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.  

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

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.

Experts by personal experience aren’t always right (guest post)

  • August 19, 2019

Professor June Andrews discusses her discomfort about advocacy based upon the questionable (but unquestioned) personal experience of individuals.

Dementia is in the news.  Stories about it could be described as fashionable.  Advocacy organisations understand the power of hearing the voice of a person who is experiencing dementia themselves, and so they are on the hunt for people, preferably famous, who can come to represent the disease.  They can be people with dementia, or the relatives of people with dementia.  At a push, they can be people who sympathise with dementia, if they are famous enough to be influential even though they don’t have a back story.

Advocates have an honourable role in the campaign of any charity to raise funds.  It’s often described as raising awareness.  But in truth, awareness is already pretty high so you can be sure the main aim is to get funding for the charity, which is often focussed on a cure.

There are two problems with this sort of representative advocacy.

Problem 1 – the unquestionable legitimacy of “personal experience”.

The press officer at the charity is not a clinician, so when someone turns up with a diagnosis, they take it on face value. The way news is curated by media editors and controllers demands tropes like “victim” or “hero” and some virtue signalling or novelty.  If the person with the diagnosis is articulate and personable, they will be good to undertake media roles for the charity. The public gets most of their information from general media, so that’s the way to let them know they need to fund a particular charity and secure a cure.  Media coverage is so relentless and fast, the representative needs to be nimble and well prepared to get the best from any opportunity that arises.

Dementia is a progressive degenerative condition, but the press officer can’t stop to ask any questions when the person is still stable, at the same level, years later.  By that time the dementia representative patient is busy and in demand for appearances world-wide.  So pervasive is the idea of “nothing about me without me” that conference organisers know they will be heavily criticised if they fail to put a person with dementia up on the platform.   The media-experienced-dementia-experienced personalities get heavily worked.  They see it as a duty and a mission, whatever it costs them. 

I have recently been alerted to the fact that any question of whether they actually have what a clinician would think of as dementia is blocked.  Dementia clinical experts are puzzled, because mild dementia is a transitional phase but these mildly affected media representatives go on for years.  If someone has been on the circuit for a long time, clinicians can with confidence say that this person is definitely not like any other dementia case.  The charity can’t afford to go anywhere near this. However odd it might seem to people who really know about dementia, the representative (who almost certainly has some other complex illness) is put up in public as just “a person with dementia”. News values demand an interesting person with dementia who is happy to be exposed in the media.  If you have one, you keep them as long as possible and are, to be honest,  grateful if they seem to survive longer than usual because it’s hard work to keep finding people with a fatal, progressive, cognitive disease and a thirst for publicity.  You invest in what you’ve got.

Any suggestion that the patient’s sense of entitlement is out of control is taboo. When organising dementia events, you may sympathise with requests for free places for people with dementia.  When they then expected travel and hotel accommodation for themselves and their partners, with a few days on either side to overcome their fatigue, organisers can’t always afford it.   My own experience is that refusal causes profound offence, and can give rise to well publicised anger and unfavourable comparisons with other conference organisers. We’d get accused of profiteering on the backs of people with dementia and failing to give voice to people with dementia.  Actually our job was not to give them voice.  It was to educate professionals about the latest research, and practical things like how to manage continence, and terminal care.   The person with dementia talking at the event was usually preaching to the converted. We had more educative value from dramatic representations of the sort of complex problems that could never be revealed in the first person account of one individual.

Problem 2 – erosion of the legitimacy of professional expertise

The second problem is related. In the environment that has been developed with the strong encouragement of the advocacy organisations, any one of these “dementia-experienced” selected representatives trumps the knowledge or experience of the rest of the world.  The individual is sanctified with an almost religious fervour, in that anything they say cannot be contradicted. Crossing them gives rise to shock and outrage.  Those who might be seen to hold heretical positions such as questioning the diagnosis or wanting to meet without a token dementia person in the room often do so secretly because to speak openly about this sort of thing can affect your funding or your job prospects.  You risk a sort of excommunication. Or you hide.

 When you’ve upset the dementia lobby, they mobilise an articulate person with dementia who goes along with their mainstream view to attack you. From experience, it is personal and vicious.  If I was earlier in my career, I believe I’d be silenced by them.  The decider is that I don’t have dementia and they do, so anything I say that they disagree with is evidence that I have no knowledge. In this way, people who have worked with hundreds of affected families and people are marginalised. One individual can say on the basis of their personal experience, with the backing of an organisation, that this is only a “so-called” expert.  Social media heats up.  It’s dangerous to come out with an alternate point of view because you’ll get attacked.

