re-set in how academics and clinicians discuss COVID science

  • November 28, 2020

One dismaying feature of our public debate about responses to the pandemic is the way that some high-profile academics and clinicians have chosen to make their contributions.  That is, there’s a big problem not with what they have to say, but how they are saying it. I recognize at least three undesirable communication styles:

Adversarial grandstanding

Lancet editor Richard Horton has made no bones about his opinions – he describes the UK’s response as “‘the greatest science policy failure of a generation’.  But whatever his views, did he need to describe the SAGE committee as “The public relations wing of a government that has failed its people”?  Many of the academics on that committee and its working groups are doing the best they can in a fast-moving and unfamiliar world, where they are dealing with a near-impossible set of politicians and their advisers. Under the circumstances the remark by Robin McKie, the reporter sent to cover the puff of Horton’s book about COVID that “Horton can sound strident, even arrogant” seems a little understated.

Horton’s abrasiveness is as nothing compared with Carl Heneghan’s, Professor of Evidence Based Medicine in Oxford, who has said that the government’s scientific advisers “specialise in causing panic and little else”.  Insulting people who disagree with you is no way to conduct a debate about research and its interpretation.

Independent SAGE is a minor variant of this adversarialism –it’s not their message I’m bothered about, it’s the mode of its delivery, where the mechanism is not simply to propose different ideas but to establish a forum defined as oppositional.

Melodrama and shroud waving

The current President of the Royal College of Psychiatrists and his predecessor have both used the word tsunami to describe apparent increases in mental health problems during the pandemic. Metaphors are tricky ambiguous things – what is this one supposed to mean? That what’s happening is a highly visible, immediately destructive result of a force of nature? That people with mental health problems represent a threat we should run away from as fast as possible?  Actually, it doesn’t seem to mean much more than – there’s a lot of it about and we ought to be planning a response. 

I’d much rather hear exactly what the problem is, how we know, and exactly what the proposed solution is. By which I don’t mean statements like Professor Neil Ferguson’s flamboyant claim that 20,000 people died because we started the first lockdown a week late. Exact perhaps, with an implicit message about a proposed solution – do what I tell you next time – but rather short on the robustness of the “how we know” element (see later in this piece).

Writing in the journal Lancet Psychiatry in November this year. Psychologist Professor Ellen Townsend says: “…UK residents have all been punished by new limits to the number of people socialising together, and have been warned that further restrictions could be imposed unless their supposedly reckless social behaviour improves.”  Social media have more of this sort of thing – mandated mask-wearing as an abuse of human rights for example. The rhetoric conflates two ideas – it is perfectly possible for something to be punishing (such as a physical training regime or schedule of book signing events) without it being administered as a punishment.

Being economical with the truth.

Since its use by cabinet secretary Robert Armstrong during the Spycatcher hearings “economical with the truth” has been taken to mean “lying” whereas its wider meaning is (as the words suggest) something like – “being strategic about the degree to which truths are revealed.”

REACT-1 is a major study in the UK’s epidemiology of the COVID, and especially during the early months the media pounced on its interim results, presented by Neil Ferguson (again). A fine example was the splash a couple of months ago that across the UK R=1.7, with important implications for numbers of cases that might be expected. The withheld truth here is that REACT-1 is one study of one sample, results modelled by one group, and results should be treated with caution until a better estimate can be obtained by pooling or at least comparing results from all available studies. A non-trivial suggestion, given that – certainly at this time – the estimates from REACT-1 modelling were considerably in excess of those from other groups, as revealed during the press conference which presaged the rationale for our second national lockdown.

Writing in the Spectator Carl Heneghan (again) and a colleague presented the results of a Danish trial evaluating the effect of wearing face masks on the likelihood of the wearer contracting a C-19 infection. The original title “Landmark Danish study shows face masks have no significant effect” proved too much for the journal to defend so it became “Landmark Danish study finds no significant effect for face mask wearers.” The article noted that since the study was an RCT it represented “highest quality scientific evidence” but failed (oddly) to mention that the medical journal in which it was published carried an accompanying editorial explaining why they had accepted a paper describing a study with so many flaws. The study’s estimate of effect was so uncertain that the authors noted that they couldn’t rule out a significant effect on mask wearers infection rates – also not mentioned in the Spectator article. And of course the Danish researchers didn’t look at rates of transmission from mask wearers to others. It’s only by leaving out all these facts that the Spectator article can conclude: “And now that we have properly rigorous scientific research we can rely on, the evidence shows that wearing masks in the community does not significantly reduce the rates of infection.”

