Culture wars, economic hardship and disdain for mental illness and learning disability – a dangerous mix.

  • January 17, 2022

Germany’s asylums between the world wars housed a mixed population – mainly of people with a learning disability or a severe and persistent mental illness. These people became the focus of Nazi interest for two reasons.

First – and this isn’t as widely known as it should be – residents of the asylums were the first large scale victims of the Nazi’s mass murder programmes. The technologies used later, on Jews, Roma, homosexuals, communists and others, were first developed in what is usually known as Aktion T4 (named prosaically enough for the original HQ address Tiergarten 4). That is, T4 developed gas chambers as an efficient method of killing, purpose-built crematoria for disposal of the bodies, and an associated propaganda programme that is hard not to see as enabling a sort of collusion with the general public. An estimated 200,000 people from the asylums were eventually killed in T4 and its sequelae. This history is covered in some detail in Michael Burleigh’s extraordinary 1994 book Death and Deliverance: “euthanasia” in Germany 1900-1945 (Cambridge UP, listed unbelievably as out of print now).

An apparently separate campaign waged by the Nazis took the form of what we would now call culture wars, with modern art as a particular target. The infamous Entartete Kunst (Degenerate Art) exhibitions curated by party members and promoted by Goebbels are well known, but less so is the link to asylum art. A number of key modernists had been intrigued and influenced by the work of apparently mad people – so-called art brut – a significant collection of which had been accrued by Hans Prinzhorn at Heidelberg and valued as being artistically important in its own right, not simply as a window into the mind of the insane.

The Nazis exploited this association in carefully managed presentations associated with the message – look how modern art is no different to the art of lunatics and imbeciles and yet you are duped into paying huge sums for the public galleries to own it.  With the related message of course – it’s all part of a (Jew-orchestrated) conspiracy to undermine true Germanic society through undermining its culture.

The two stories inevitably intersect, with many (amazingly not all) of the asylum art works destroyed and the artists who made them perishing in the mass euthanasia programmes. This story is well told in a new book The Gallery of Miracles and Madness by Charlie English – unlike Burleigh a journalist rather than historian, with a predictably different but nonetheless well researched and engaging style.

The asylum artists who died in the T4 programme were caught in a perfect storm – of culture wars used by an authoritarian government to garner support for their wider political project; the motivating force of economic hardship coupled with the idea that alien enemies are to blame; the promotion of “euthanasia” as a solution to the societal problem of burdensome lives. Sound familiar?

Two excellent books about psychosomatic illnesses

  • January 9, 2022

There’s something both familiar and unfamiliar about neurologist Suzanne O’Sullivan’s book It’s All in Your Head:stories from the frontline of psychosomatic illness, which discusses her experience of psychosomatic illness while working as an NHS consultant.

The familiar first: O’Sullivan describes typical cases that come up in her clinical practice – seizures that aren’t due to epilepsy; weakness or paralysis when there is no identifiable neurological disease; persistent symptom states like chronic pain or fatigue when there is no apparent explanatory pathology. She is not talking about neurological diseases waiting to be diagnosed but about presentations in which “no disease is found because there is no disease to find. In those people the medically unexplained symptoms are present, wholly or partially, for psychological or behavioural reasons”. Refreshingly uninterested in worrying about terminology, she calls these conditions psychosomatic.

The book’s case histories contain some familiar details – responses to the diagnosis range from bemusement to downright hostility and rejection. And contact with a close family member or friend can provide revealing detail about likely causes or perpetuating influences.

And the unfamiliar? Like most doctors, O’Sullivan sees the cause of psychosomatic conditions as being primarily psychological and in her own practice she regards psychiatry as a part of the management plan. However, she is (far) more than usually willing to state this unambiguously and is interested herself in understanding what are the underlying problems. Here she encounters such a variety of stories – complicated bereavements, family and other interpersonal predicaments, gender discomfort, loneliness and more – that although she sees their relevance she cannot really discern a common theme.

O’Sullivan has clearly read more widely than many a clinician, for example in the history of psychosomatics and psychodynamic theories, and she is comfortable with the idea that the mechanisms driving psychosomatic presentations are unconscious and often involve a sort of dissociation – that is a disorganisation of usually-integrated mental processes. She sees the symptoms as having a function, perhaps defending against emotional breakdown or in some other way helping the patient adapt to the otherwise intolerable.

