Accountability

On 31st March, a week or so after the coronavirus pandemic lockdown began, I was contacted by the HCPC.

I am writing to inform you that we have received a concern about your fitness to practise” the letter began. “We will now carry out an initial investigation into the potential fitness to practise issues identified in the concern. This may involve gathering relevant information from a number of sources.
  
In order to assist with our enquiries, I would be grateful if you would provide the following information:
  
– Confirmation that you are the owner and/or moderator of the site ClinPsy.org.uk.
– Confirmation of whether you, or any of the other owners/moderator of the site have received any concerns/complaints about the content of the forum, particularly regarding [celebrity psychologists]
– If yes, please provide a copy of the complaint/s and the site’ s response.
– If not provided above, you are welcome to provide a brief response to concerns raised.
– Confirmation of your current employment arrangement.
– If applicable, please provide the name and email address of your line manager and HR director.

I replied the same evening:

I own www.clinpsy.org.uk I can confirm that I have never had any complaints in any form about any comment on [celebrity psychologists] on the forum – in fact I have never even heard of [the complainant], and can find no reference to him on the forum. I’m afraid you will need to let me know what comment is being complained about to enable me to respond to it.
As to my employment, I am self employed and run my own small business, so there is no line manager or HR involved – but I have to ask why you would think that relevant when a person is complaining about an unspecified comment on social media?

I then contacted my professional indemnity insurance provider and spoke to Mike Wang, chair of the ACP (he was my MSc supervisor and then my clinical course director, and we have stayed loosely in touch since then) who were both reassuring that this wasn’t a legitimate complaint. Later I got legal advice through my membership of the FSB, to check I had fully understood my legal obligations as a forum owner. All of us wondered why the HCPC would launch an investigation at all, given that I had never made a comment myself about any of the individuals named in the complaint, and the forum had been very proactive in ensuring no defamatory content was permitted. The forum does have a thread about “celebrity psychologists”, where legitimate concerns are raised about individuals who appear on television or in the newspapers making comment as “psychologists” who are outside of the scope of HCPC registration. But I could see nothing defamatory in it. In fact the moderating team had carefully checked the content and I had even posted a reply to remind people about our defamation policy and how to raise a concern. So I started to draft a full reply to the HCPC.

Just to be sure, I spent many hours obsessionally trawling through content on the forum and my social media and could find no interaction with the individual concerned, or any defamatory content about any celebrity psychologist on my forum. That isn’t to say members of the forum haven’t criticised such individuals, or that I don’t share similar concerns. Quite the opposite, I’ve been raising concerns about the limited scope of regulation for psychologists and therapy professionals for more than a decade and see this as another example of where the legislation fails to protect the public. However, I have never expressed this as a personal attack on an individual, or said anything unprofessional or defamatory.

At this juncture it might be helpful for me to note what defamation is, what a complainant can do about online defamation, and what the legal rights are both of the individual who believes they have been defamed, and the established defences against claims of defamation, as they will set this complaint in context.

Defamation is the action of damaging the good reputation of a person through the oral or written communication of a false statement about them that unjustly harms their reputation. The important part of that definition is that the statement must be false, and it must cause them harm (which must be demonstrable within 12 months of publication). Being rude about someone or insulting towards them would not normally be defamatory, though it might be unprofessional. As a website owner I am technically the publisher of the content shown on the site, and whilst I cannot be held legally accountable for other users being rude or insulting (though we have worked hard to create a professional culture and to have policies that prevent personal attacks or unprofessional behaviour), I would be accountable if something defamatory was published – if I was aware of it and failed to act to remove it when requested to do so by the individual it affected.

The problem here was that the HCPC did not share any details of the complaint with me, and the complaint communicated was entirely vague and did not refer to particular comments or even allege defamation. It was also made by a third party, rather than the individual that the complainant said had been maligned – making it rather extraordinary that the HCPC would give it even a cursory investigation.

But even with the assumption that someone had said something on the forum that an individual had felt was defamatory – which was far from the case – the law requires that individual (not a third party) to inform the publisher and ask them to remove the content, within 12 months from publication. And in this case most of the comments about celebrity psychologists had stood for 7 years, and no complaint had ever been raised with the forum – despite every post having a button to report it to moderators for review, and a prominent defamation policy that was linked by me in the very thread concerned, in a post giving the forum email address to make such a report.