Does any of this matter?

Some of this has been noted before. For example, writing in The Conversation on 6 October Danny Dorling deprecated the polarised approach to the specific question of lockdown policy. But does it really matter? Is the style of communication noted here just what’s necessary to get debate about science into a media that is largely scientifically-illiterate?

Public communication about the implications of the COVID-19 pandemic has not been good. The government has led the way with inconsistent messages, untrusted presentation of results aimed at boosting their image rather than telling the truth, and a prime minister whose incoherence and vagueness has ceased (if it ever was) to be amusing. In that context this academic behaviour could be seen as doing no more than adding a little to our woes – making it that much harder to guide the public response to risk.

Unfortunately it goes further than that, as misrepresented science is picked up by those lobbying for a particular viewpoint. It suits the libertarian perspective to present modellers as hopeless, biased academics who present misleading findings to politicians and use them to press for draconian interventions – a pitch that is easier to make when bolstered by hints that perhaps over-confident prediction and error-proneness go together.  

In the longer-term the damage comes from a dogmatic and attention-seeking style that  misrepresents science – when natural uncertainty and healthy debate are portrayed as incompetence and division, there will inevitably be a loss of public confidence in the role of science in policy making.

Much has been made of the re-set in Government that is likely to follow the departure of the poisonous Dominic Cummings. Surely now is the time to re-set the tone of the scientific debate – there are enough thoughtful, articulate academics out there. We need to be pressing for a change in tone by challenging unhelpful communication – not for what is being said but for how. And a research idea: behavioural science hasn’t contributed much to thinking about how we should respond in the pandemic – perhaps research is needed into the impact on behaviour of declining interest in listening to over-confident and over-definite experts, what we might call rhetoric fatigue.

Functional neurological disorders

  • November 11, 2020

Research and treatment should involve understanding why and not just how they develop

The group of clinical conditions that are now described as Functional Neurological Disorder (FND) used to be known by more uncomfortable names – hysteria, conversion disorder, or the hybrid hysterical-conversion. The change of terminology is welcome, although perhaps not its usage in the singular; after all the category brings together some quite disparate conditions.

With this change in terminology comes a change in the academic and clinical discourse. For the last century or so, the majority view has been that these functional disorders have psychological causes:  how they develop comes about through a process of loosening and disconnection between usually connected functions that need to be co-ordinated for effective motor or sensory function – dissociation; why they develop is explained as a response to some sort of psychological conflict that cannot be satisfactorily resolved – the emergence of disorder representing either symptomatic breakdown or a defensive manoeuvre to contain the conflict.

A shift in emphasis

The current FND discourse is relatively uninvolved with ideas about why FND occurs. Its focus is on antecedents that seem relatively trivial psychologically and upon mechanisms of symptom production – the how. Modern approaches in neuroscience allow studies of the physiology of symptom production that give new meaning to older ideas like dissociation and somatosensory amplification and more recent ideas about interoception, helping to explain some of the specifics of presentation – how some symptom states are generated – or to suggest why some individuals are especially susceptible.  Such research may yield interesting insights into the nature of these conditions and perhaps offers the future possibility of new therapeutic approaches.

A corollary has been a tendency to downplay the role of interpersonal factors in aetiology or maintenance: early or later life experience is hardly discussed as having a potentially meaningful relationship to onset or persistence of FND. Enthusiasts for a quasi-neurological cause for FND are keen to quote a systematic literature review1 which found that many people do not report severe life events as antecedents to onset. Three of the most widely used patient-facing resources2 lead on “problems with functioning of the nervous system” in their definitions of FND, while not offering the possibility that an important cause might be psychological. Psychological intervention, if any is offered, is focussed on overcoming barriers to social and physical rehabilitation and formal psychological therapy may not even mentioned as an option3-4.

There are apparent clinical benefits to this approach, which no doubt account for its current popularity. Most significantly it can facilitate engagement during consultations and thereby rehabilitation efforts, especially in those cases where a less medical-sounding diagnosis is “not well accepted by patients who feel that (it) implies that their symptoms are inauthentic…”5

Where does psychotherapy fit in now?

Against this background a recent systematic literature review6 has summarised evidence for the effectiveness of psychological therapies in FND – 12 studies of CBT and seven of psychodynamic therapy. Therapy trials ought to be a test of some of the ideas about causes of FND and its associated disability, because CBT sits mainly as an adjunct to rehabilitation whereas psychodynamic therapy is aimed at the interpersonal distress that, putatively, has a causal as well as maintaining role.

