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.  

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.

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?

New NICE guidelines on management of self-harm won’t lead to the changes needed – lack of investment and the culture in mental health services will see to that.

  • January 28, 2022

It is more than a decade since NICE last published guidelines on the assessment and management of self-harm, so the recently released new guidelines (out in draft for consultation) will be read with some interest.

What we find is a mixed bag. For the most part the proposals are unexceptionable, the generation of novel ideas and advice no doubt hampered by the desperate lack of funded research in the area. Some suggestions are not impressive – for example a blanket endorsement of CBT for all adult self-harm is limited to put it mildly, and the section on harm minimisation is ill-informed and muddled.

There are, however, some welcome recommendations, most notably “1.6.4 Do not use aversive treatment, punitive approaches or criminal justice 5 approaches such as community protection notices, criminal behaviour 6 orders or prosecution for high service use as an intervention for frequent 7 self-harm episodes.” – a clear response to the HIN/SIM scandal and one that will make a difference, not least because it is supported by NHS England.

My guess would be that this is the only recommendation likely to make a substantial difference to service provision in the next few years because there are two barriers to change that NICE can’t really influence – the first is lack of resources and the second is culture in mental health services.

When David Owens and I wrote a lament for the state of self-harm services in the UK my friend Nav Kapur wrote a Pollyanna-ish reply, but in truth the situation is dire. Existing services like CMHT’s and IAPT will see hardly anybody and those they see will get an appointment neither on a timescale nor in the numbers needed for the nature of the problem. Liaison psychiatry services do most of the assessment but none has the clinic capacity to arrange therapeutic follow up. The few specialist services there are will see a small number of referrals for intensive longer-term therapy but only if strict eligibility criteria are met. There are several reasons for this state of affairs, but one of them is undoubtedly lack of investment in trained staff to do the work. Against a background of government “austerity” cuts, money has been found for psychotherapy provision in the NHS (through IAPT) and for an expansion of liaison psychiatry services, but none of it has found its way into the budget for self-harm aftercare. You can come up with as many recommendations as you like about support for people who self-harm, but if there are no services to deliver that support then nothing’s going to happen.

Culture eats strategy for breakfast, and the other piece of the puzzle resides exactly in culture. There are plenty of people who think, and behave as if, self-harm isn’t that important and the people who do it are just a bit of a nuisance. Patient feedback about services repeatedly makes this point – ED isn’t a great place, waiting to be seen is stressful, assessment doesn’t achieve much if there are no useful services to which somebody can be pointed after the assessment, but a lot of this can be tolerated if it doesn’t come with a message of hostility or indifference from the clinician seeing you. Of course it isn’t every clinician but it’s enough…especially for those unfortunate enough to have copped a diagnosis of personality disorder.

These two things play off each other – negative attitudes lead to, or at least lead to tolerance of, poor service provision, and lack of services leads to stressful uncomfortable encounters in which it is all too easy to slip into a hostile or blaming frame of mind.

I don’t think this is all there is to it but these two factors, which I have named here rather than unpacked very carefully, seem to me a good part of why the draft NICE guidelines bring such a sense of anti-climax. Most clinical conditions are now managed in established services delivering care that might be improved by careful attention from a positive and trained workforce to standardised evidence-based practice; that’s what NICE guidelines are for. In self-harm those conditions just don’t apply. Let’s not blame the NICE guideline development team, let’s look elsewhere for solutions.

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!!

Self-harm in the NHS: time for change

  • June 29, 2020

Twenty five years ago my colleague David Owens and I wrote a lament for the state of NHS responses to self-harm – noting little research investment, haphazard service provision and no evidence of central strategy. Revisiting the scene recently in an editorial for the British Journal of Psychiatry , we found little to celebrate in the way of real progress. My friend and colleague Nav Kapur wrote a riposte which was less of a counterblast and more an invitation to peer at glimmers of light at the end of the tunnel.

A recent post on the Recovery in the Bin site puts some flesh on the bones. The author sees an explanation for her experience of poor care in an intimate connection between inadequate service provision and negative attitudes among mental health professionals. This isn’t a self-centred social media rant, but a reasoned account of what it’s like to be on the receiving end as a person whose self-harm requires physical and mental healthcare.