The book throws down a gauntlet in the form of a question: “If psychosomatic symptoms are so ubiquitous, why are we so ill-equipped to deal with them?” It is picked up in O’Sullivan’s second book on the topic The Sleeping Beauties and other stories of mystery illness, which describes her exploration of a number of “mass” episodes of psychosomatic illness. This could be a horrid parade of grotesques but it isn’t, instead providing a sensitive exploration of external social influences on illness and its course. Everywhere there are “…moral dilemmas, inconceivable choices, inequality” and the unenviable role of women in society.

The answer to the gauntlet question comes at least in part from the medical and other social and official responses, which do not come out of it well. They are often disparaging or dismissive, and mistrust of officialdom plays an important part in the difficulty of forming a shared therapeutic response.  An important observation is made about the part played by official responses that simultaneously confirm the absence of underlying disease while at the same time downplaying or ignoring the psychological and social. This loops back to the first book with a comment about the currently favoured label of Functional Neurological Disorder which is “…used to imply that the brain is not functioning – therefore (rather ham-fistedly, I would say) placing the source of psychosomatic disorders firmly in the biology of the brain” – where O’Sullivan believes it does not belong.

Again, psychosomatic illnesses are seen as serving a purpose: “…perhaps we need release valves and coping mechanisms, face-saving ways of addressing conflict and grappling with ambivalence. Sometimes, embodying and enacting conflict is either more manageable or more practical than articulating it”.

Where next? There is work left undone by these two books. One task is that more work is needed to link lessons about the causes of what we might call the epidemic cases in Sleeping Beauties to the sporadic cases in All in Your Head: in particular to ask – is there really no common theme to the apparently disparate adversities that lead to onset of psychosomatic illness? This links to the need to consider other explanations for the onset of symptoms in the face of such adversities. We accept that depression can follow loss, anxiety can follow threat and PTSD can follow trauma, and we usually see such conditions as symptomatic breakdowns rather than adaptive responses. Perhaps we could look at psychosomatic illnesses in the same light, as manifestations of how we break down when faced with adversities that represent (the common theme) persistent and seemingly unresolvable conflicts, challenges and dilemmas.  

Picturing Long COVID – time to drop a subtly undermining visual rhetoric.

  • October 13, 2021

Usually I ignore the accompanying pictures when I am reading a newspaper article about health. Just recently however, I have noticed something about the pictures that accompany articles about Long COVID.

Here’s a typical example – a picture of somebody, and it’s nearly always a young woman, reclining on a sofa looking exhausted. Of course we don’t need a photo to help us understand the idea of being exhausted, in the way that we might want an illustration for an article about recent floods or trouble at a street demonstration. So I took to wondering what was going on.

The use of such pictures may represent no more than a desire to break up blocks of text.  But there are a couple of features that drew me to thinking of how similar images have been used to convey something about other conditions.

First, here’s a rather typical image from an article about the 19th Century malady neurasthenia: a woman reclines and does not look, if truth be told, especially discomforted by her experience.

From a different era and with another typical feature (hand on forehead) I didn’t have to look far to find this illustration (left) from an article about premenstrual syndrome.  

And just to counter the idea that these things are entirely gendered here’s a picture (below) with another typical feature – it’s the back of the hand on the forehead – from an article about man flu’.

Perhaps what I’m seeing is no more than a lazy use of stock images but regardless of motive it occurs to me that there’s more to be said. The visual rhetoric hints at connections that the written text may not – between Long COVID and a group of conditions that have over the years shared some degree of being dismissed, of dubious provenance and melodramatic in presentation. And by implication, faintly ridiculous.

I don’t think this representation of illness does any favours to the discussion about the nature of Long COVID – not just to the question of possible underlying pathophysiology but also to the question of whether some cases are psychosomatic (functional) in part or whole.

My solution would be twofold: time to drop the use of the term Long COVID for the trouble it causes by bundling together so many disparate conditions. And when writing about the sequelae of COVID infection it’s time to drop the use of pictures of tired people resting, hand-on-forehead, on the sofa.

Long Covid: the numbers don’t add up, so why do we keep collecting them?

