What exactly is empathy in clinical practice?

  • February 19, 2024

In a recent British Journal of Psychiatry editorial summarising key points from the latest NICE guideline on management of self-harm, the authors led with a section headed “The need for empathy” – a rallying call that seems on the face of it unproblematic. Empathy is however underspecified in their article (as it so often is in psychiatry) both in terms of its defining features and in relation to what exactly should be the interventions to ensure it happens.

Interestingly the word empathy appears for the first time only in the supplement to the OED. It has gained currency since then but with a rather blurry feel-good meaning. The OED defines empathy as: “The power of entering into the experience of…emotions outside ourselves”. An early use referred to the experience of a work of art, the ability to “feel oneself into it”. These definitions too are rather hard to grasp but they suggest a state that it is unrealistic to expect a clinician to achieve – especially in relation to somebody met only briefly and in unusual circumstances, whose emotions and responses to them are likely to arise from experiences well outside the clinician’s own.

Some people claim that they can teach healthcare professionals how to be empathic. What it seems to boil down to is usually something like being attuned to implicit or non-verbal expressions of emotion, acknowledging and responding to them. This of course isn’t empathy but a sort of social practice. For that reason the more sophisticated versions of acknowledging and responding to patients has been likened to method acting.

Instead of continuing with this (frankly rather pretentious) focus on empathy, there are some less nebulous aspects of sensitive and non-aversive care that can be taught.

First is courtesy and professionalism. These, unlike empathy, can be taught and supervised by attention to behaviour – how to introduce yourself, asking how the patient wants to be addressed, paying attention to privacy and confidentiality and so on. And if that fails there is a question about lack of professionalism for which there are other remedies.

Second is being well-informed about causes and consequences. My own experience suggests that many clinicians are not au fait with what is now known about reasons for self-harm – in the sense of what its functions might be. One indication is the frequency with which discussions centre around diagnosis, which is except in a minority of no help in understanding what is going on. Another is the persistence of stereotypes about self-injury. It is difficult to undertake a sensitive and meaningful psychosocial assessment if you don’t know what you’re looking for. I wouldn’t downplay the importance of person-centred care or the value of service user involvement in training, but clinically oriented postgraduate education also needs to develop in this space. This sounds too fact-based to have anything to do with “empathy” but then I have always thought that a better word than empathy is sympathy – the sense of feeling onside with somebody that comes from a shared understanding of the situation. And how to elicit that shared understanding can be taught.

Third is the question of competence in practice and here there is a real challenge. Hardly anybody provides comprehensive psychological or psychosocial treatment services in the post-acute period – not in liaison psychiatry where most acute presentations are seen, nor in clinical psychology, nor in CMHTs. Good management involves, for sure, a professional attitude and behaviour and sound knowledge both about therapies and about the specific problem being tackled – but also the generic (transferable) skills, behavioural and emotional repertoire and expertise that come from experience. How can we enhance care in this area if we don’t provide the services within which all this can be developed?


If we are to improve how we treat people we need to go beyond rather general appeals to good practice. We need to develop self-harm services and to specify the curriculum for education and supervised training that will develop those working in such services to act professionally and sympathetically, as well as with a competence derived from education and from experience in practice.  

Social media harms: Mark Zuckerberg’s evidence-based practice

  • February 6, 2024

At the recent Senate judiciary hearing on “Big Tech and the Online Child Sexual Exploitation Crisis” Meta CEO Mark Zuckerberg said to parents present: “I’m sorry for everything you’ve all gone through, it’s terrible… No one should go through the things that your families have suffered and this is why we invest so much and we are going to continue doing industry-wide efforts to make sure no one has to go through the things your families have had to suffer.” This statement to an unimpressed looking audience was widely, and perhaps rather generously, reported as an apology (“a regretful acknowledgement of an offence or failure”) and it received a great deal of press coverage.

Less heavily reported, but to my mind much more surprising, is something else…

At the start of the hearing, Zuckerberg said, “The existing body of scientific work has not shown a causal link between using social media and young people having worse mental health.  I think it’s important to look at the science, I know people widely talked about this as if that is something that’s already been proven, and I think that the bulk of the scientific evidence does not support that.”

On the face of it this statement is a flat contradiction of much of what has been taken as read in recent public debates about harms from social media. But…Zuckerberg’s remarks are, like his apology, carefully worded. In particular the second of his assertions isn’t wildly out. It is true that the bulk of evidence doesn’t support a causal link because it is cross-sectional and shows only associations. And it is also true that some of the case has been overstated – for example there is little robust evidence that social media “cause” depressive disorders or suicidal thinking in people not already struggling with those problems.

