Government White Paper: Online Harms

  • June 24, 2019

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

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

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

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

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

There are three issues here:

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

What is the risk of disproportionate or untargeted action?

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

What steps to take?

There are two steps:

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

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

What is Liaison Psychiatry?

  • June 21, 2019

Liaison psychiatry involves clinical practice, teaching and research in psychiatry that takes place in non-psychiatric settings.  In the UK that has meant mainly in acute (general) hospitals or in specialist settings such as neurology centres, although there have been small scale attempts to practice liaison psychiatry in primary care (general practice). The rationale for liaison psychiatry is that people with mental health problems don’t get the best care if they are being seen in a non-psychiatric setting, unless there is a specialist team available to see them where they are.

The main areas of activity in liaison psychiatry are:

  • Mental health problems that co-exist with physical disease, which is sometimes called co-morbidity or multi-morbidity. Each condition tends to complicate the treatment of the other and can lead to poor outcomes for the patient.
  • Medically unexplained symptoms such as pain, chronic fatigue, weakness or loss of bodily feeling. These conditions often have a psychological component, although it upsets some people to say so.
  • Psychiatric emergencies such as suicidal behaviour, acute psychosis, or delirium – all of which are seen in acute hospitals.

Liaison psychiatrists can work in the emergency department, on acute inpatient wards, in specialist hospital departments, and in their own specialist outpatient clinics.

The Royal College of Psychiatry has a Faculty of Liaison Psychiatry . There’s more information on the Faculty website. The textbook Seminars in Liaison Psychiatry covers the subject in detail: the 3rd edition is currently in preparation.   

Mental health and physical illness: what’s the role of liaison psychiatry?

  • May 28, 2019

Discussions about services for people with co-existent physical and mental health problems usually start with a brief account of how common that state of affairs is, and how important it is.  Fair enough, but there’s another step in the discussion: how do you decide who is best placed to respond to the needs of the people affected?  Of course clinicians who specialise in physical health should know something about mental health and vice versa: my question is what to do when help is needed from specialists in this so-called co-morbidity? And more specifically, what’s the role of liaison psychiatry?

To begin at the beginning…

Below is a schematic representation of a clinical service, pictured as a simple care pathway. It acknowledges that at each stage some people will not be referred on or will refuse referral, some accept referral and do not attend, and some attend but drop out early. Also at each stage there are some who complete treatment at each level but do not improve. These groups are represented on the right.

The pathway also acknowledges, in line with standard thinking about stepped care, that some people present with such severe and complex needs that they should be referred directly to a special service.

In the UK, brief psychological therapies are usually delivered in primary care through a service known universally by the acronym IPAT (pr. eye apt) and in secondary care by a range of services, most typically clinical health psychology, or psychiatric nurse therapists working in liaison mental health services.

The numbers who move along the branches of this pathway into the complex/severe end are huge.  To take one example – figures from NHS Digital indicate that only about a third of those referred to IAPT for a talking therapy complete the course of treatment and of these only just over a half have “moved to recovery” by the end of treatment. We know from other research that relapse rates after brief therapies are high – up to 50% over the next 1-2 years.

So…the pathway above is right to indicate the need for a specialist service for complex and severe cases. What are the features of such cases? The answer is – no two cases are the same.  Here’s a list of some of the features of complex and severe problems.

1. Diagnostic complexity (physical health)

  1. Multiple or persistent severe symptoms that don’t fit standard diagnostic categories (including don’t fit standard MUS categories like fibromyalgia, CFS) or encompass multiple diagnostic categories
  2. Multiple drug treatments including opioid or equivalent analgesia
  3. Multiple physical diagnoses, including some validated (so both significant LTC and MUS)
  4. Erroneous physical diagnosis assigned in past or by 3rd parties
  5. Disability out of proportion to physical disease severity
  6. Major non-adherence or misuse of therapeutic regime, including induced illness, with serious physical consequences

2. Diagnostic complexity (mental health)

  1. Illness conviction, especially non-affective – can sometimes have a delusional quality, sometimes shared by close others
  2. Suicidal and related thinking, self-harm history or current risk

 3. Organisational complexity (healthcare)

  1. Frequent unscheduled attendance – GP surgery; ED; other healthcare
  2. Recurrent unscheduled acute admission
  3. Recurrent unwarranted physical investigation
  4. Multiple healthcare providers
  5. Drop out from or failure to respond to first line treatment, with persistent problems

4. Organisational complexity (social care)

  1. Receipt of benefits dependent upon non-recovery
  2. Various forms of assisted living for functional disabilities

5. Social complexity

  1. Wider social dysfunction – tension or conflict with others, impoverished illness-centred social network – having an impact on health or healthcare that acts as a barrier to effective brief psychological therapies
  2. Children or others as enmeshed carers
  3. Involvement in long-running and contested litigation or complaints related to health or healthcare

The origin of liaison psychiatry and the fuel for its growth in the UK (until recent years) was the demand for expertise in the management of such cases.

However, not only does a comprehensive service need a component to deal with chronicity/complexity/severity, it also needs to be able to offer integrated care – across primary and secondary care and between the various components of mental health care. So…what are the characteristics of integrated care? Here’s another list.

All this points to a (to my mind) relatively obvious conclusion. Liaison psychiatry services have an important role in the care of people with mental and physical co-morbidity and, at least in secondary care, it would be best if services were arranged so that IAPT, clinical health psychology and liaison psychiatry were brought together in a genuinely-integrated multidisciplinary service. There are barriers to that development – professional resistance is one, and in my experience mainly from clinical psychology; in recent times liaison psychiatry services have been swamped by the acute/urgent component of liaison work, not least because of NHS England policy; manpower shortages and funding limitations consequent on government policy – all play a part. It would be great to see this practical and basically cost-free improvement to care adopted as a national strategic priority by all the key interested parties.