The results are, frustratingly but not surprisingly, inconclusive. Most of the studies are small and had methodological weaknesses that prevent us getting a definitive answer. The lumping together of participants with quite different clinical presentations makes it impossible to answer the question “what might work for whom?”. We don’t know what proportion of eligible patients will accept either therapy when it is offered in an encouraging and supportive way.

Even so, two results stand out from this useful and well-conducted review. The first is that psychotherapy, including psychodynamically-informed therapy, can be acceptable to people with a range of functional disorders. The second is that the CODES trial7 – by far the largest and best conducted in the field – produced a number of non-specific benefits in mood, wellbeing, quality of life and so on, but had no effect on the frequency or severity of the primary presenting problem which was non-epileptic (functional) seizures.

Where next?

The discourse on FND needs to be rebalanced. A full formulation should include an understanding of psychological and social factors in the generation and maintenance of functional states – not just as coincidental co-morbidities or as natural consequences of disability but as meaningfully related to the disorder. Current evidence on life adversity is not robust enough to dismiss this possibility:  severe threatening events are not what one would typically expect to find as the explanatory exposure in this context8, and life events interviewing is a blunt tool for exploring more nuanced interpersonal conflicts.

The framing of FND as primarily a problem of nervous system function may get in the way of this broader formulation, making it harder for people to discuss and understand the psychosocial aspects of their illness.

Caricaturing of psychological perspectives doesn’t help.  If clinicians really say to their patients  “It’s all in your head”9  or describe them (presumably to colleagues) as work-shy hysterics10 then what’s needed is some re-education of those clinicians rather than reformulating functional disorders so that patients learn to say “I have a real dysfunction of networks in my brain”9.  We must be careful not to collude with the stigmatising of mental health problems by a reluctance to acknowledge that they too are respectable states with which to be diagnosed.  When I first started in medicine, patients were frequently not told they had cancer – as a way of avoiding distressing and uncomfortable consultations. Nobody accepts that now, but it feels as if that’s where we are with FND.

It is a mistake to believe that everybody wants a disease-like diagnostic label and not everybody is offended by sensitively handled discussion of psychological causes of physical illness. For example Markus Reuber and colleagues in Sheffield have shown, as does the latest literature review, that if care is taken with early introduction of the ideas then psychological therapy, even when informed by psychodynamic principles, can be delivered in brief and acceptable formats to people with functional symptoms. Of course not everybody will accept a psychological approach, but an early over-emphasis on mechanistic explanations and short-term goals in therapy just makes it more difficult to address important psychological and social issues at a later stage, if all is not going well.

Writing a little while ago, Anthony David11 talked about a happy “we’re-all-friends-together-let’s get-rid of Cartesian-dualism” camaraderie that pervades this field. He was talking about something a bit different, but it’s still true that “an end to dualism” won’t do to explain where we are now. Apart from the misunderstanding of dualism that the slogan implies, it’s wrong because what we need is more openness about discussing with patients the possible primarily psychological causes and treatments that are relevant in FND even if that may bring uncomfortable consultations – a part of the continuing confrontation of stigmatisation in psychological illness. These ideas need to be tested in careful clinical trials that allow for testing of the value of psychological formulation and intervention as a substantial rather than adjunctive part of treatment, and involve evaluation of mediators and moderators of outcomes that can help unpack the complex nature of this group of disorders. We should do no less – we are still a long way from understanding functional disorders and treating them effectively, and the prognosis for FND is certainly not good as things stand12.