On the other hand, the first assertion seems shakier. It says more definitely that there is no evidence across the whole area of mental health. And yet any reasonable conclusion based upon what we know about how the online world works (some of it reviewed by experts in our recent book on social media and mental health) is that it is likely harms will flow from addictive patterns of social media use, from online bullying and harassment, malicious use of personally-shared photographs, solicited contact by predatory adults and the like.

Unfortunately a “reasonable conclusion based upon what we know about how the online world works“ is not the same as rock-solid proof that is going to stand up against hot shot lawyers from Team Zuckerberg arguing about what “shown a causal link” and “worse mental health” mean.

I can’t help thinking that fulminating about the bad faith of the tech CEOs is about as productive as grumbling about the ignorance and bias of academic peer reviewers. There may be political and legal avenues to follow in pursuit of a safer online world, but for researchers the next step must be to revisit how we undertake studies in a methodologically and logistically challenging area: what exactly is the research we need to do that will produce irrefutable proof that certain sorts of remediable social media experiences are bad for the mental health of those experiencing them? And perhaps as importantly – how can we explain the findings to politicians and legislators?

The Online Safety Bill is supposed to protect young people with mental health problems: how will we judge if it has any effect?

  • October 19, 2023

After a long public and political debate about what form legal regulation of social media should take, the UK’s Online Safety Bill (2023) has passed into law. One of its highly-publicised aims is to protect young people from harmful exposure to content likely to lead to lowering of mood and an increased risk of self-harm and perhaps suicide. Now that we have moved to the stage of implementing the measures outlined in the Bill, how will we know if it is achieving its aim of reducing severe mental health harms to young people?

Our research and that of others, published in a multi-author book this month, suggests that the answer to this question will not be easy to establish. Preoccupation with the need to suppress harmful content has not led to great precision in the definition of what constitutes harmfulness, or of what we can think of as the social in social media – including the ways in which social media are used and by whom. Little attention has been paid to the problem of unintended consequences, and especially the possibility that regulation might lead to loss of positive aspects of social media use. And we are unclear what measures of outcome will be feasible.

In the early years of this debate we were working with a doctoral student whose thesis involved an analysis of more than 600 images posted on social media with a tag that included self-harm. Our student’s findings suggested a more interesting, in some ways surprising and more complicated picture than was reflected in the public debate. While communication of distress was common so were stories of recovery and many of the associated comments were encouraging and supportive. The posts identified were by no means restricted to explicit discussion of self-harm and in more than half the accompanying image did not represent self-harm directly – labelled with the self-harm tag were discussions of a range other topics including the nature of gender and the female body and concerns about identity and belonging. Even when tagged as “self-harm”, the space was being used to discuss these other matters of emotional concern to young people.

We decided to follow this single study with a review of the research literature to explore the issues further. The review was undertaken on behalf of the mental health charity Samaritans and explored the relation between social media use and mental health, and in particular the effect of accessing content about self-harm and suicide. We found that the nature of this content was diverse. There was content that would universally be considered harmful, such as detailed description or video streaming of methods and active, explicit encouragement to act. However, there was little evidence that much of the content in isolation could be considered unambiguously harmful.

When looking at outcomes of exposure to self-harm and suicide content, we found that previous research studies have indeed identified negative consequences – the reliving of distressing personal experiences, a sense of pressure to present oneself in certain ways or to offer help to others when one was not in a position to do so, sometimes a stimulus to further, perhaps more severe, self-harm. But research also identified positive aspects of the social media experience – a feeling of reduced isolation and support from a community of people sharing similar experiences in a non-judgmental way, the opportunity to achieve some self-understanding through recounting personal experience online, and for some people access to practical advice such as details of helping agencies or guidance on hiding scars.

It was also clear that an important influence on outcomes was not just the content of social media but the way in which they were being used – such as the intensity of interaction with other posts and the amount of time spent online, and the interactions with and reactions from others to content posted. At least as important as harmful content is whether social media use leads to connection but to an unhelpful online community, to trying for connection but failing to find a community with which to identify, to being harangued for sharing experiences, or to asking for help that isn’t forthcoming. It is unclear how such experiences could be regulated or their effects mitigated except by the individual online.

There are formidable challenges in researching this area, not least that social media are valued by many people because of their anonymity, and it is difficult to apply high quality research methods to unbiased samples. For this reason we decided that it would also be valuable to gain a wider understanding of expert opinion across this field. In other words we wanted to know if there is a consensus among experts studying the relation between social media use and mental health about what can and cannot be considered harmful and what would be the most desirable responses to this relatively new feature of the social landscape. We approached academics known for their interest in the area, and the result is the multi-author book edited by us – Social Media and Mental Health  and published by Cambridge University Press.