I understand fear and rage, and as a psychiatric nurse, I’ve worked with lots of that.  What offends me is the channelling of that by organisations and lobbies for their own ends, using people with dementia, patients, dementia sufferers – whatever you are allowed to call them – as a human shield. They like to imagine they have the moral high ground, but they don’t.  For them, it’s just business and the sooner we reveal that, the sooner other sorts of experts will be able to say what they know without needless anxiety.

Does using substitutes or proxies for self-harm help?

  • August 10, 2019

An intriguing recent study was done no favours by melodramatic misreporting of its findings.

Substitutes or proxies for self-harm include doing painful but non-damaging things like holding on to ice cubes or eating hot peppers.  They are quite commonly cited in advice about self-harm.  For example, when I put <How can I stop self-harm?> into a search engine recently, using substitutes came up in the advice offered by my own Royal College, by a private healthcare chain and by a 3rd sector organisation.  There’s actually very little evidence behind this advice, so it was good to see a recent study exploring the experiences of young people with such approaches.

The study had two parts: an online questionnaire to which 758 people replied, and an interview with 45 people. What were the main findings? Only 7/758 people who completed the questionnaire said they had used any of the techniques; it isn’t known why the other 99% hadn’t. In the interviews, 29 people said they’d used at least one of the techniques – some found they didn’t help at all, some found they did. 

This sort of small numbers qualitative study can’t tell us how common certain experiences are, only what the nature of such experiences might be. So the Sky News opener “Many of the techniques used to reduce self-harm do not work for most people…” could only be accurate if the sentence had finished “…because most people don’t use them”. Unfortunately that wasn’t the message being conveyed.

There’s a further twist.  In the questionnaire study 18 people, and in the interview study at least 6 people, said they had used one of the techniques (snapping an elastic band against the skin) as a means to self-harm. Now, given that one sort of harm reduction involves “strategies that aim to ensure that the same method of self-harm [AOH: in this case damaging the skin] has less medically severe consequences” this might be less of a bad thing than it sounds – elastic bands do less harm than broken glass or razor blades.  The news report (of course) took the opposite tack “The therapies could even become abusive in their own right”.

My experience is that most mental health professionals are rather sceptical about proxy or harm minimisation approaches, thinking that if they do help some people then any effect is likely to be fairly weak or transient given that they don’t tackle underlying problems. They might provide a bit of breathing space but they can’t substitute for therapy. I don’t think most will mind very much that such techniques get a poor press through this report, although we could do with some more discussion about what part they might play in selected situations. However, what they should mind is yet another example of mental health reporting being slanted by poor understanding of science and a need for dramatic headlines.

Psychiatry’s worst idea

  • August 2, 2019

Here’s a typical news story from a local paper – about a police call that led to a house search prompted by smelling cannabis.

“The search of the property unearthed two dozen plants being cultivated with a hydroponic system in a cupboard and two more in a nearby wardrobe, said Mr David Swinnerton, prosecuting. Police estimated the crop had a potential yield of over £7,000.

However it was claimed at court that […] might have been pressured into growing the drugs. Mr Thomas Griffiths, defending, said unemployed […] who had several previous convictions and had recently become a father, suffered from a personality disorder and might have been exploited by others because of his naivety.

What does it mean to say that a defendant in a case like this has a personality disorder?  Here’s the answer from the NHS website

“A person with a personality disorder thinks, feels, behaves or relates to others very differently from the average person. There are several different types of personality disorder. This page gives some information about personality disorders in general, linking to other sources for more detail.”

In other words, personality disorder is a diagnostic label attached to who you are. To my mind this is psychiatry’s worst idea – the use of diagnostic labels to describe somebody’s personality.

Here’s an edited version of what I said in my book Undertstanding and Responding to self-harm

“There are real problems with this way of thinking. First, and rather obviously, it leads to an emphasis on the individual as the source of their problems and therefore downplays the role of other people and circumstances…

…Second, the diagnosis is often experienced as a way of saying ‘the problem is about who you are as a person’ and it is widely used in a critical or dismissive way by professionals in health and social care. The person on the receiving end can easily be stigmatised and become (rightly) angry – that anger then being used as further evidence of what’s wrong with them. Not surprisingly, lots of people given this diagnosis don’t like it and don’t like the effect it has on the way others treat them.

This isn’t to say that people don’t have recognisable and enduring characteristics. We all know somebody who is particularly obsessional, prickly, paranoid or prone to emotional outbursts. Sometimes these characteristics do indeed seem important in explaining self-harm. For example, impulsivity is a tendency to act on the spur of the moment, without much thought and without consideration of the consequences. This characteristic is quite commonly associated with self-harm, especially when it is coupled with negative ways of thinking.

What isn’t right is elevating these observations into diagnostic statements – putting people into categories as if somebody’s personality is a mental disorder – which is indeed where personality disorder sits in the main diagnostic systems used worldwide.

