I have been struck by how often academics and clinicians writing about functional disorders feel the need to announce the death of dualism – aka mind-body dualism or even Cartesian dualism, depending on the author. It isn’t easy to understand what is meant exactly by this claim and I have been doing a bit of reading between the lines to clarify, at least for myself.
Dualism in philosophy
First, it is worth saying that Descartes understood the mind and body not as radically separate but as in some way highly integrated. Here he is in the VI Meditation on First Philosophy:
‘Nature also teaches me, by these sensations of pain, hunger, and thirst, that I am not merely present in my body as a sailor is present in a ship, but that I am very closely joined and intermingled with it, so that I and the body form a unit. If this were not so, I, who am nothing other than a thinking thing, would not feel pain when the body was hurt, but would perceive the damage only by intellect, just as a sailor perceives by sight if anything in his ship is broken.’
I now understand the mind to be coextensive with the body – the whole mind in the whole body and the whole mind in any of its parts.
Descartes was writing nearly 400 years ago, so it’s not surprising that the terms used in the debate have changed somewhat. Modern philosophy of mind concerns itself, in this context, with the nature of consciousness or intentionality and how subjective experiences are to be explained, and (typically) with the question of how such experiences are related to something physical in the structures and functions of the brain. I think it’s fair to say that philosophers (well, the ones I’ve read) regard the idea that studying the brain can sort this out as bordering on the absurd. Tim Crane for example suggests that in exploring the mind-body relationship we should stop “considering those options which frustrate our understanding of our minds – for example…that we should look for consciousness by inspecting the sticky fatty matter of the brain”. Putting it slightly differently, Galen Strawson comments that even accepting that “…the known phenomena of experience are wholly a matter of the physical nature of ordinary matter under mild conditions (the mild of special conditions that obtain in the brain), … the physics and neurophysiology of the brain don’t enable us to understand how this is so”.
Dualism in clinical thinking
Actually, I don’t think that “dualism” is being used, in the context of clinical writings about functional disorders, in the philosophical sense at all. Rather it refers to the idea that a comprehensive account should include both mind and body mechanisms as expressed here: “A dualistic mind-body understanding of functional neurological disorders (FNDs), also known as conversion disorders, has led to the view that the cause of the symptom should be either psychological (psychogenic) or physical (neurogenic-“organic”).” … “The authors argue that the conversion concept is consistent with recent neuroscientific research findings, and the model allows psychological and neurobiological concepts to be reconciled within a single account of FND that begins to resolve the dualistic mind-body dichotomy.”
In one sense this is not at all a new idea – we have known for a long time that brain states accompany mental states and no doubt this is what Tony David meant when he said that dualism between mind and body “went in the nineteenth century”.
Looking further at this idea…here is an anecdote from the memoir of Geoffrey Keynes, a surgeon who served in the Great War:-
“On one occasion, when I happened to be in my dressing station …. a message came that a gunner had been wounded and was lying beside his gun at the edge of the lake. Would I, please, come at once? I then experienced a feeling which it is hard to describe. It was my duty to walk immediately with stretcher-bearers from a position of comparative safety to a gun pit, which was being accurately shelled every few minutes. I ordered my legs to take me there, but at first they refused to move. My mind was equal to the ordeal, but another part of my brain declined to pass on the necessary instructions….”
Geoffrey Keynes The Gates of Memory 1983
Can we describe a mechanism whereby the brain declines to pass on the mind’s instructions? The dualism abolitionists would say – perhaps not perfectly but we’re getting there. I think that’s wrong, and here’s a different vignette to explain why. Suppose I am crying at a funeral and three friends are discussing my plight. A psychiatric friend says – he has been bereaved (a social state), and he is crying because he is grieving (a mental state). The neurologist standing next to her says – ah, but he is crying because of activation of a multi-component pathway in the brain that includes the anterior cingulate gyrus. Wretched dualists! says the third, can you not see that the mental state of grief causes activation of the neural pathway and you need both elements to answer your question? Apart from noting what odd friends I have, you might wonder if my anti-dualism friend is really contributing anything apart from putting the two accounts (psychological and neurological) into the same sentence.
Dualism in clinical discussions
This points to what I take it the end-to-dualism claim actually means in practice: not that we have resolved the mind-body problem nor that we can produce a genuinely unitary account of functional disorders – how could we without solving the mind-body problem? Instead it means that when we speak about functional disorders we know longer use highly-articulated psychological explanations for what is going on. We pull this off in one of two ways.
One approach is to drop the psychological altogether or to trivialise or marginalise it. We should understand instead that for functional neurological disorders the problem “lies within the brain and its complex networks” and we should communicate this to patients in ways that enable them to say to themselves “I have a real dysfunction of networks in my brain”. If we use analogies they should be mechanical ones like the computer hardware-software distinction, or other neurological problems like phantom limb.
The other approach is to use a sort of language mash-up, as in a recent review that summarised studies from neuroimaging, cognitive psychology, biological markers, and epigenetic studies to generate a model that “…allows psychological and neurobiological concepts to be reconciled within a single account of FND that begins to resolve the dualistic mind-body dichotomy”. This is a (well-meaning) fudge: What happens is that a faux-integrated accounts allows for a misleading impression that the psychological side has been properly worked out because the neural mechanisms associated with it are now better understood. It would better to say that there are likely psychological mechanisms at play and likely neurological mechanisms, and we don’t understand how the one acts on the other.