Some of the issues raised include not just the content of postings but the great diversity in who accesses or posts, how they use social media and how they respond to specific content: outcomes cannot readily be attributed either to content alone or to the person alone – they are likely to arise from the interaction between content, person and context. While a central issue is algorithmic pushing which increases duration and intensity of exposure, there remains no specific definition of degree and type of exposure when it comes to this social aspect of a regulatory framework.

Another aspect of social media use that was under-explored in earlier public debate about the Online Safety Bill was the role of social media as a source of positive help. At the time of our own review into online resources for self-harm, we found that most sites were extremely limited in what they offered as practical help to people seeking it. Positive resources need to move beyond encouragement to take care and to seek professional help. What our contributors describe is their involvement in programmes of work that serve as a pointer to the next generation of online resources – developed on sound theoretical grounds and principles of practice and involving young people in determining format and content.

In addition to these challenges in monitoring to the form and content of online experience, there is a question of how to assess outcomes. Rates of distress, of self-harm or of suicide in young people are likely to fluctuate, but how would we know if any improvement could be attributed to the recent legislation? An associated reduction in accessing certain social media content might be taken as evidence, but correlation is not proof of causation and there are other interpretations of such an observation.

For all these reasons, we are left uncertain whether it will prove possible to evaluate the effect of the Online Safety Bill on the mental health of young people. That is, in terms of processes, whether we will be able to identify changes that incontrovertibly represent reduction in harmful content and harmful types of social media use, that do not have the unintended consequence of reducing access to helpful online interactions, and that increase the availability of genuinely helpful resources. And in terms of outcomes, to identify changes in rates of mood disturbance, self-harm or suicide that can be attributed to the effects of legislation.

In an age of misinformation mainstream media need a verifiability policy

  • February 28, 2023

Journalism should take a zero-tolerance approach to publishing false or unverifiable claims

I often ask friends – when you read an article in mainstream media about a topic in which you have some expertise (about health if you are a doctor for example), how often do you notice that it contains incorrect information? The majority of answers fall at the frequently/very frequently end of the Likert scale we’d be looking at if I were polling rather than chatting. I’m not talking here about serpent-headed aliens, microchip-containing vaccines or stolen elections. But I am talking about mundane examples of misrepresentation through partial presentation of the facts and fabrication.

I give illustrations from the Guardian newspaper, not because it’s a major culprit but because it isn’t. If the problem is present even in the best, it’s present everywhere. I am a long-time reader of the Guardian and subscriber to its online edition. I value its balanced coverage and regard it as standing head and shoulders above all other daily newspapers in the UK for its reliability and lack of bias. But at times I am left wondering, even in this newspaper, about a particular piece – is this true? How would I know?

On the surface the examples I will give may seem like minor infringements, but unreliable reporting in any part of the paper can lead to lack of trust in the reporting of every part of the paper; and we are storing up trouble for the future if journalists following examples such as these come to believe that writing a good story takes precedence over writing an entirely accurate one. There is a fairly simple solution to the problem but before considering it, a few examples.

An article in January 2023 described a survey which was said to have “…found that one in five LGBTQ+ people and more than a third of trans people in the UK have been subjected to attempted conversion…”. As part of an online survey, respondents were asked whether they had ever experienced someone taking any action (my italics) to try to change, cure or suppress their sexual orientation or gender identity. Describing the findings, the phrase “subjected to” appeared in the article headline, in the final sentence and three times in the text. There was no link to the survey report but when I found one it revealed that the campaigning group commissioning the survey has a particular take on what “subjected to” means.

“There must be no “consent” loophole… Conversion practices are abuse and it is not possible to consent to abuse …The definition of conversion practices should include religious practices…”. So examples of what respondents were “subjected to” included “I saw a counsellor…” and “My partner ended our relationship because of God and then the people from church prayed for us to become straight.” For sure, there were quotes about much more unpleasant experiences but even there the reframing was unusual: being beaten up because you’re gay is wrong, but it’s a stretch to call it a conversion practice. There was no indication of a typology of practices or the prevalence of various practices – anything and everything goes towards the headline figure.  This strikes me as a long way from what most people understand by the sort of conversion therapy that might be banned by legislation, but you wouldn’t know it from the way the survey was reported.

An article in June last year headed “Brain damage claim leads to new row over electroshock therapy” reported that electro-convulsive therapy (ECT) “…is now the focus of a huge row – which erupted last week – over claims that it can trigger brain damage, that guidelines covering its use are weak and that it is used disproportionately on women and the elderly.” Again there was no reported evidence of a huge row; just a link to a 5 year old Guardian article retailing the same criticisms from the same source as described in the 2022 article. The bust-up seems to have been imagined into life to act as a hook for the otherwise non-story.