There are also two main complete defences to defamation allegations; truth and honest opinion. If a statement is true it cannot be defamatory. For example, to say that a celebrity psychologist is not a registered practitioner psychologist or does not have a doctorate is not defamatory if these statements are factually correct. The other defence is that someone is expressing an honest opinion or making “fair comment”. This allows discussion of matters of public or professional interest, and means it is not defamatory to express a view that an honest person could have held on the basis of any facts or anything asserted to be a fact by reasonable sources available to them at the time. That is, if I said “Boris Johnson is a liar” this could not be defamatory because numerous sources have asserted this to be the case. Honest opinion can also be a reaction to something else that has been published, and can even defend someone posting something that is incorrect, if it was an honest belief based on the information available at the time (for example, writing “X isn’t registered with the HCPC” wouldn’t be defamatory if a person had their HCPC registration in a different name, or it didn’t show on the website yet, or the name checked was spelt incorrectly because that was the spelling used in the article under discussion).

As far as I could see, all comments that were on the forum about celebrity psychologists, or made or retweeted by me on social media, involved telling the truth or making fair comment about known or published facts.

On the other hand, my investigations showed me that the complainant was someone who frequently threatens properly registered mental health professionals who criticise his favoured celebrity psychologists with referral to the HCPC. I also found that the individual concerned had used anonymous IDs to respond aggressively to critics of his favoured celebrity psychologists, and to place more flattering quotes and reviews about them into the public domain. I also heard from other colleagues who had been harassed for raising similar concerns. One noted:

This is one of the perversities about the register and use of the title psychologist; as [celebrity psychologists] are not registered they are able to freely mislead the public about their status and not be held accountable and yet they can put in complaints to the HCPC about those of us that are properly qualified.  The complaint is vindictively motivated [and yet effective as a deterrent/punishment for critics]

So on 2nd April I sent the HCPC a robust reply:

I have had a better look into this and I am now in a position to reply more fully.

For reference, the forum has run for 13 years and contains 152,000 posts on over 15,000 topics. We have never had a formal complaint about our content, and we have a team of moderators who are all HCPC registered clinical psychologists who help to ensure we maintain a professional tone in all content. Every user has to agree a statement about the rules of the site to sign up (which can be read here: https://www.clinpsy.org.uk/forum/viewtopic.php?f=2&t=16012) and we have written guidance for users that spells out our rules (which can be read here:https://www.clinpsy.org.uk/forum/viewtopic.php?f=2&t=10). The guidance is sent to each user in a welcome message as they sign in for the first time and cautions against personal abuse or defamation. Rules 9 and 11 specifically talk about being respectful of others even when disagreeing, avoiding defamation and ensuring posts do not risk bringing the profession into disrepute. It also explains how any post can be reported to moderators by clicking the small triangle button and stating your concerns. We have a pinned post giving specific guidance about defamation (see here: https://www.clinpsy.org.uk/forum/viewtopic.php?f=2&t=9&p=10) that is linked prominently from that guidance, and note it includes the means to contact us to report any content that is potentially defamatory at the bottom of the page: “If you believe a post has been defamatory about you, or an organisation you represent, please email us at clinpsyforum@gmail.com and we will respond as quickly as possible”. 

We have a proper process for responding to a complaint, and a team of qualified CPs who act as moderators that I consult with. However, our complaints process has only been activated once (when an approach to purchase the website turned into correspondence disputing our negative review of a travel agency offering work experience placements to psychology students, but they did not register a formal complaint and we did not find any content that was not factually supported when we investigated) and I can confirm that we have never had any complaint from any of the individuals mentioned in your email. We respond frequently to reports on individual posts, which mainly notify us of spam but can also highlight inappropriate content such as potential breaches of confidentiality. These are dealt with within 3 working days. We have never had a report in relation to defamation or to any content relevant to this complaint.

We do have one thread where [celebrity psychologists] are mentioned – you can read it here: https://www.clinpsy.org.uk/forum/viewtopic.php?f=12&t=13708. It was started in 2012 where forum members raised concerns about “celebrity psychologists” who do not have HCPC registration but appear to be giving the public the impression they are regulated professionals. The thread stood for 8 years and the majority of content was posted two or more years before I contributed to it at all. I did review the entire thread at that point and found nothing defamatory. Nonetheless my response includes the following: 

“The issue of psychological therapists who practise outside the scope of professional regulation is one that is important to many of our members who work hard to gain practitioner status with the HCPC, because we believe in the principle being important to protect the public (regardless of the individuals involved).