  1. Ludwig L, Pasman JA, Nicholson T, Aybek S, David AS, Tuck S, Kanaan RA, Roelofs K, Carson A, Stone J. Stressful life events and maltreatment in conversion (functional neurological) disorder: systematic review and meta-analysis of case-control studies. The Lancet Psychiatry. 2018 Apr 1;5(4):307-20.
  2. FND Action https://www.fndaction.org.uk/what-is-fnd-2/; FND Hope;  https://www.fndhope.org/   Neurosymptoms https://www.neurosymptoms.org/
  3. Johns R. I feel I am missing a piece of the puzzle. BMJ. 2020 Apr 8;369.
  4. Wong M. Telling me you don’t know is ok. BMJ. 2020 Jan 8;368.
  5. Dimsdale J, Creed F, Escobar J, Sharpe M, Wulsin L, Barsky A, Lees S, Irwin M, Levensen J (2013). Somatic symptom disorder: an important change in DSM. Journal of Psychosomatic Research, 75, 223-228.
  6. Gutkin M, McLean L, Brown R, Kanaan RA. Systematic review of psychotherapy for adults with functional neurological disorder. Journal of Neurology, Neurosurgery & Psychiatry. 2020 Nov 5.
  7. Goldstein LH, Robinson EJ, Mellers JD, Stone J, Carson A, Reuber M, Medford N, McCrone P, Murray J, Richardson MP, Pilecka I. Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial. The Lancet Psychiatry. 2020 Jun 1;7(6):491-505.
  8. Kanaan RA, Craig TK. Conversion disorder and the trouble with trauma. Psychological Medicine. 2019 Jul;49(10):1585-8.
  9. Burke MJ. “It’s All in Your Head”—Medicine’s Silent Epidemic. JAMA Neurology. 2019 Sep 16.
  10. Popkirov S, Baguley DM, Carson AJ, Brown RJ, Stone J. The neurology of the Cuban” sonic attacks”. The Lancet Neurology. 2019 Sep;18(9):817.
  11. Edwards MJ. Functional neurological disorder: an ethical turning point for neuroscience. Brain 2019 Jun 26;142(7):1855-7.
  12. David AS. Functional disorders, Cartesian dualism and stigma: where does the dualism really lie? Journal of Neurology, Neurosurgery & Psychiatry 2012;83:869.

The emperor wants a new set of clothes

  • August 10, 2020

Is covid-19 really a justification for more funding for behavioural science?

Behavioural science (essentially health psychology) came to applied health research with a big promise – that the application of psychological theory would lead to effective interventions for changing important health-related behaviours. In its strongest form the claim was that it was only such theory-based interventions that could be effective.

This promise was taken up enthusiastically by the UK’s main research funders, the MRC and NIHR, so that in recent years it has become a default expectation that all interventions aimed at changing any aspect of the behaviour of patients or populations should be informed by behavioural science. Their committees started to include behavioural scientists along with statisticians and economists – experts whose knowledge was required to make a decision regardless of the specific topic being considered for funding.

There have always been straws in the wind that this idea might have been a tad oversold.  Initially it was individual evaluations of theory-based interventions that failed to deliver as expected. A discussion paper in 2013 found no evidence that the approach had generated  cost-effective interventions for common behaviour-related health problems like obesity and smoking.  And then a major review of the evidence for the so-called theory-effectiveness hypothesis, published in 2019 in the British Journal of Health Psychology, concluded “Theory-based interventions as currently operationalized in systematic reviews were not found to be more effective than non-theory-based-interventions.”

Still, the idea has taken root. As everybody knows, even that great thinker the former Prime Minister David Cameron was convinced. So when the COVID-19 pandemic arrived it was no surprise that one of the SAGE subcommittees, SPI-B, was charged with applying behavioural science to the problems posed by a need for widespread adoption of changes in lifestyle and day-to-day activities. What has come as a surprise is how little we hear about that committee compared with, for example, SPI-M the committee which is concerned with measuring and modelling the progress of the pandemic. A March statement about the role of behavioural science in the coronavirus outbreak consisted mainly of platitudes and an appeal for urgent research, and since then we have heard hardly anything.

In the past week that relative silence has been broken twice. First has been a vehement denial that the idea of behavioural fatigue comes in any way from the behavioural science stable – an intriguing entry into public debate coming just as it’s clear that whole sections of the public are no longer taking any notice of pleas to maintain social distancing or wear face masks.

Second, an article has appeared in this week’s British Medical Journal with the rather belated acknowledgement that “there is almost no relevant evidence on how to promote adherence to behaviours such as distancing from other people and households, hand cleansing, effective use of face coverings, and avoiding touching one’s eyes nose or mouth with contaminated hands.” They might have added “or willingness to collaborate with contact tracing agencies”.

Why has behavioural science ended up in this position? Michie and West suggest that it’s because they haven’t had enough research funding. More to the point are two features inherent to the whole enterprise. Modern health psychology has taken a robustly individualistic approach – privileging psychological characteristics (such as self-efficacy) and psychological processes (such as the forming of action intentions) to the neglect of interpersonal, social and cultural influences on behaviour. And in its incarnation in health, behavioural science has privileged theory as the foundation of its claims to truth, neglecting the sorts of research approaches that would test those theories in real world settings.