  • October 5, 2021

How common is Long Covid?  Top of the range, with estimates of nearly 40% of people who’ve had Covid still being symptomatic 12 weeks later, come the REACT-2 study and a recently-published analysis from a US database. In the basement come estimates of 0% from a follow up study of children in Melbourne who had recovered from mild or asymptomatic infection, 2.3% at 12 weeks (the Zoe survey), 4% from a study of schoolchildren in Zurich, and 5% for symptoms at 12-16 weeks from a recent ONS survey. And other estimates in between…

Why is there so much variation? There are the usual suspects – results may be influenced by differences in the samples in terms of age, gender, BMI, vaccination status and so on. Many of the symptoms reported are non-specific (such as fatigue, aches and pains, difficulties with concentration) and endorsement is likely to depend upon exactly how they are asked about and whether an attribution to Covid infection is required. Response rates varied greatly – only 13% in a substantial UCL UCL study of young people and 20% in an ONS study of school children. Some attempt to adjust is possible but response bias and confounding can’t be entirely discounted.

Maybe there’s an issue of reporting threshold – the higher estimates coming from counting relatively minor experiences while the lower estimates count only more severe symptoms. Certainly there seems to be an inverse relationship between number of symptoms and prevalence, but severity (intensity, intrusiveness) is harder to gauge from readily available reports. An ONS survey from earlier this year suggested that only about 1 in 10 respondents was limited a lot by their experiences. An intriguing finding from a study of NHS general practice records suggests that GPs are recording very few cases by comparison with those reported from research surveys – in fact about 100th of the numbers, with a quarter of GPs using NHS codes for Long Covid to describe no cases at all in the study period. The headline of the Guardian’s report of the study this article was amended after publication. An earlier version said that GPs in England were “failing to recognise thousands of long Covid cases”. The headline was changed to indicate that the research concluded that “long Covid coding in primary care is low compared with early reports of long Covid prevalence”.” An acknowledgement that at least one possible explanation is that GPs are applying a clinical-severity filter not recognized by researchers.

Another way to ask about the significance of “Long Covid” symptoms is to consider the prevalence of the same sort of symptoms in the general population. For example persistent fatigue is reported by between 10 and 20% of the general population and something like 50% of people with an identified physical disorder. Not many Long Covid studies collect data from comparison groups, but one ONS survey suggested 3.4% of non-Covid respondents had the same symptoms as the Covid+ respondents and the UCL study found a figure of 16%. In both studies the Covid respondents had more symptoms than the non-Covid respondents, but between-study differences raise again the question of why so much variation – no doubt it’s down to sampling, how the questions were asked, and response rates.

So … what is the value, and what is the likely outcome, of collecting not-very-accurate information on underspecified populations of people who have had a Covid infection and who for the most part have non-specific symptoms that are common in the general population? It may be that the result will be a better understanding of the nature of longer-term problems attributable (or attributed) to Covid infection, but it isn’t clear that these surveys are the most efficient way of getting there. And there are potential pitfalls – Long Covid manifestly isn’t a single condition and it is difficult not to see, in the current approach to researching it, the process that Ian Hacking called Making Up People – the bringing into being of a new category of people with what may turn out to be a transient illness (transient as a medical category that is, not for the individual) – in ways that are not beneficial to anybody concerned.

A start would surely be to stop using the term Long Covid. It’s unlikely we’ll convince the media or pressure groups to drop it, but a move in the right direction would be if researchers and clinicians started using more specific terminology to describe exactly what it is they are studying and why.

NICE’s ME/CFS 2021 guideline: a much-needed pause for reflection

  • September 9, 2021

There’s more to the debate than disagreement about research findings: prejudice against psychological diagnoses and treatments is also a factor

NICE’s decision to defer publication of its guidance on ME/CFS is welcome, allowing as it does time for reflection about what is going wrong that prevents consensus on the management of this group of conditions.

Actually, just a read through the draft (consultation) guidance provides some clues. It reads less like a dispassionate review of the evidence and more like a one-sided position statement from the ME Association. There is talk about listening to and believing patients, about energy envelopes, and criticism of trials that use “subjective” outcome measures – like self-reported fatigue and quality of life. What exactly these ideas mean isn’t always made clear. Disbelief isn’t likely to be about somebody being ill (symptomatic with functional impairment) but more about that illness being caused by a yet-to-be-identified physical pathophysiology. The energy envelope is an interesting term that I have not come across in this context (as opposed to engineering or acoustics)  except when used by people who dislike the idea of activity pacing, but its physiological (“objective”) basis is as far as I know undefined. Treatments that “only” change symptoms are described as non-curative but then so are stroke rehabilitation, paracetamol and hip replacement.