There’s a lot of catching up to do, and three organisations should contribute:-

NHS England should invest in comprehensive outpatient follow up services for self-harm, where therapy is offered regardless of diagnosis. These services could be a part of liaison psychiatry services, since that is where most acute assessment goes on. In a recent straw poll conducted during a webinar for liaison psychiatrists, more than 80% agreed with the idea of liaison psychiatry providing such a service.

The National Institute for Health Research (NIHR) should make a strategic commitment to fund self-harm and suicide intervention research – perhaps as part of one of their themed calls. Ad hoc responses to researcher-led proposals is not driving the necessary improvement in the research evidence needed to support change.

The Royal College of Psychiatrists should campaign assertively in this area, tackling negative attitudes among its own members and lobbying for policy change, intervention research and investment in services. Alliance with the Royal Colleges of Nursing and of General Practice would bring support from the other two clinical practitioners most directly involved.

We need to move beyond words to make action on self-harm a national priority.

Social media, self-harm and suicide

  • October 30, 2019

Another missed opportunity in the Molly Russell case

There are two views of how people with mental health problems experience social media. In one view they are places where you wander alone, drawn into an immersive atmosphere of depressive messages and images – self-harm and enticement to suicide everywhere you look. In the other they offer a space where you can come out of hiding, share otherwise secret fears with peers, gain an element of support and advice.

In the former view, risk of suicide is increased by the mood lowering effect of the content and by a sort of creeping familiarity with the idea of self-harm or suicide – called sometimes desensitisation or normalisation – and greater awareness of the methods involved.  In the latter view the social or networking function creates opportunity for reducing the sense of disconnection or lack of belonging, and the sharing of detail allows some alleviation of the burdensomeness of feeling uniquely troubled 1.

The Janus-faced nature of social media is outlined in a report by Barnardo’s about young people, social media and mental health – Left to Their Own Devices. The natural conclusion is that different people are likely to be affected differently by their online experiences, and the same person may be affected differently on different occasions. Which raises the question – how to minimise risk without at the same time suppressing useful content? It’s a tricky question and one that requires (you might hope) a careful public debate involving as many interested parties as possible in coming to a solution that considers all the competing demands of the situation.

In the UK, a fair bit of this public debate has centred recently around the suicide of teenager Molly Russell, not least because her father has pressed forcibly the case for the damaging effect of social media and the need to suppress content that might (in his view definitely does) encourage suicide.

Once the case surfaced, the early signs were not encouraging for those of us looking for a wide-ranging and informed discussion. The BBC opened their coverage with an oafish interview of Steve Hatch, the MD for Facebook in Europe, by the BBC’s Media Editor Amol Rajan who, as far as I am aware, knows nothing about self-harm or suicide.

After some grandstanding political outrage by the likes of health secretary Matt Hancock the government produced a White Paper – Online Harms – that bundled encouraging self-harm or suicide with incitement to terrorist activities, dissemination of child pornography, and drug dealing in the dark web. The main direction hasn’t therefore been about self-harm and suicide prevention at all, it’s been about steps to regulate the tech giants.

The response from the principal player in this case – Facebook/Instagram – has been as dispiriting as one might expect.  After a laughable attempt to use Nick Clegg as a front man to reassure us of their good intentions, they announced earlier this year a ban on images of self-harm described as graphic or explicit – with no definition of either offered by way of clarification. Now Instagram has announced a ban on drawings or cartoons.  There’s again lack of clarity about exactly what this means; in the linked article the specific example is of text linked to an innocuous drawing.

Where is the commission-like meeting of organisations, clinicians, academics, people with personal experience, that should be leading the debate and informing the decisions? The social media companies don’t want it – they want to manage the debate and avoid swingeing statutory regulation.  The government doesn’t seem want it – they’ve had long enough to organise it if they did. The mainstream media don’t want it – they just want a story to tell, sentimental or sensational if possible. Samaritans has an interest but it’s a slow train coming.

Where are the professional bodies in all this – my own Royal College of Psychiatrists, the British Psychological Society, the Royal College of Nursing, the Health and Care Professions Council? I don’t mean where are they in offering uncontentious opinions, I mean where are they in organising the high profile, mature debate that’s needed to replace what’s going on now?  They are nowhere, and that failure of leadership is what represents the real missed opportunity.  


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


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