Where next?  “…we urgently need a major coordinated programme of research to develop and evaluate behavioural, environmental, social and systems interventions that will be effective and viable in tackling the covid-19 and future pandemics.” Well maybe, but it isn’t at all clear, given the history, that “behavioural” should be at the front of that list – except that it makes the acronym snappier. There are other ways to think about the rationale for population-level interventions and we should be conducting a wider search for answers – for example through the social and political sciences and humanities.  And adding “political” to the list of interventions would help: any applied health researcher will vouch for the ineffectiveness of the cleverest interventions if they aren’t implemented competently, consistently and comprehensively.

There’s plenty of time to consider the options here. The UK’s pandemic response is in the hands of a government that is influenced by many factors, and high on its list of priorities is not attention to the complexities of science as it applies to population health behaviours. I’m sure they won’t be pressing for answers before Christmas, although they might be looking for people to blame when it’s clear they don’t have those answers…

Mental health care in a Warr zone

  • July 14, 2020

Another NHS review is trailed in our newspapers – this one apparently aimed at clipping the wings of NHS England and Public Health England. Anyone who knows the first thing about British politics will know that neither Boris Johnson nor Matt Hancock has the ability or the interest to lead a strategic overhaul of our health service, so no doubt the output will be determined to a large extent by the prime minister’s Svengali, Dominic Cummings. What does that tell us about the likely consequences for mental health care in this country?

Cummings likes to pose as an outsider but his scruffy T shirt and stubble is as much an affectation as his employer’s tousled hair and faux-Churchillian gestures. He is a mainstream Tory – privately educated, Oxbridge humanities degree, socially and politically connected. His interest in IT and modelling is a quirk; his real drivers are authoritarianism and disdain for Little People – justified to himself by his self-appraisal as the cleverest man he knows. Cumming’s foot soldiers are the SPADS he employs to run the prime minister’s (and Number 11’s) office. What he seems to be creating sounds a long way from the team of talented weirdos and misfits he famously advertised for and more like just another insiders’ clique.

Cumming’s place man as Number 10’s adviser on Health & Social Care, Life Sciences and Technology is one William Warr, who fits the bill nicely. A standard issue arrogant white man, he has no claim to expertise in health and social care apart from entry-level training in public health and failing to complete his PhD, but he has connections and holds the right political opinions. And those opinions, outlined in (of course) The Daily Telegraph, don’t bode well for our health services – antipathy to an NHS that wastes all its resources treating ill people, overvaluation of the role of tech, tired ideas about smartphone apps and nudge interventions, unthought-through ideas about personalised medicine based upon genetic testing. And Warr seems to have skipped the modules in his MPhil on social determinants of health and on secondary and tertiary prevention.

I’m wondering what all this has to offer people struggling with long-term mental illness, or with the unglamorous admixture of physical and mental disability, poverty and educational under-achievement described so well in Frances Ryan’s book Crippled. The answer is, I’m afraid, nothing. The ability to exercise informed choice about lifestyle is not to be dismissed, but it is overprivileged by those who don’t like the idea of a welfare state.  A Zoom chat with a mental health support worker and an offer of gene sequencing is no substitute for good housing, education, a safe environment, proper treatment from a multidisciplinary team of specialists, and a society that values support and participation over competition and acquisition.

The Collected Schizophrenias.

  • June 30, 2020

I read this collection of essays by Esmé Weijun Wang (Penguin, 2019) in our work-based book club Many Stories Matter, organised by my work colleague Helen Coop to encourage discussion about equality and diversity. These are my own notes.

Wang has a diagnosis of schizo-affective disorder and what is presented is her account of living with that diagnosis. The book’s opening two-word sentence , “Schizophrenia terrifies”, is not encouraging. The second paragraph begins “People speak of schizophrenics as though they were dead without being dead…” and goes on to cite psychoanalyst Christopher Bollas about “schizophrenic presence” as “being with [a schizophrenic] who has seemingly crossed over from the human world to the non-human environment”. Whatever that means.

A first impression is that, notwithstanding the purple prose, Wang embraces a fairly standard medical-psychiatric view of what is going on. She talks frequently about diagnostic statements by the (several) psychiatrists she has consulted – she has herself worked administering research diagnostic interviews and seems to take them at face value as disease labels. Drug names are scattered through the text. Diagnosis apparently equals prognosis, although Wang points out the disparity between her own “high functioning” and the usually expected course of schizophrenia-like illnesses.  On the other hand, there are descriptions of the abusive nature of inpatient treatment and of physical restraint. One of her psychiatrists (Dr M.) is described as suggesting her final diagnosis during an email consultation. And there is a disturbing account of a summer camp at which she and her husband, untrained and largely unsupervised, “looked after” a number of children diagnosed, along with multiple other conditions, as bipolar. All this suggests a more ambivalent relationship with the uncertain practice of psychiatry.