What is being played out in these guidelines is a long-standing opposition to (sometimes expressed as hostility, anger or aggression) treatments such as CBT and GET. What is that opposition about? The debate is sometimes framed as being about the status of trials’ evidence but I don’t think that explains the emotional tone. I detect in the background a drive to reject these therapies because they suggest there is a large psychological or motivational element to the illness.

We live in a society in which the idea is not widely accepted that physical illness can have predominantly psychological causes or treatments, and of course the personal experience of physical symptoms is so pressing that psychological ideas can just not seem to work as explanations. Beyond that starting point there is something more going on and I think it is an active prejudice against the idea of psychological (and specifically psychosomatic) diagnosis. There are several reasons for such an aversion. The diagnosis may be misunderstood as meaning that an illness is imagined or even deliberately feigned. No doubt this is also part of the “not believed” complaint. On the other hand it is assumed that if the diagnosis is accurate, the person so diagnosed must be really odd. This idea has its roots, I think, in the history of hysteria and its conflation of the hysterical illness with the hysterical personality. And of course there is a threat inherent in the idea that somebody can be so lacking self-awareness that their body generates an illness in a mysterious way that is outside their control.

Is prejudice too strong a word? I don’t think so: it explains the animus in the reaction to psychological research and practice in the field, which clearly reflects more than disagreement about the interpretation of trial results. And it surfaces even in some of the milder critical responses to NICE’s decision, such as use of the word “relegated” to describe people offered psychological diagnosis or input, with its implications of inferiority and failure.

How can professionals with an interest respond? Of course there is a continuing need to engage with constructive critical appraisal of the research literature, including discussion of the use of so-called PROMs (patient-reported outcome measures) in applied health research. In addition there is a need to explore new ways to discuss attitudes to psychological causes and treatment for functional or psychosomatic illnesses, tackling the idea that these are somehow disreputable or demeaning approaches.

This last question is sensitive because of the anger and resistance it can provoke in some quarters. My own sense is that the result of this sensitivity is some professional foot-shuffling. Too much is made of findings that many functional states are not preceded by severely threatening or traumatic life experiences; psychotherapy is discussed at times as if it is synonymous with CBT which in this context functions largely as an adjunct to rehabilitation rather than as a way of exploring more widely into the psychosocial context of illness development and maintenance; a welcome interest in the physiological mediators of symptom production is unnecessarily and incorrectly accompanied by claims that such research heralds the end of dualism (implication, using a psychological vocabulary is so passé…).

Time will tell, but my own prediction is that for these reasons the impasse will not be resolved merely by a renewed critical appraisal of the literature. Maybe a “form of words” will be found, but a more useful conclusion would be an acceptance that psychological treatments are important because psychological disorders are important – real, potentially serious, treatable and not inferior to physical diseases.

Helpful words for people who self-harm

  • August 12, 2021

Emergency Departments and their associated mental health services don’t always get good press when it comes to feedback about how they respond to people who repeat self-harm and attend for help: this leaflet which has just become available online is a positive contribution and a good example of collaboration between statutory services and the people who use them. Just the fact that there is such a leaflet is itself a positive message – saying that the service takes the problem seriously. And the content is supportive and practical – it certainly bears the hallmark of having been written by people with personal experience. Maybe a small step but nonetheless a step in the direction of building bridges and improving mental healthcare. To be emulated!!

Searching for meaning in a book “about” mental illness.

  • June 27, 2021

I detect a drift into the mainstream of the idea of personality disorder, and in an attempt to understand why I have been reading some pop books – perhaps the best known being Ronson’s The Psychopath Test.

The book is subtitled “A journey through the madness industry”: it’s never clear what Ronson means by the madness industry but it’s true that the main structuring device is a journey, although it’s from one person to another rather than (unfortunately) from one idea to another.

We start with Ronson meeting a neurologist in a café in London, and an anecdote about an anonymous incoherent book she has received. There are warning signs here about this careless superficial book – the person he’s meeting isn’t a neurologist and even a casual conversation with a few mental health clinicians would have marked his card about how common it is, if you work in that world, to receive unsolicited books and articles from people hoping to interest you in their idiosyncratic view of how things work, and how little such gifts really tell you about either mental illness or mental health services.