There’s another practical problem with this ‘diagnostic’ approach to personality, which is how little use it is in explaining anything… circular reasoning is really common in practice, [for example] using repeated self-harm as part of the basis for diagnosing a personality disorder and then using the diagnosed ‘condition’ to explain the repeated self-harm.”

And that’s not to mention the observation that a “disorder” that’s inherently part of who you are tends to “get better” over quite short periods of time.  

It’s perfectly possible to practice psychiatry, and the law, without this diagnostic practice. Time we all started doing just that.

Government White Paper: Online Harms

  • June 24, 2019

The Government White Paper: Online Harms has been out for consultation for the past three months. Its main proposal is to establish a regulator charged with ensuring that a duty of care is exercised by all those who produce, host or distribute potentially harmful online material.

This sounds like an idea with which few could disagree, and the consultation questions are mainly about how to make it work properly. There are however some real problems raised by the inclusion of online content about self-harm.  The other topics covered by the White Paper include incitement to terrorist activities, dissemination of child pornography, and drug dealing in the dark web. While it’s difficult to imagine a socially desirable component to the online presence of any of these activities, the same doesn’t apply to self-harm.  Here’s my own reply to the consultation’s Question 8…

Q8:  What further steps could be taken to ensure the regulator will act in a targeted and proportionate manner?

In relation to self-harm, the main need is for a clear and specific definition of the nature of harmful content.  It is responsible management of such content that constitutes the duty of care to be imposed on those who make self-harm content available online. The White Paper talks about “content and behaviour which encourages suicide and self-harm” (para 7.32) and “content that provides graphic details of suicide methods and self-harming” (para 7.34). Neither definition is specific enough to inform practice and without a tighter definition the regulator is at risk of idiosyncratic or inconsistent intervention.

What is the challenge in coming up with a workable definition of harmful self-harm content?

There are three issues here:

  • Examination of online material about self-harm reveals substantial diversity in form and content. Those who post and those who respond to posts are engaged in conversations not just about the manifest topic of self-harm and suicide, even when the relevant posts are explicitly tagged as self-harm: content is also about emotional problems more generally, about relationships, fitting in or belonging, and about attractiveness, sexuality and body image. The mixture of textual and visual messaging leads to communication the ambiguity and irony of which can be missed by reading one without the other.
  • Much of this is regarded as helpful by those who access it, and that includes direct communication about self-harm including images of self-injury. Such images can help an isolated person (anything up to a half of people who self-harm don’t confide the fact to anybody in their personal life) feel less alone. The images may come with messages about self-care or harm minimisation. It is reasonable to conclude that content some people find unhelpful is found helpful by others, and that whether a particular content is found to be helpful or unhelpful by a particular individual depends upon the immediate circumstances in which it is accessed.
  • It isn’t clear what the pathway to harm is, following exposure to self-harm material online. Words like graphic, explicit or glamorising are in themselves not tightly defined but they imply that the underlying mechanism is an invitation to copy the behaviour. Linking this argument to suicidal behaviour is problematic – for example most online images of self-harm are of self-injury (cutting or burning) and yet these are extremely rare methods of suicide, especially in young people. If the putative pathway to suicide isn’t copying then presumably it is by exposure leading to low mood and hopelessness – in which case it isn’t clear that images of self-injury are more problematic than other mood-influencing content.

What is the risk of disproportionate or untargeted action?

For much of the content covered by the White Paper, there really isn’t much doubt about what’s bad and needs to be suppressed – drug dealing, distributing child pornography, inciting terrorism. In the case of self-harm however there are risks of going too far in suppressing content. Those risks reside in the diversity of material that comes under the online rubric of self-harm; the likelihood of blocking access to material experienced as beneficial by isolated and unhappy people, and the uncertainty about what’s genuinely harmful in self-harm form and content. Clumsy, excessive or inconsistent intervention – in the name of reducing harmful exposure and (by implication) habituation or normalization – may have the unintended damaging consequence of increasing the sense of disconnectedness and burdensomeness experienced by people with mental health problems who self-harm.

What steps to take?

There are two steps:

If the White Paper is to include action on self-harm content then the regulator needs expert and specific advice on what content should be regulated and limited immediately – even taking into account the considerably uncertainty outlined above. That is, the advice should identify that material for which we can be confident that harm is likely to accrue from accessing it and the risk of harm obviously outweighs the possibility of benefit.  This advice should be provided by an expert panel that consults a diverse range of academics and mental health specialists. Its recommendations should be for limited immediate action given how little we know about harms.

As a second step, the regulator should seek regular reports on emerging research findings that support changes to its practice – to ensure that practice is evidence-based rather than opinion-based.

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