Something from the pandemic. An article from January 2021 reported that the “Prince’s Trust happiness and confidence survey produces worst findings in its history”. Three accompanying comments linked the findings to the impact of the pandemic. The findings as reported were literally true (just) but a reading of the whole report gives quite a different picture. In 2021 just 56% of respondents said they were happy about, and 64% said they were confident about, their emotional health. Certainly the lowest on record but the corresponding figures for 2018 were 57% and 65%. In 2021 56% said there were always or often anxious. Again, the highest on record but the figures for the preceding years 2018-2020 were 53%, 54% and 55%. The really big changes have come since 2010 when more than 70% said they were happy and confident about their emotional health and fewer than 20% said they felt anxious or depressed all or most of the time. So a study that shows a decade-long decline in the emotional health of young people is reframed as a story about the impact of the pandemic by the simple expedient of not reporting most of its findings.

In a piece from January this year promoting assisted dying and entitled “Today, 17 people will likely die in unimaginable pain…” regular contributor Polly Toynbee writes, after a warm up about torture chambers, excruciating pain, horror and humiliation, that “On average 17 people a day die in terrible pain that can’t be relieved by even the best palliative care.”  The claim is based upon a review undertaken by the Office for Health Economics which, like the research it is reviewing, refers nowhere to the severity of pain but only to “unrelieved pain” much of which, it would be clear to anybody familiar with the clinical scenarios, will not match the descriptions offered. Toynbee’s account of unimaginable pain in end-of-life care comes in fact from her own imagination.

Much of this would be avoided if journalists put a bit more work in – didn’t just recycle press releases and did some of their own fact-checking, aided by basic critical appraisal skills. How would we know if they were doing that? Online encyclopedia Wikipedia, in facing its own questioning about reliability, has developed a policy it describes as Verifiability, not truth. “Verifiability” means that material must have been published previously by a reliable source, cited by the writer and consulted by them. Sources must be appropriate, must be used carefully, and must be balanced relative to other sources. 

Citing reliable sources, with a clear statement that the journalist has consulted them, gives readers the chance to check for themselves that the most appropriate authorities  have been used, and used well. In fact none of the four examples I give here would be compliant with such a policy. If respectable and respected mainstream media are to maintain their reputation for trustworthiness they need to demonstrate how they manage reliability in their reporting and not just assert that they do. An explicit, and explicitly followed, verifiability policy would be a good start.

A book about suicide research and a suicide researcher

  • November 2, 2022

Rory O’Connor is a health psychologist who has published extensively on suicide. He is also active in discussions about suicide aimed at the general public and about suicide prevention policy, especially in Scotland where he lives and works.

His book When it is Darkest: why people die by suicide and what we can do about it  is divided into four parts, covering the main facts (and misconceptions) about suicide, its main causes, what preventive interventions might be effective, and supporting people who are suicidal or who are living in the aftermath of the suicide of somebody close. Further resources are mentioned throughout and there is a list at the end. The emphasis, especially when considering causes, is on the psychology of suicide and includes a review of the author’s own framework for organising the disparate associations with suicide into what he calls the Integrated Motivational-Volitional Model.

O’Connor’s aim is to combine personal and professional perspectives. The style is informal, written in the first person. Interspersed throughout are anecdotes about his personal experiences, his contacts with people who have felt the impact of suicide in another or of feeling suicidal themselves, and his career in suicide research. At the same time it is in parts quite technical and ends with 48 pages of academic references, with a leaning towards his own research.

The book covers a lot of ground without being exhaustive or exhausting, especially of course in its review of prevailing psychological theories. And it offers a sustained attack against fatalism in the face of suicide and the apparent impossibility of eradicating it: we can move to understand more and to develop effective prevention strategies.

No book like this can be entirely comprehensive but there are some important gaps. There is too little on the personal and social impact of drug and alcohol misuse, either as a risk for the individual or as part of the reason people become isolated or alienated from social support. Mental disorder and its treatment may not be the most important part of suicide prevention but even so it deserves more consideration than it gets. Many of those who die have been in contact with helping agencies – GP, the mental health services, university counselling services or whatever – and there is not much here about how such services might do better or what families feel about this aspect of how tragedy might have been prevented. Suicide needs to be seen in social and cultural context if we are to focus public health interventions. Psychology can’t explain the wide regional variation in rates, and some of these wider issues feel undercooked. In a laudable attempt to combat negativism the effectiveness of suicide prevention interventions is overstated.