It’s difficult to identify a theme in what follows. To start with it seems to be an exploration of psychopathy, which Ronson has been persuaded is routinely diagnosed in clinical and forensic practice on the basis of Hare’s Psychopathy Checklist and as an explanation for which he mentions repeatedly a half-baked idea about amygdala function. So we get a visit to a special hospital, a skimmed review of some aspects of the Oak Ridge scandal, and an interview with a ruthless businessman, but half way through he seems to lose interest in that line of thinking and we get an account of David Shayler’s mental illness, an interview with a guest-booker for (among others) the Jeremy Kyle show, and a drift off into stuff about DSM and the overdiagnosis of bipolar disorder in children in the USA.

All this is sketchily researched. The piece about the Oak Ridge scandal doesn’t mention the Class Action lawsuit started in 2001 against The Ontario Government and Drs. Elliott Barker and Gary Maier for breaching the basic human and civil rights of participants. The account of Shayler’s mental illness has no obvious point in relation to understanding ideas about psychopathy and the egregious picture of Shaler dressed as a woman suggests the main aim is to invite sniggering. In his report of an interview with Hare himself, there’s a recycled anecdote that comes from the introduction to Hare’s 1993 book about psychopathy. The interview with Charlotte Scott (the Jeremy Kyle producer) is mainly a rewarmed version of her earlier mea culpa published in the Guardian.

The people Ronson interviews have a habit of speaking in odd tabloid journalese, issuing stupid one-liners like if you’re worried about being a psychopath then you’re not one. Adam Curtis asks him – what does all this say about our sanity? – one example of recurrent cod philosophy about the difference between sanity and insanity that reminded me of nothing more than Rosenhan’s fraudulent paper On Being Sane in Insane Places.

Reviewers, at least those quoted in the book, apparently find it all hilarious. Will Self says he found himself “laughing like the proverbial loon” for page after page. And this coupled with a comparison one of them makes between Ronson and Louis Theroux provides a clue about what is going on. Ronson tries disarming mentions of his own tendency to anxiety and of the intrusive and disabling nature of mental illness, but in truth this is Barnum and Bailey psychiatry, a parade of grotesques (people and ideas) at which we might laugh or shudder depending upon our disposition. Its appeal is to Hollywood stereotypes – Gordon Gekko meets Michael Corleone – and doesn’t offer anything interesting about the contentious diagnosis of personality disorder (antisocial or otherwise) or sympathetic to the popular understanding of mental illness or the people who try to treat it.

I guess it’s that appeal to the familiar that accounts for the popularity of this grim book – the offer of a reassuring romp through a landscape populated by really odd people who aren’t like us. I didn’t find it remotely funny, just rather unpleasant.

Mental health problems in the COVID-19 pandemic: we need more careful presentation and interpretation of facts and less melodrama.

  • June 24, 2021

Since early on in the COVID pandemic there have been expressions of concern about its impact on mental health and, at least as reported in the mainstream media, those concerns have been couched in frankly melodramatic terms.  In May 2020 the then president of the Royal College of Psychiatrists expressed fears1 that “lockdown is storing up problems which could then lead to a tsunami of referrals.” The (by comparison) rather more muted claim that the pandemic was having a “major impact” on mental health came in the reporting of a questionnaire survey conducted later that summer2. The current president of the Royal College of Psychiatrists, who has echoed his predecessor’s use of the tsunami analogy, attracted headlines towards the end of 2020 by suggesting that the consequences for the nation’s mental health will be the greatest since the second world war3. The doom-laden tone has persisted into this year, with The Prince’s Trust declaring4 that “The pandemic has taken a “devastating toll” on young people’s mental health” and a report from Bradford in West Yorkshire suggesting5 that “The pandemic has had a deep impact on children” who are “a lost tribe in the pandemic”.

There’s a tiresomeness to this sort of coverage, with its implication – familiar to those who regret the stigmatising of mental disorders – that there is something frightening and uncontrollable going on. But melodrama has other more tangible disadvantages.