The complexity in this book resides in more than the ambiguity of the author’s position. There is no obvious organising principle, thematic or chronological, and even within chapters it can be difficult to follow the thread. It is surprisingly difficult to gain a detailed picture of what exactly is Wang’s personal experience of her illness and its evolution.  Scattered and uncritical references are made to Rosenhan’s discredited On being Sane in Insane Places, to the laughable film A Beautiful Mind, to the opinions of astrologers, and to the Big Pharma sponsored National Alliance on Mental Illness – as if these sources jostle with the more orthodox for explanatory influence. Passing comments about family tensions and a history of repeated self-harm are not expanded upon or integrated into the narrative. Finally there is a long derailment into describing Wang’s pursuit of psychic healing and treatment for chronic Lyme disease as solutions to the failure of conventional psychiatry.

It is difficult to know what to make of all this. Is the narrative style an intentional or performative device, aimed at representing Wang’s experiences? Or a more-or-less unselfconscious demonstration of her current way of remembering it all? Andrew Scull’s review in the Times Literary Supplement was subtitled “A fragmentary memoir of mental unrest” and that seems about right. I was left unclear how much this is a collection of essays about psychosis as opposed to being about the author’s overshadowing attempt to frame her life as somebody with psychosis. Perhaps that is at it should be: the book’s main value is to illustrate one of the dilemmas inherent in living with longstanding mental disorder – the appeal of certainty that resides in psychiatric diagnosis and treatment comes with the limitations of its purview and the disbenefits of its actual practice, while the broader search for personal and cultural meaning does not always yield useful insights or practical solutions.

Self-harm in the NHS: time for change

  • June 29, 2020

Twenty five years ago my colleague David Owens and I wrote a lament for the state of NHS responses to self-harm – noting little research investment, haphazard service provision and no evidence of central strategy. Revisiting the scene recently in an editorial for the British Journal of Psychiatry , we found little to celebrate in the way of real progress. My friend and colleague Nav Kapur wrote a riposte which was less of a counterblast and more an invitation to peer at glimmers of light at the end of the tunnel.

A recent post on the Recovery in the Bin site puts some flesh on the bones. The author sees an explanation for her experience of poor care in an intimate connection between inadequate service provision and negative attitudes among mental health professionals. This isn’t a self-centred social media rant, but a reasoned account of what it’s like to be on the receiving end as a person whose self-harm requires physical and mental healthcare.

There’s a lot of catching up to do, and three organisations should contribute:-

NHS England should invest in comprehensive outpatient follow up services for self-harm, where therapy is offered regardless of diagnosis. These services could be a part of liaison psychiatry services, since that is where most acute assessment goes on. In a recent straw poll conducted during a webinar for liaison psychiatrists, more than 80% agreed with the idea of liaison psychiatry providing such a service.

The National Institute for Health Research (NIHR) should make a strategic commitment to fund self-harm and suicide intervention research – perhaps as part of one of their themed calls. Ad hoc responses to researcher-led proposals is not driving the necessary improvement in the research evidence needed to support change.

The Royal College of Psychiatrists should campaign assertively in this area, tackling negative attitudes among its own members and lobbying for policy change, intervention research and investment in services. Alliance with the Royal Colleges of Nursing and of General Practice would bring support from the other two clinical practitioners most directly involved.

We need to move beyond words to make action on self-harm a national priority.

Social media, self-harm and suicide

  • October 30, 2019

Another missed opportunity in the Molly Russell case

There are two views of how people with mental health problems experience social media. In one view they are places where you wander alone, drawn into an immersive atmosphere of depressive messages and images – self-harm and enticement to suicide everywhere you look. In the other they offer a space where you can come out of hiding, share otherwise secret fears with peers, gain an element of support and advice.

In the former view, risk of suicide is increased by the mood lowering effect of the content and by a sort of creeping familiarity with the idea of self-harm or suicide – called sometimes desensitisation or normalisation – and greater awareness of the methods involved.  In the latter view the social or networking function creates opportunity for reducing the sense of disconnection or lack of belonging, and the sharing of detail allows some alleviation of the burdensomeness of feeling uniquely troubled 1.