What about readership? It requires high levels of general and scientific literacy and that will limit its utility. The presentational style will not suit everybody. I personally didn’t like the idea of calling suicide The Big S.  I also wasn’t keen on the idea that suicide is not usually about the desire to die but about the desire to end suffering. After all “suicide” means death as the result of an act intentionally designed to end life, so this is a paradox that on close inspection just doesn’t make sense. There are few accessible books on suicide for the general reader (Mark Williams’ Cry of Pain is one, and the Help is at Hand booklet for those bereaved by suicide is excellent); this text will therefore find a place as a useful review for the interested and well-educated non-specialist.

Social media and mental health: we need much more attention to the detail of what regulation might entail

  • October 25, 2022

Coverage in the mainstream media of the findings of the Molly Russell inquest concludes that the case is now made for direct action on regulation. However, in these and other similar pieces there has been little discussion of what specifically such regulation might entail or of the challenges of implementation. Here is a sample from just one newspaper:

Why is it so hard to say specifically what should be done? For sure there will be resistance from the tech companies, but an additional dilemma is that much of the content under consideration (about depression, self-harm and suicidal thinking) is seen as helpful by those who use social media – valued for its 24/7 availability and anonymity and for the supportive nature of sharing and viewing user-generated content. The challenge therefore is to eliminate the negative impact of social media without blocking access to its helpful elements.

Although the main emphasis in discussions about regulation has been on harmful content, that is only one of three aspects of the problem to be considered.

A central issue is algorithmic pushing which increases duration and intensity of exposure. We know that people with existing mental health problems are more likely to spend long periods online and more likely to use sites with content related to self-harm, and there is some evidence that such extended exposure makes matters worse. So, what limits should be set on these quantitative aspects of social media viewing?

The question of what to do about algorithmic “recommendations” is confounded with one about content. It is generally accepted that it would be no bad thing if searches for key terms (self-harm, suicide and so on) were to trigger responses offering links to helpful resources, which raises the question of how to identify specific content as helpful (OK to recommend) or harmful (not OK). In relation to moderation of content, harmfulness is usually defined by terms like glamourising, normalising and encouraging. These words are used without definition and yet proposed as the main criteria upon which any duty of care will be judged. How are they to be defined and identified in ways that don’t just rely on individual opinion?

Monitoring and responding to problematic patterns of use is a key issue in debates about online gambling – how to achieve it without driving away those who resent the idea of surveillance and loss of privacy?

Journalists may not see it as their job to grapple with these questions. Here are three suggestions from non-journos whom we might consider as having something important to say:

The coroner in Molly Russell’s case issued a prevention of future deaths report:- in which he said:

“I recommend that consideration is given by the Government to reviewing the provision of internet platforms to children, with reference to harmful on-line content, separate platforms for adults and children, verification of age before joining the platform, provision of age specific content, the use of algorithms to provide content, the use of advertising and parental guardian or carer control including access to material viewed by a child, and retention of material viewed by a child.”

The government’s plans are to be found in its Online Safety Bill. At the point at which they published their last factsheet (April 2022) on the topic, this is what they had to say:

“Platforms likely to be accessed by children will also have a duty to protect young people using their services from legal but harmful material such as self-harm or eating disorder content. Additionally, providers who publish or place pornographic content on their services will be required to prevent children from accessing that content.

The largest, highest-risk platforms will have to address named categories of legal but harmful material accessed by adults, likely to include issues such as abuse, harassment, or exposure to content encouraging self-harm or eating disorders. They will need to make clear in their terms and conditions what is and is not acceptable on their site, and enforce this.”

The coroner’s report covers all three bases in some ways but shares an important feature with the much more limited Online Safety factsheet – undesirable content is identified by the single word “harmful” which is not defined apart from a suggestion in the factsheet that it is likely to include “encouraging” which isn’t defined.

Multiple charities with an interest in the mental wellbeing of young people wrote a letter to the then prime minister Liz Truss in October, in which they attempted to unpack the idea of harmfulness in a constructive way:

“We are writing to urge you to ensure that the regulation of harmful suicide and self-harm content is retained within the Online Safety Bill…[defined as]

  • Information, instructions, and advice on methods of self-harm and suicide  
  • Content that portrays self-harm and suicide as positive or desirable
  • Graphic descriptions or depictions of self-harm and suicide.”

The first two criteria look as if they ought to be amenable to careful definition; “graphic” is more problematic. One person’s clear and vividly explicit detail is another’s matter-of-fact account. Or does it mean – any image (depiction) at all, that is not shaded/pixelated or whatever – descriptions of how to look after or conceal your wounds for example?

There seem to me to be two risks here. The first is that decisions will be left to Ofcom and (presumably) to the courts. The second is (perhaps less likely) that the tech companies will decide they can’t be bothered with all this and will go for some variant of blanket suppression of interactions about self-harm and suicide. Neither is desirable: the former if it leads to the sort of adversarial debate that failed to clarify these questions during the inquest, the latter if it ends up denying access to helpful content. There is emerging research that can contribute and health professionals should lead in arguing for its inclusion in decision-making, so that a realistic balance is struck between risks and benefits of social media in an important areas of public health policy.