First is the lost opportunity to conduct, and demonstrate how to conduct, a balanced discussion about the difficulties and uncertainties that attend the interpretation of data. Much of the media coverage consists of anecdotes – the personal interest stories so favoured by journalists – or small-scale interview studies. Data on health service contacts are problematic because of the degree to which disruption caused by the pandemic changes the relation between population prevalence of disorders and attendance rates. So what is, for now, the best evidence probably resides in population surveys.

However, results from self-report symptom questionnaires require more cautious interpretation than they are often given. Self-reported symptoms are mainly markers of distress, and although very high scores can be an indication of mental disorder the likelihood that is so depends upon the context. Two studies that have taken repeat measures suggest that most of the distress created by conditions during lockdown resolves quite quickly 6,7. The major impact headlined in one report2 proved due to a difference between 10% (previously) and 12% (at the time of the survey) in endorsement of a question about thoughts of suicide but did not spell out how often such thoughts are an accompaniment of distress and lead neither to suicide attempts nor to suicide – suicidal thoughts in population surveys are about 1000 times more common than suicides in the same population.

A bias in thinking about attribution arises with this use of language. A few attempts have been made to link Government policy to an increase in mental health problems among the young8, but for the most part no explicit suggestions are made. Instead the resort to analogies with war or natural disaster and talk of unprecedented crisis implicitly leads to foregrounding of the pandemic as the main explanation for mental health problems. To be sure, there are stresses in the current situation but there are also longer-term forces at play9-11. Years of government austerity strategy have done great damage not just to mental health services but to community assets, employment stability and family security – the main resources that constitute resilience for the most vulnerable in society.

Mental health is a vague umbrella term that is used to cover everything from the boredom and frustration that so many of us feel for being unable to see friends or go out socially, to severe mental illness. Not all mental health problems require treatment from the mental health services. Even before the pandemic something like a third of those identified in the Adult Psychiatric Morbidity Survey12 as having depression had not been so diagnosed by a professional. A third of adults referred to the Improving Access to Psychological Therapies (IAPT) service do not attend for the first appointment – voting with their feet 13.

Of course we need better mental health services. We also need to repair the damage done by years of austerity to schools, community resources and the quality of life of the poor and disabled. And the mental health services need to be planning about exactly where their efforts are best placed – blanket statements about mental health do not help with thinking about who needs exactly what sort of assistance, either preventive or therapeutic. These are challenging tasks the public and government support for which isn’t going to be recruited by melodrama rather than reasoned analysis and careful presentation of the facts.

  1. https://www.bbc.co.uk/news/health-52676981 accessed 12 February 2021
  2. https://www.bbc.co.uk/news/health-54616688   accessed 12 February 2021
  3. https://www.theguardian.com/society/2020/dec/27/covid-poses-greatest-threat-to-mental-health-since-second-world-war accessed 12 February 2021
  4. https://www.princes-trust.org.uk/about-the-trust/news-views/tesco-youth-index-2021 Accessed 12 February 2021
  5. https://www.bbc.co.uk/news/health-55864573 Accessed 12 February 2021
  6. Fancourt D, Steptoe A, Bu F. Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England: a longitudinal observational study. The Lancet Psychiatry. 2020 Dec 9.
  7. Shevlin, Mark and Butter, Sarah and McBride, Orla and Murphy, Jamie and Gibson-Miller, Jilly and Hartman, Todd K. and Levita, Liat and Mason, Liam and Martinez, Anton P. and McKay, Ryan and Stocks, Thomas V.A. and Bennett, Kate and Hyland, Philip and Bentall, Richard P., Modelling Changes in Anxiety-Depression and Traumatic Stress During the First Wave of the COVID-19 Pandemic in the UK: Evidence for Population Heterogeneity in Longitudinal Change. Available at SSRN: https://ssrn.com/abstract=3749211 or http://dx.doi.org/10.2139/ssrn.3749211
  8. Townsend, E COVID-19 policies in the UK and consequences for mental health, The Lancet Psychiatry, 2020; 7(2): 1014-1015,
  9. British Medical Association. Cutting away at our children’s futures: austerity and child health. https://www.bma.org.uk/media/2060/cutting-away-at-our-childrens-futures-austerity-child-health-guuk-2016.pdf accessed 12 February 2021
  10. Cummins I. The Impact of Austerity on Mental Health Service Provision: A UK Perspective. Int J Environ Res Public Health. 2018 Jun 1;15(6):1145. doi: 10.3390/ijerph15061145.
  11.  https://blogs.bmj.com/bmj/2020/05/21/young-people-were-reporting-deteriorating-mental-health-even-before-covid-19-struck-we-need-to-take-their-concerns-seriously-going-forward/ accessed 12 February 2021
  12. Adult Psychiatric Morbidity Survey, 2014 https://files.digital.nhs.uk/pdf/t/6/adult_psychiatric_study_ch2_web.pdf accessed 12 February 2021
  13. Improving Access to Psychological Therapies Annual report 2019-20 https://files.digital.nhs.uk/B8/F973E1/psych-ther-2019-20-ann-rep.pdf accessed 12 February 2021