Dualism lives – in philosophy, in clinical practice and (hidden in plain sight) in the accounts we offer of functional disorders. Nothing to be embarrassed about, even if some people are made uncomfortable by thinking about psychological causes for illnesses.
In professional (clinical) discourse, the definition of self-harm is pretty well established now. Rather clunkily the World Health Organisation defines it as: “an act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behaviour that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising changes which the subject desired via the actual or expected physical consequences”.
More succinct is the definition adopted by the UK’s National Institute for Health and Clinical Excellence “self-poisoning or self-injury, irrespective of the apparent purpose of the act’”.
Really the only debate among clinicians is whether it’s a good idea to include motivation in the definition. Those who do think it is a good idea will typically go with the staggeringly popular term non-suicidal self-injury. Those who (like me) think it isn’t a good idea take note, for example, of the ambivalence and uncertainty about motivation that so many people express and the apparent paradox that a non-suicidal act is a risk for a suicidal one. There’s a strong tendency for those who write about non-suicidal self-injury to conflate episodes and people. People with alcohol dependence may prefer drinking wine or beer or spirits, and there may be differences between those who major in one or the other (gender, wealth, social class or whatever) but basing an analysis of problem drinking upon preferred tipples doesn’t seem a very interesting way to think about the underlying problem.
Looking outside the rather limiting arena of diagnostic labelling, I have been struck by the diversity of places in which the idea of self-harm crops up, and I have wondered what that tells us about what self-harm means in the day-to-day world. Here are some examples.
Eating disorders and alcohol or drug misuse. One of the commonest questions I have been asked by people who learn that I have an interest in self-harm is whether that interest includes eating disorders. Certainly there is overlap between these states – self-harm commoner in those with eating or substance misuse problems, and both those problems commoner in people with self-harm. Conventionally however a distinction is drawn: harm to the body is not the intended aim even of life-threatening anorexia nervosa or addictive alcohol or drug consumption.
Punishing routines. Here I include extreme sports like ultra-marathon of high altitude marathon running, transient phenomena such as the ice bucket challenge, and sadomasochistic (BDSM) activity – explicitly sexual or otherwise. Here again, infliction of damage is not (or is rarely) the intended aim but rather the infliction of pain or the enacting of role play involving dominance or passivity.
Body modification can take many forms – typically tattooing, piercing or (less commonly) scarification. Although Favazza draws strong parallels in his classic text on the topic, they are generally considered separate behaviours on the basis that although the resultant bodily changes are intended that are seen as aesthetically desirable and therefore neither harm nor damage, and they are, except in extreme cases, seen as socially sanctioned rather than signs of individual pathology.
Mortification of the flesh – something of a cross between punishing routines and body modification, practices like flagellation and prolonged fasting are perhaps less common than they were. Their aim is to damage the body but with reasons that are socially sanctioned by at least a sub-group of the population – usually undertaken for religious or political purposes.
Organisational self-harm is the term I apply, for now, to instances that crop up in the media of self-harm used to describe an action undertaken by a corporate body or group of people and regarded as self-defeating by its critics. Examples might include a football team getting rid of a favourite player or manager mid-season, or the UK’s decision to leave the EU. Here the idea seems to be that damage may not have been intended but the guilty party’s actions were so reckless as to consequences – “What on earth were they thinking?” – that the harm might as well have been intentional.
Some of this is widely recognized in the self-harm literature, some of it less so. With the exception of the link to eating disorder it is largely ignored in the mainstream media but quite well represented in social media – for now, unless it is to be clumsily suppressed in the name of “regulation”. What it speaks to is self-harm as a phenomenon with social and cultural meanings that needs to be responded to in ways that go beyond melodrama and appeals for more investment in mental health services. A public debate along these lines has hardly got off the starting blocks.
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:
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.
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.
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”9or 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.
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.
Johns R. I feel I am missing a piece of the puzzle. BMJ. 2020 Apr 8;369.
Wong M. Telling me you don’t know is ok. BMJ. 2020 Jan 8;368.
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.
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.
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.
Kanaan RA, Craig TK. Conversion disorder and the trouble with trauma. Psychological Medicine. 2019 Jul;49(10):1585-8.
Burke MJ. “It’s All in Your Head”—Medicine’s Silent Epidemic. JAMA Neurology. 2019 Sep 16.
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.
David AS. Functional disorders, Cartesian dualism and stigma: where does the dualism really lie? Journal of Neurology, Neurosurgery & Psychiatry 2012;83:869.
Edwards MJ. Functional neurological disorder: an ethical turning point for neuroscience. Brain 2019 Jun 26;142(7):1855-7.
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…
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.
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.
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.
Another missed opportunity in the Molly Russell case
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
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.
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.
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.
other ideas about risk of suicide are covered in Thomas Joiner’s book Why People
Die by Suicide (Harvard UP 2005)
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.”
“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.
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.
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.