New NICE guidelines on self-harm: show it’s not possible to hit three targets simultaneously

  • October 9, 2022

Writers of NICE guidelines have to take on three tasks. They have to marshal the evidence and integrate new findings into the existing guidance. They have to present their findings in different formats to suit different audiences. And they have to ensure that any guidance can reasonably be taken up, by taking into account such research as there is on barriers to implementation.

In the context of self-harm these tasks are more than usually demanding. Most obviously there just isn’t that much new evidence – a symptom of underfunding as much as it is of researcher indifference or incompetence. And such research as there is may be based upon populations far removed from the typical UK patient seen in ED or primary care. Much practice is therefore consensus or opinion based and new guidance cannot simply take the form – now modify treatment regime A by substitution or replacement to make Regime B.

Second, much self-harm is seen initially by practitioners who have no great depth of knowledge of self-harm theory or research; even when working in mental health services they are often generalists rather than part of a specialist self-harm team. Guidance therefore needs to take the form of clear and specific pointers to action, of a sort that does not rely on implicit knowledge.

And third, existing culture could not be described as conducive to dispassionate evidence-based practice. Influential and unhelpful ideas about personality disorder, non-suicidal self-harm or emotional instability exert a dismaying amount of influence.

It strikes me that these three demands are impossible to reconcile into a single document, as the latest NICE guidelines on the management of self-harm illustrate.

In an effort to stay based upon evidence the review recommends only two psychological treatments, neither with advice about how the recommendations will be read and implemented: CBT-informed therapy the definition of which does not take account of interpersonal factors and which will therefore be interpreted as “CBT-lite” by most people, and DBT for young people with “significant emotional dysregulation” without indicating how that will be determined in routine clinical practice or what happens to all the other young people who aren’t getting a label of emerging borderline personality.

Some of the advice to non-specialists is unhelpfully vague – I don’t think the average GP needs to be advised to refer to mental health services if they are concerned after assessment in primary care, and I don’t know that school staff will know without some specifics how to meet the recommendation that they identify “self-harm behaviours”. On the other hand some key questions – about the role of diagnosis in management decisions, how to get to the meaning of suicidal thinking with a patient, the important differences between one-off presentations in crisis and long-standing repeated self-harm, the origins and response to professional stigmatising – are hardly touched on.

Implementation challenges don’t get much of a look in. To give one example: it’s impossible to discuss how to improve self-harm services if we don’t acknowledge that aftercare is likely to require referral to CMHT who can’t/won’t see people without a “serious mental illness” or clinical psychology who won’t see suicidal people or who will if they’ll sit on a months-long waiting list.

I don’t think the problem here is primarily down to the expertise of the guideline group, which contained some experienced and sensible clinicians. A major problem resides in remit. This is a three-in-one document: a (short!) document giving a synthesis of what’s new in research; an assessment and treatment manual written with specific readers in mind (so actually a series of manuals) and a trouble-shooting guide to tackling current problems in service provision. NICE guidance just isn’t set up to meet such diverse aims and I wouldn’t therefore expect these latest guidelines to make much difference to the grim reality of service provision for people who present after self-harm.

Conversion therapy – there’s still a need for better evidence.

  • May 16, 2022

A notable feature of the debate about conversion therapy is the degree to which it borrows from, implicitly or explicitly, the language of evidence-based practice. There are other criteria of course: the value-based judgement that all attempts to change sexual orientation or gender identity are wrong, or the pragmatic argument about unintended consequences that might come from poorly drafted legislation. Nonetheless it remains reasonable to ask how good the research evidence is, evaluated independently of these other arguments, in providing grounds for proposed legislation to make it illegal.

An immediate problem is posed by the broadness of the definition usually employed. For example recent government documents describe conversion therapy as…“techniques intended to change someone’s sexual orientation or gender identity. These techniques can take many forms and commonly range from pseudo-psychological treatments to spiritual counselling”. What this means is that the form, content or style of any intervention being evaluated is often unclear, or that widely differing interventions are conflated in a single intervention category.

Another barrier to interpreting research findings is the lack of attention given by many commentaries to the question of consent. For example the nature of consent is not reported in the UK survey of experience conversion therapy: the results show that more people were offered than received therapy, but not how many had consented to or even actively requested it. In a US study of the experiences of men who have sex with men, 40% of respondents who had experienced therapy said the decision to initiate therapy had been “mostly” or “completely” theirs. One might expect that unwanted or coerced intervention would be more likely to have negative outcomes, but the necessary analyses don’t seem to have been undertaken.