A shorter version if this comment appears in BMJ Opinion

Fake news in academia

  • May 14, 2021

To an impartial reader there was always something odd about Rosenhan’s famous paper “On being sane in insane places”. It didn’t read like a report of high-quality research of the sort you might expect in Science, and the enthusiasm with which it was received (it has been cited >4000 times according to Google Scholar) seemed out of proportion to its form and content as a single author patchily written account of an un-replicated study involving 8 subjects.

Susan Cahalan’s book The Great Pretender goes further along the road of questioning the study, making the case that the whole thing was a fraud. She was unable to find any research records related to the reported results, and when she eventually traced two of the pseudo-patients they confirmed that they had not made the detailed observations reported in the paper and indeed hadn’t been asked to. One of the two was dropped from the final report, perhaps because his experiences were too positive, and yet in the rewritten final paper (now with 8 pseudo-patients) all the other numbers were identical to the earlier draft with 9 pseudo-patients. And most damningly, when the clinical records of Rosenhan’s own admission surfaced they showed that he had lied about what he told the admitting psychiatrist, in fact retailing fairly standard symptoms of schizophrenia.

No doubt the study proved so popular because it suited people to take it at face value. Psychiatry was in a dire state with diagnosis almost meaningless and the abusive nature of inpatient care widely recognized. Calhan quotes Chief Bromden: “It’s the truth even if it didn’t happen”.  Rosenhan had provided a stick with which to beat the system. Calahan reports that even Robert Spitzer knew some of the facts – he had apparently seen the notes of Rosenhan’s admitting psychiatrist but kept quiet because he was keen to force through a more standardised approach to diagnosis. Calahan’s conclusion overall: “The messages were worthy; unfortunately the messenger was not”. Although at the same time as apparently approving of the function of the report in highlighting the need for change in psychiatry, she recognizes the problems with the way the paper was used. It formed part of the rationale for an aggressive deinstitutionalisation which has had catastrophic effects on care of the severely mentally ill in the USA, and it helped feed the growth of the DSM behemoth.

The ambivalence of Calahan’s conclusion is at odds with her book’s unequivocal title, and it started me thinking. If fraudulence and integrity exist in science, how shall we know them? My preliminary take on this is that researchers who misrepresent research fall into four categories, of course with blurry boundaries. It isn’t entirely clear that we know what to do about any of them.

The out-and-our fraudsters. Burt, Wakefield, and now Rosenhan are infamous. They just made stuff up. The list of members of this group is long and will grow. Of course we call out individual studies, but what of the individual academics? Is everything they ever researched to be negated? Lance Armstrong’s Tour de France wins are no longer acknowledged, but every other race he won?

The embellishers.  Perhaps not everything they wrote is made up, but there is no great clarity about which bits were truth and which bits weren’t. To my mind the most under-acknowledged member of this class is Oliver Sacks. He was coy about it, but clear enough: “I mean, perhaps it’s a case that I seized on certain themes, imaginatively intensified, deepened, and generalized them.  But still”.  Or again: “I don’t tell lies, though I may invent the truth”.

And yet Sacks has never, to my knowledge, been called a fraud. Why not? Perhaps because some of the content of his cases would be familiar to many clinicians in the right specialties, and therefore everything he wrote clearly wasn’t made up. Even more so than for the out-and-outers, we can’t be entirely sure how much of the output of people in this group is trustworthy, and therefore what we should do about it.