The Janus-faced nature of social media is outlined in a report by Barnardo’s about young people, social media and mental health – Left to Their Own Devices. The natural conclusion is that different people are likely to be affected differently by their online experiences, and the same person may be affected differently on different occasions. Which raises the question – how to minimise risk without at the same time suppressing useful content? It’s a tricky question and one that requires (you might hope) a careful public debate involving as many interested parties as possible in coming to a solution that considers all the competing demands of the situation.

In the UK, a fair bit of this public debate has centred recently around the suicide of teenager Molly Russell, not least because her father has pressed forcibly the case for the damaging effect of social media and the need to suppress content that might (in his view definitely does) encourage suicide.

Once the case surfaced, the early signs were not encouraging for those of us looking for a wide-ranging and informed discussion. The BBC opened their coverage with an oafish interview of Steve Hatch, the MD for Facebook in Europe, by the BBC’s Media Editor Amol Rajan who, as far as I am aware, knows nothing about self-harm or suicide.

After some grandstanding political outrage by the likes of health secretary Matt Hancock the government produced a White Paper – Online Harms – that bundled encouraging self-harm or suicide with incitement to terrorist activities, dissemination of child pornography, and drug dealing in the dark web. The main direction hasn’t therefore been about self-harm and suicide prevention at all, it’s been about steps to regulate the tech giants.

The response from the principal player in this case – Facebook/Instagram – has been as dispiriting as one might expect.  After a laughable attempt to use Nick Clegg as a front man to reassure us of their good intentions, they announced earlier this year a ban on images of self-harm described as graphic or explicit – with no definition of either offered by way of clarification. Now Instagram has announced a ban on drawings or cartoons.  There’s again lack of clarity about exactly what this means; in the linked article the specific example is of text linked to an innocuous drawing.

Where is the commission-like meeting of organisations, clinicians, academics, people with personal experience, that should be leading the debate and informing the decisions? The social media companies don’t want it – they want to manage the debate and avoid swingeing statutory regulation.  The government doesn’t seem want it – they’ve had long enough to organise it if they did. The mainstream media don’t want it – they just want a story to tell, sentimental or sensational if possible. Samaritans has an interest but it’s a slow train coming.

Where are the professional bodies in all this – my own Royal College of Psychiatrists, the British Psychological Society, the Royal College of Nursing, the Health and Care Professions Council? I don’t mean where are they in offering uncontentious opinions, I mean where are they in organising the high profile, mature debate that’s needed to replace what’s going on now?  They are nowhere, and that failure of leadership is what represents the real missed opportunity.  


1 These and other ideas about risk of suicide are covered in Thomas Joiner’s book Why People Die by Suicide (Harvard UP 2005)

Down with “mental health”?

  • October 14, 2019

I was lucky, early in my career, to meet Professor Geoffrey Rose.  One of his (typical) quietly provocative remarks was that there are no categories in nature – I remember we touched on dead/alive and pregnant/not pregnant and then gave up trying to think of examples to prove him wrong. So for a long time I’ve been keen on the idea of illness or disability as being on a spectrum or continuum.

In my own field the umbrella term “mental health” has come to represent this idea – not that all mental disorders are the same but that they all share something important that makes them related to each other, belonging in the same category of illness.  Recently I’ve begun to wonder if it’s such a good way of talking.

An article in the Guardian newspaper this month highlighted a damning series of investigations by the Care Quality Commission (CQC) into the care offered by privately run mental health units. As I read to the end my eye was caught by the line of tabs at the bottom, linking to “related stories”, and particularly this first one in the row.

Really? How is the anger and dismay of let-down football fans “related” to the neglect and abuse of vulnerable and severely disabled inpatients in special units?

I have come to see some serious disadvantages to “mental health” as a catch-all.  There are several versions of an unintended but malign effect of the term – which can trivialise or distort the true nature of mental disorder.

  • Success or “recovery” stories from one part of society can overplay the likely benefits of intervention in what are essentially intractable problems, as pointed out recently by the parent of a child with autism, who wrote:  ‘These stories don’t show the child who is non-verbal, who screams and growls for hours on end and attacks his or her parents on a daily basis’…”For once I’d love to see a story that celebrated a child managing to say “drink”, rather than screaming for two hours. That’s our idea of success.”
  • When “diagnostic” labels are applied (especially following self-diagnosis) the result can be misleading and demeaning to others. Being socially awkward isn’t the same as having autism; lacking emotional equanimity isn’t the same as having bipolar disorder; being greedy isn’t the same as having bulimia.
  • Well known people “coming out” about their own mental problems may indeed be helpful.  A healthy society needs to be able to acknowledge and respond to all aspects of the lives of its individual members, and we are all better off for the brave people who have in recent years talked about their sexuality or emotional problems.  There is however a downside to the invited comparison, as there is to all celebrity endorsement – most people with mental disorders aren’t rich or creative or successful: if they are lucky they are ordinary; if unlucky then they are disabled, poor and harassed. 