Apart from this (rather obvious) observation that coerced intervention may be the more harmful, there is another complication that arises. People who request therapy may be seeking help with a range of relationship problems that are conflated with their sexual orientation or gender identity, making it difficult to tease out the effect of the “conversion” element. The recent publication of Patricia Highsmith’s journals and diaries provides an example if a rather atypical one.

Reported outcomes typically describe one of two domains: change in sexual orientation or gender identity rarely occurs; negative effects for example on mood and sense of self-worth are commoner than in those who have not received therapy. The evidence is by no means clear that such negative effects are universal and by comparison, benefits have been rarely sought or reported.

One exception is a study of LGBQ individuals affiliated with the Church of Jesus Christ of Latter-day Saints, 720 of whom provided unstructured comments on their experiences in addition to completing structured assessments. The authors note, of these comments “Many found therapy to be a helpful, even life-saving experience. To be able to talk to a knowledgeable professional about a very private concern was salutary. Others reported improved relationships with family or other close associates. Of particular interest was the large number of individuals who reported decreased levels of depression and anxiety and improved feelings of self-worth…For some participants, psychotherapy was clearly unrewarding. As a general rule, however, experiences of harm or iatrogenic distress were much less frequent than reports of benefit.”

Qualitative studies suggest that benefit accrues from aspects of therapy such as discussions about the meaning of the immutable nature of sexual orientation or gender identity or about how to manage any resultant dissonance that arises in the family or religious groups. One interpretation of how attempts at conversion might contribute is that they can act as a sort of behavioural experiment the results of which will depend upon how they are handled. Sensitive discussion can help, while insensitive, coercive or rejecting responses will not. For example, one study of people who had experience of conversion therapy found that those who had subsequently left the religious community for whatever reason were more negative about the effects of therapy than those who had not. One consequence of the definitional problem (see above) is how difficult it is to find much in the research literature that notes whether conversion therapy came with a certain package of other responses or not.

One piece of evidence I have been unable to dig up is what happens next in countries where legislation has already been passed. Has it led to prosecutions? What is the effect on religious communities? In most of the relevant states evangelical Christian groups predominate and it is hard to find anything about other religions. What happens in the madrasa or orthodox Jewish groups? I think we simply don’t know.

In summary – nobody surely would disagree that imposed or coercive attempts to change somebody’s sexual orientation or gender identity are abusive and should not be allowed. However, the proposed UK legislation initially promised to impose a blanket ban on any form of conversion therapy. Even consented or requested therapy, competently delivered as part of a wider discussion of the issues, would be criminalised.

This takes us away from a popular caricature of conversion to a more complicated picture of a type of talking therapy that might be actively sought, with more mixed motivations and with attempts to use effects of the process as the basis for wider exploration. Should that really be criminalised?  Such an approach might be argued about on the basis of values rather than evidence, but it is difficult to read the research literature and find unequivocal justification for it.

As things stand, the government has backed off (again) and now says it will not legislate on consented therapy involving adults. It is difficult to believe, of this government, that the decision is one of principle – more likely a response to legal advice about difficulties of drafting the law. Only time will tell what the eventual bill contains. Meanwhile some careful planning of prospective research would be a good idea.

  • Steven Meanley, PhD, MPH, Sabina A Haberlen, PhD, Chukwuemeka N Okafor, PhD, MPH, Andre Brown, PhD, MPH, Mark Brennan-Ing, PhD, Deanna Ware, MPH, James E Egan, PhD, MPH, Linda A Teplin, PhD, Robert K Bolan, MD, Mackey R Friedman, PhD, MPH, Michael W Plankey, PhD, Lifetime Exposure to Conversion Therapy and Psychosocial Health Among Midlife and Older Adult Men Who Have Sex With Men, The Gerontologist, Volume 60, Issue 7, October 2020, Pages 1291–1302, https://doi.org/10.1093/geront/gnaa069
  • American Psychological Association, Task Force on Appropriate Therapeutic Responses to Sexual Orientation. (2009). Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Retrieved from http://www. apa.org/pi/lgbc/publications/therapeutic-resp.html 9 May 2022
  • Kate Bradshaw, John P. Dehlin, Katherine A. Crowell, Renee V. Galliher & William S. Bradshaw (2015) Sexual Orientation Change Efforts Through Psychotherapy for LGBQ Individuals Affiliated With the Church of Jesus Christ of Latter-day Saints, Journal of Sex & Marital Therapy, 41:4, 391-412, DOI: 10.1080/0092623X.2014.915907

Putin’s mental state? It’s time we dropped the childish and uninformative mad man view of history

  • March 4, 2022

Former UK foreign secretary David Owen has recently been reported as saying that Putin’s aggressive behaviour on the international stage may be a consequence of taking steroids. The evidence for this assertion is that Vlad’s got fatter in the face in recent times and is being unreasonably aggressive.