As with any other thread on the forum, if any of the content of this thread is considered defamatory the the individual involved is welcome to email the site (clinpsyforum@gmail.com) and point this out and we will remove it.” 

The thread was then dormant for nearly six years, before being raised to discuss the way some “celebrity psychologists” were using BPS membership to give the impression of professional qualifications, whilst apparently breaching BPS guidance. I had raised these concerns with the BPS and mentioned doing so on the forum and on twitter. However, as with the content in the thread, the concerns were about the misrepresentation of professional titles and skills, and the role the BPS take in giving credibility to psychologists who are not HCPC registered practitioner psychologists, and their lack of will to intervene or regulatory teeth when concerns are raised about these individuals. Whilst one or two of my posts are critical of specific things that [individual celebrity psychologists have] written or said I cannot see any defamatory content. I have made no direct criticism of [the individuals named in the complaint], and there has never been any mention of [the complainant] on that thread or elsewhere on the forum.

Nobody has raised a complaint about that thread. I have reviewed it today, and whilst there is legitimate concern about misrepresentation of qualifications and the public perception of psychologists, based on things written or said by various unregulated “psychologists” in the media, I cannot see anything defamatory in the content. [Far from being unprofessional, I believe we have gone above and beyond requirements to prevent defamatory or unprofessional content. I posted in that very thread] how to report any concerns about defamation, and have been mindful to allow only appropriate professional concerns about misrepresentation to be raised on the forum, rather than personal attacks or potentially defamatory content.

I do not believe that it can possibly impair my fitness to practice as a clinical psychologist to have hosted or participated in discussion about potential misrepresentation of professional qualifications by “celebrity psychologists”. This has not been defamatory, and I believe it to be legitimate for members of a clinical psychology forum to raise professional regulatory concerns about public figures – especially when these are factually based, shared by many practitioner psychologists and early career stage psychologists, and have been raised appropriately with professional bodies including the BACP and BPS. The posts on the forum that were critical of these individuals were based on the content of their newspaper columns and television appearances, how they are introduced in TV programs, and their stated qualifications and experience on their websites. For example, it is a true fact that Emma Kenny is not a clinical psychologist, despite being introduced in a BBC television series as being one, and this being a breach of the regulations that brought us under the auspices of the HCPC.

I would note that it is entirely lawful for individuals to publish honest opinions on a matter of public interest and based on facts which are true – this is known as “fair comment” or “honest opinion”, and has been tested through the courts by cases such as British Chiropractic Association vs Simon Singh, which led to the Defamation Act, 2013. This introduced a number of protections against allegations of defamation, including truth, honest opinion, public interest, and a defence for website operators hosting user-generated content, provided they comply with a procedure to enable the complainant to resolve disputes directly with the author of the material concerned or otherwise remove it. This ensures that individuals who own or run websites that allow comment are not liable for the content of other user’s comments on it. It requires that the complainant must contact the site owner or administrator to raise a complaint in which they specify the complainant’s name, the statement concerned, where on the website it was posted and explain why it is defamatory, before taking any other action in relation to alleged defamation. These complaints can only be made by the person who has allegedly been defamed or their legal representative.

We have never received any complaint or notification of potential defamation, or any communication from [celebrity psychologists] or their legal representatives, and as previously stated we have never mentioned, heard of or communicated with [the complainant]. Thus a non-specific complaint to the HCPC made by an individual who has never been mentioned on the site seems quite inappropriate as a means to address concerns. I would therefore hope that the complaint can be quickly dismissed.

Yet the case still wasn’t dismissed, despite the fact I had demonstrated that a) I had not made any defamatory comments about the individuals concerned and b) there was no legal basis to hold me accountable for posts made by others on a forum that I own (even had any been defamatory, when none of them had been).

I was then asked on 6th April to provide proof that no complaints had been made to the website. Aside from the fact that it is not my burden to prove a negative, and almost an impossible task, I spent the next 3 hours responding to this request, searching the email correspondence, administrator and moderator report logs for each name or the word complaint, and submitted screen shots of every search. These were acknowledged on the following day.

Yet the case still wasn’t dismissed.

I then heard nothing for 4 months. So I wrote on 12th August to ask whether the complaint had been dismissed. This email was acknowledged, and I was told I would receive a reply within 5 working days, but received no reply. I therefore emailed again on 20th August, which again had no reply. So on 26th August I raised a complaint.