I have concluded that we’d be better to drop the term “mental health” – making the effort instead to be specific about each particular problem in which we are interested.  Maybe it’s evidence of rising levels of distress or anxiety in school students, or self-harm in middle-aged men, or moderate levels of depression in people consulting their GP. With more specific use of vocabulary we can have a more meaningful discussion than we do currently about public health and health services for those struggling with emotional disorders and mental illness.  Changing how we discuss things is easier said than done, but I’m going to give it a try.

Lemn Sissay asks why

  • September 23, 2019

Lemn Sissay is a British author, poet and broadcaster. His memoir My Name is Why has just been published, and describes his life as a child in the care system from the age of 12.

The book is an important reminder of the damage an uncaring society does to young people who should be its most cherished members. It is a moving account by somebody with a special ability to communicate his personal experience, but it surely can’t be read without it reminding us of a wider picture of mistreatment: sexual abuse of children in care and the brutality of Young Offender Institutes are part of the same story and anybody who has worked in mental health will have seen its victims.

There’s another equally depressing aspect to the book, and that is the readiness of those around Sissay to attribute his emotional state and behaviour to individual characteristics rather than to try and understand him in his world. At primary school he cops for racial stereotyping as a charming lad, amiable but feckless. At home the friction with his devoutly Christian parents is attributed to his evil nature. In his teens in institutional care his uneasy rebelliousness is treated as the sort of delinquency that sees him guided to the start of what could easily have been a young adult life of crime and detention. With a history of self-harm, drug use and rule-breaking it’s a miracle he didn’t graduate to adult life with a diagnosis of personality disorder.

The degree to which we lean on personal attributes for our understanding of people is the degree to which we risk a biased neglect of their personal circumstances. Sissay gives us another reminder; the message can’t be repeated too often.

Geoffrey Boycott and domestic abuse

  • September 15, 2019

A footnote on the psychiatric “evidence”

Cricketer Geoffrey Boycott has been in the news recently, following the award of a knighthood in outgoing Prime Minister Theresa May’s honours list. The coverage has not been celebratory, with criticism of the decision focusing on Boycott’s conviction in a French court for beating up his then partner in 1998.

It’s a shabby affair, and I followed it up mainly because I wanted to understand more of the French investigatory (rather than adversarial) approach to testing evidence – described disinterestedly by Boycott as being assumed guilty unless you can prove yourself innocent. In the middle of the contemporaneous coverage of the original verdict in the Independent newspaper I came across this striking paragraph about an aspect of the case I hadn’t previously seen reported: 

The judge, Dominique Haumant-Daumas, indulged Boycott and his lawyer when they presented hours of muddled evidence from, among others, a psychiatrist who had never met the victim, Margaret Moore, 46. (He judged her, from television clips and conversations with a former husband, to be a “hysterical psychopath”.)

The case was dug up again by The Telegraph newspaper in 2015, with the assertion that “Geoffrey Boycott ‘must be knighted’ after new evidence points to his innocence over domestic abuse case.” The paper was more expansive about the nature of the psychiatric evidence:

Dr Peter Wood, a consultant forensic psychiatrist who was consulted by Boycott’s legal team, concluded that Miss Moore: “Has a diagnosable psychiatric disorder in the form of a personality disorder with hysterical and psychopathic features. It is likely that there is an additional factor, namely chronic excessive intake of alcohol, probably alcoholism…there is clear evidence of her lying on a repeated basis. She is probably a pathological liar.”

I have no idea if Theresa May thinks Boycott is innocent – after all it was only a French court in which he was tried – or whether she accepts the verdict but thinks it’s irrelevant to the award of a national honour. I don’t know anything about the psychiatric report(s) seen by the court, beyond what is quoted in the national press. What I do know is that this way of describing somebody’s personality as a mental disorder offers an uncomfortable illustration of one reason why so many people find psychiatric practice objectionable.  The roots of the diagnosis of personality disorder are in pejorative and misogynist labelling and no amount of “destigmatising” can change that. It’s time we dropped the whole idea – neither medicine nor the law would be any the poorer if we did so.