Owen has form in the cod diagnosis of politicians – giving us in 2019 the ridiculous condition of Hubris Syndrome – or hubris as we used to call it. My reading of the formulation there (excuse the technical jargon) is that after a few years in power people tend to get up themselves a bit, arrogant and not keen on being contradicted. However, I may be wrong and there’s more to it: a senior neuropsychologist tells us that Hubris Syndrome affects the frontal lobes drenching them in dopamine, and this could be the cause of Putin’s behaviour.

In the same article that reported the Hubris Syndrome idea, a different expert suggests that it’s something to do with the cognitive effects Long Covid. No less absurd as a hypothesis but I suppose it has the advantage of being bang up to date.

If any of this sounds familiar that’s because it is. Not that long ago experts were telling us that President Trump wasn’t just horrible but mentally disordered – most infamously in the multi-contributor volume The Dangerous Case of Donald Trump. And of course the most famous mad man of recent history is Hitler – name-checked 59 times in the Trump book in case we didn’t spot the provenance of the line of thinking. I could keep going but the trail is long – back to Suetonius at least (I’d have to stop there, my ancient history’s a bit thin).

It’s tempting to dismiss all this as ridiculous, which of course it is. It’s raised a momentary laugh when I’ve chatted about it with friends and that’s about what it’s worth. But there are reasons to think we could do with less of it, for the effect it has on the quality of public discourse.

First, pathologizing of political motives as symptoms of mental disorder is really just a variant of psychiatric name-calling, which is a form of insult we could do without. And it infantilizes public discussion about serious matters. Do we really think that the Ukraine invasion is the result of an aggressive impulse by somebody who has temporarily taken leave of his senses? Or that one man can run not just a complex military adventure but a whole country – without the collusion of others in it for the power, money, sex or whatever it is that motivates them?

Malignant despots have something in common, I think, with buffoon politicians like our own prime minister. They are symptoms of the system that allows them to stay where they are, their endurance reflecting not just something about their callous self-interest but also the values of those on whose collusive support they depend.  All of which is kept out of the spotlight by daft pseudo-diagnostic medicalisation, a sort of dark-side version of the Great Man of History story which downplays the systemic and societal and privileges the role of the individual actor.

Personality disorder as a diagnosis: stereotyping and discrimination aren’t avoidable complications, they are inherent to the diagnostic process.

  • February 14, 2022

In clinical practice, a full diagnosis typically consists in the description of a particular presentation coupled with an account of the associated (causal) pathology that explains the presentation.  Thus: you are breathless and I can’t hear breath sounds on the right side when I listen with my stethoscope (the presentation) because you have fluid surrounding your lung due to tuberculosis (the explanatory pathology). Diagnosis in psychiatry is rarely full in this way, typically consisting only of a description of the presentation.

If we consider the diagnosis of personality disorder in this light, does it make sense? The diagnostic statement is that the person is the presentation, and although there is assumed to be some sort of underlying deficit in psychological function that constitutes the associated (causal) pathology, it has to be said that after 100 years of inquiry what it is remains to be revealed. We are left with the diagnostic statement – your emotions, actions, thoughts aren’t symptoms of some condition you have; they are simply the expression (presentation) of your personality and therefore who you are is a mental disorder.

If that’s right, can debate about the status of the diagnosis be bracketed with debates about the clinical or social status of autism or physical disability? That is, the diagnosis can be criticised for pathologizing diversity or for essentialising the individual who becomes the problems they present?  I don’t think this quite works as an analogy. For example, there is no ineluctable presentation in personality disorder which is why categorising sub-types has proved such a failure. Autism is autism is autism, while psychopathy can look like any number of things.

Apart from the mutability difference, there is something different from the neuro-diversity analogy in the way the “disorder” of personality disorder is defined – not just in social or interpersonal terms but in judgemental terms. The judgements are, at root, about acceptability of behaviour, emotional expression and so on.

So, making a diagnosis of personality disorder isn’t stereotyping or stigmatising as an unfortunate side-effect of the way some ill-informed people choose to treat those so diagnosed, it is inherent to the diagnostic process. If we say that who somebody is constitutes a mental disorder the features of which are socially and personally undesirable, and this “who somebody is” fits them in a category of similar people with the same mental disorder, then how could it be other than stereotyping and stigmatising, with the resulting responses being those we might expect towards anybody who is by definition undesirable?

error

Subscribe to keep updated!