My complaint was that this “fitness to practise concern” was obviously spurious from the start, and should never have reached the point of even a cursory investigation (given the complaint was from a person I had never interacted with, about comments made by people other than me about people other than him). But even if it did, in error, reach a cursory investigation, surely the information I provided within 3 days was enough to say “sorry, it is now clear this isn’t a legitimate complaint” and not keep me under the stress of a formal fitness to practise investigation? How this can still be hanging over my head five months later is very troubling. Surely there must be a process for checking the prima facie validity of complaints, that should have dismissed this? What if I had been employed, and this had led to me being suspended or fired? How you could do this to a person struggling to sustain their business through a pandemic lockdown over such a trivial and spurious complaint is beyond me.

On 4th September the investigation was officially closed. The HCPC informed me:


I am writing to let you let you know that we have now completed our initial investigation into the concerns we received about your fitness to practise.

During our investigation, we obtained information from the Complainant and yourself. We have now assessed the concern, and all the information we received, against our threshold criteria for fitness to practise investigations.

In doing so, we have considered whether this matter may be a breach of the following HCPC Standards of Conduct, Performance and Ethics:
2. Communicate appropriately and effectively
6. Manage risk

The outcome of our assessment is that the threshold criteria for fitness to practise investigations has not been met in this instance. This means that we do not consider that the concern, or the information we have obtained about it, amounts to an allegation that your fitness to practise may be impaired.

The reasons for our decision are explained in more detail below:

Issue 1 – comments of an offensive, bullying or inappropriate nature on social media

Registrants are not prohibited from expressing their opinions on social media, provided the content or language used is not inappropriate or offensive.

HCPC Guidance on Social Media advises Registrants: ‘ When using social media you should apply the same standards as you would when communicating in other ways. Be polite and respectful, and avoid using language that others might reasonably consider to be inappropriate or offensive. Use your professional judgement in deciding whether to post or share something.’

From the links and screenshots provided, the content of the forum appears to be confined to a discussion of professional concerns and information already in the public domain. Regarding the opinions and concerns expressed in the forum, the HCPC would be out of place to prohibit its Registrants from having a free discussion about their concerns or limit their ability to express their opinions. Of the information provided and the search conducted, I am unable to find any statements which amount to ‘trolling’  or bullying.

As our process is evidence based, we cannot proceed with our investigation without evidence to support the concerns. The Complainant was given multiple opportunities to provide evidence that you contributed to and offensive or inappropriate content, but has failed to provide information which supports the concerns.

Issue 2 – hosting comments by others of an offensive, bullying or inappropriate nature on your site

You have provided evidence that you have put multiple protections in place to ensure the tone, language and content of the forum is not defamatory and does not stray into inappropriate content or language. Where members breach these terms, you have a team of moderators who will respond.

In providing individuals the ability to report specific posts and comments, you have acted in accordance with your professional duty to support and encourage others to report concerns(SCPE 7.2). You have evidenced that you have not received complaints on this thread, and therefore have not been in a position to respond to such concerns.

In the absence of any evidence to suggest you have not complied with the relevant obligations, there is no information to suggest that your fitness to practise may be impaired.

We will therefore not be taking any further action in relation to this matter and have closed our file on this case. However, please continue to be aware of our communication guidance when reviewing your forum/website.

We appreciate that this has been a very stressful time for you and would like to thank you for your co-operation and patience during our investigation.


So, to my relief, they got there in the end and the complaint has been dismissed. However, my question is why the complaint got through the starting gates, and why it took 5 months, 2 emails and a formal complaint to resolve.

But more than this, why do the BPS continue to endorse these “celebrity psychologists” and do nothing to protect or support genuine practitioner psychologists against this kind of attack? Despite numerous complaints about “celebrity psychologist” Jo Hemmings in the context of her article about Meghan Markle being manipulative, the BPS sat her down for a chat and took her at her word that she would be more careful in future. And they’ve not replied to any of my emails in the six months since I suspended my membership, saying I would not continue membership until they responded to the concerns I raised about their endorsements not protecting the public.

And more than this, why does the legislation not distinguish genuinely qualified and accountable professional psychologists within the scope of regulation from anyone who calls themselves a psychologist? In Australia it is an offence with enormous financial penalties to misrepresent someone as a psychologist or claim to be a psychologist if not within the scope of statutory regulation. So the public cannot be misled by the media citing quacks or charlatans who claim qualifications, but actually have to check their registration before using them as experts. Here we haven’t even got that protection for who can be called as an expert witness to inform critical decisions in the courts. The scope of current regulation fails to protect the public, yet nobody – not professional bodies or politicians – seems to care.