The spin doctors. Here the behaviour is nothing like making up results; it’s not fraud. Most typically it involves secondary research, reviewing and synthesising the findings of others. This is a difficult skill to get right (see my fourth group) but the efforts of the members in this class are so wilfully wide of the mark, their failure to raise uncertainties or to consider biases so glaring, their findings so predictable from their pre-existing position on the question at hand, that you have to question motives rather than competence. These are academics who should know better. During the pandemic, Heneghan’s approach to COVID transmission is one contemporary example. In my own field I place Kindeman’s outrageous claim that there is no more evidence for the efficacy of ECT than there is for that of homeopathy. Here the answer seems to be attempted rebuttal rather than looking the other way, tempting though that is. Not that it’ll influence the people involved, but perhaps it’ll influence their standing in the academic and wider communities.

The academics who produce flawed evidence is a class that includes pretty much all the rest of us. We try but often get things wrong or present results in a biased way. A personal example. Some years ago, I led a programme part of which involved a case-control study exploring whether life stress might precede the onset of stroke. The answer looked like a tentative Yes and we published in a leading stroke journal. Much later I was approached to consider giving expert evidence in a case involving somebody who had suffered a stroke after a shocking event that was apparently a third party’s fault. My study was being cited. An expert for the defence had produced an eight page critique pointing out the flaws in my study and all I could say to the plaintiff’s team was “fair cop”. The main answer here is rigorous peer review and an academic climate that encourages serious adult debate about uncertainty.

This is a muddy field. Lack of rigour merges into recklessness with the facts and that merges into complete disregard for the facts. There are parallels in the wider public discussion about fake news and online media. A tighter regulatory environment may be one answer but is unlikely to be achievable at scale and with sufficient meticulousness. We need therefore to have a better, that is more critical, approach to engaging with academic and related sources.  Perhaps critical appraisal skills teaching needs to include skills in appraising authors as well as their outputs…

Why are self-harm services so poor?

  • May 13, 2021

In the latest addition to the BMJ series What your patient is thinking, an anonymous contributor writes of their personal experience of seeking help for repeated self-harm: “I am more than a body to stitch up and label”. Their conclusion is familiar and depressing “I do not expect long term input from NHS mental health services anymore, but there should at least be crisis input available for self-harm”.

I say familiar because it is no news to anybody, surely, that self-harm services are not in a fit state for the scale and importance of the task they should fulfil. Of course, a significant part of the problem is the shameful under-funding of our mental health services, a policy pursued with gleeful vigour by the UK government since the banking crash of 2008. But that alone won’t do as an explanation – we have known about poor services for decades and it’s not the first time I’ve touched on the topic in my blog yet there is still no sign of real improvement. Why is it that so little changes? Apart from the serious external constraints, I see three factors that are internal to mental health services.

The first is attitudes. I’m not going to rehearse the well-known argument about negative attitudes among staff – they exist, they’re unprofessional, they’re not universal. They affect the immediate individual exchange, but in a way what’s more important is the resulting lack of priority given to self-harm services when they are in competition for limited resources. One aspect of this that isn’t often enough pointed up is the unwillingness of clinical psychology services, and more recently IAPT, to get involved. The IAPT therapies manual (v.4, 2020) only mentions self-harm once, to say that the risk needs to be assessed without saying what to do about it. A typical local IAPT service will therefore say “In line with National IAPT standards, the service does not work with…people who present with active risk of significant self-harm”.

A second problem is muddled thinking about the nature of self-harm and especially what it means to say that self-harm is non-suicidal. The big culprit here is the idea of non-suicidal self-injury and how readily what should be (if it means anything) a description of an act becomes a description of a person. The result is that repeated self-harm is not seen as serious, or at least not serious enough, to merit special attention even though it is in fact a risk for pretty much all the poor outcomes you can think of in psychiatry.

Third, and lying behind much of these other factors, is the damaging idea of personality disorder, who you are as a mental illness, and especially the idea of borderline or emotionally unstable personality disorder. Inherent to this diagnosis is the notion that somebody has a sort of inbuilt emotional instability to which self-harm is a response. This formulation comes with a downplaying of experienced life adversity as causal, and with an over-emphasis on framing responses in terms of personal responsibility rather than need for specialist help. It flies in the face of what we know about the many reasons for self-harm that simply aren’t captured by thinking of it as a symptom of an abnormal personality.

Mental health services are off the pace here. Self-harm is a hugely important mode of presentation by people who want and need help and we should rethink how we are going to respond in more effective ways than we currently do. Otherwise we’ll be reading pieces like this one in the BMJ for another 25 years.