Pessimism, propaganda and politics

I can’t be on the only one being crushed into learned helplessness and pessimism by the triumphalism of the far right taking over British politics, and the impending Festival of Brexit. Unlike the Brexit referendum result, the election of Trump and the results of past elections in the UK, this time I knew it was coming. But that hasn’t made it easier to accept. So how did we get here? And what should we do now? I figured I’d split some content out from a diversion on a previous blog and then share some thoughts about the leadership of the labour party.

It seems evident we are now in a time of propaganda and fear-mongering, where the truth has been lost amongst distortions and misinformation. Adam Curtis captured this prophetically in Charlie Brooker’s 2014 end of the year show (shown in two tweets from the marvellous Carole Cadwalladr here). Misinformation and bias is now pervasive in the way we receive our news, which is mostly delivered via social media and decided by algorithms based on past viewing choices in a way that reinforces our narrow bubbles. The news we read is skewed by the need to to keep us coming back to see the advertising content that funds it. And that means it is full of carefully curated fear, uncertainty and doubt, in between the filler of social media anecdotes and celebrity gossip. No wonder it feels like there are so many layers of bad news in the world at the moment.

Even when we take the time to read a newspaper cover to cover, we hear about so many hideous individual crimes not just in our locality but nationally and internationally because the world is so connected now – the latter often only identifying their location way down the article, meaning the headlines make us feel these are all risks that affect us personally. It makes it feel like the world is getting more dangerous even though the reverse is actually the case. There seem to be so many horrendous incidents of stabbings and shootings, and the ongoing human cost of the various war/conflicts going on in the world. And we start to feel as powerless as we do about the terrible weather events of different types that are being reported all around the world, from forest fires to floods and loss of ice fields. You’d think we know enough already to stop the global warming that is fueling the volatile weather, address the causes of conflicts and mediate solutions, and have effective police and criminal justice systems around the world. But no. It seems as developed nations, we prefer to make superficial changes to actually implementing real change when it comes to the environment.

Sadly, that is no surprise given the disproportionate influence multinational corporations have over policy. We seem to have increasingly allowed the super-rich and corporations to covertly buy influence through donations and lobbying. This lets them promote the kind of politicians who will increase the wealth gap further still, remove consumer protections and “red tape” and allow creeping privatisation of public services. The same forces let the far right foment prejudice and anger through internet and tabloid propaganda, so the focus of blame is always downwards toward vulnerable groups and not upwards to those with wealth and power. To compound and consolidate this, in the UK we have chosen to immobilise our entire system of government, civil service and public and private sector management for three years whilst deciding how many feet to shoot ourselves in under the banner of Brexit. This has never been more obvious than in the last week, where we are now poised to undermine all the checks and balances, and scupper the next few years of economic growth to entrench this new post-truth hard right populist culture for future generations.

And whilst the Labour party try to elect a new leader with the credibility and passion to challenge this, the left is fragmenting rather than regrouping. I’ve seen so many posts about Corbyn and Corbynism, trying to make out that idealogical purism is still the way forward, that we lost the election but won the argument and should do more of the same. Another Angry Voice posted as if it was irrational fear of renationalising transport and utilities that was the problem, concluding “If you’re afraid of Jeremy Corbyn’s economic policies, I’m afraid you’re pretty much the dictionary definition of a narrow-minded little Englander aren’t you?” I couldn’t disagree more. Frankly, I doubt many progressives disliked Corbyn’s policies, especially individually. However, together his policies will have seemed very disruptive and expensive not just to conservatives but to a lot of the middle ground and left-of-centre voters that are so vital in gaining a majority in UK politics – meaning he didn’t have mass appeal. Yet he was undoubtedly a good guy – warm, kind, genuine and thoughtful, and held in high regard by everyone who knows him personally. So was this also an example of a tendency to make snap judgements by first impressions, another consequence of unhelpful stereotypes of what a good leader is like, proof of a corrupt media or some combination of all of these things? I’m not sure.

Even to the diehard lefties (and I’d consider myself left of Blair, and someone who had great hopes for Corbyn in the beginning) Corbyn wasn’t the right fit for the job of heading up the opposition or being elected prime minister. Many of us worried about his leadership ability, his ability to be decisive and persuasive, to convey ideas in simple soundbites, and his failure to crack down on antisemitism within the party – giving the biased millionaire-owned media a stick to beat him with. But most of all, we worried about his choice not to articulate that Brexit was a tax evasion ploy by the super-rich that would harm the most vulnerable most, but also cause child poverty, cuts in public services, the break-up of the union, weaker negotiating positions that allow US pharmaceutical companies to charge more to the NHS and infringement of our right and liberties. Instead he believed/pretended that labour could offer a “good Brexit” of some kind, and lost half his supporters. He then failed to form any kind of progressive alliance, and instead allowed attacks on progressive peers in other parties, which was the nail in the coffin for the election.

So where do we go from here? Is it just about getting a new leader who gives a better first impression? It seems to me that politics has polarised the historic broad and diverse parties on either side of the house into narrow camps at either extreme of the political spectrum, leaving a lot of us disenfranchised by the first past the post voting system and the recurrent gerrymandering of constituency boundaries. We can see it in the hard-right Brexiteers that now dominate the Conservative party, but we can also see it in the way that a dominant and vocal minority supporting Corbyn and accepting no deviation towards incorporating a broader range of voices or considering what policies might be popular or electable has taken over the Labour party. Perpetuating this narrow view of purist socialism in which everyone else is “narrow minded” or a “red tory” is a very significant part of the problem – to win elections you need mass appeal, not to attack and alienate anyone even one degree outside of your bubble. I think Tim Minchin is right that its a massive problem with social media culture that the Overton window for each tribe is now tiny and any deviation leads to people being shamed and out-grouped (“I am afraid to write anything that might upset my own tribe”).

As this twitter thread articulates, I’d much rather have a centre-left prime minister doing many cumulative good things that are slightly less rapid or radical, than for all my beliefs to remain represented by an increasingly narrow, segmented and ineffective opposition. An amazing amount can be done within a party and set of policies that have broad appeal. For all his flaws, the centre-left Blair government made a huge amount of impact in numerous areas:

They lifted 600,000 children and 1 million pensioners out of poverty, provided winter fuel payments, free bus travel for over 60s, free TV licenses for over 75s, and improved a million social homes. It doubled school funding for every pupil, added 36,000 extra teachers and 274,000 teaching assistants, transforming education, leading to record literacy and numeracy. They opened 2,200 Sure Start centres and provided free nursery places, giving a better future for millions. They raised child benefit by 26%, introduced child tax credit and 3 million child trust funds. They invested in the NHS, employing 85,000 more nurses, cutting NHS waiting times by 82% and got in-patient waiting lists down half a million. Heart disease deaths fell by 150,000 and cancer deaths by 50,000. They implemented the smoking ban that has contributed to a 30% decline in the number of smokers in the UK, with massive impact on numerous health morbidity statistics. They created NHS Direct. They also improved employment rates and conditions: they introduced minimum wage, created 1.8 million new jobs, cut long term unemployment by 75%, doubled the number of apprenticeships, and introduced right to 24 days holiday and 2 weeks paternity leave. They employed 14,000 extra police, cut crime by 35% and increased criminal justice (court) spending by 21%. They negotiated peace in Northern Ireland, brought in the Human Rights Act, doubled overseas aid, wrote off debts for the poorest nations and created GiftAid. They Scrapped Section 28 and introduced Civil Partnerships. They banned fox hunting, and gave free entry to museums and art galleries. They also managed to couple this with the longest period of low inflation growth since 1960, and created less debt than the governments before or since them, despite bailing out the banks. I’d say that’s pretty remarkable, and something to aim for achieving again.

However, at the last election, perhaps because of Brexit and this ideological purism – we (on the progressive left) didn’t manage to instill hope for positive change in the people of Great Britain, or to challenge the vacuous headline of “get Brexit done”. The election results were depressing but felt somewhat inevitable. As frustrating as it is that we have a government the majority of the population didn’t vote for, giving us a hard brexit that the majority of people don’t want, whilst we watch the world polarise and allow neo-fascist populists to rise, there are some tiny silver linings: The Tories have to work out how to do Brexit and will be responsible for the consequences and, hopefully, the Brexit party are gone.

I think this time around we need to pick someone who stands for all the right values, but has been able to articulate them in a way that has made real traction and can engage a much wider range of people. As much as I’d like that to be a woman, ideally from the north of England, supported by someone with a differing ethnic or cultural background, from the line-up on offer, I think Keir Starmer is the right person for the job. He’s spent his whole career knowing, following and effectively challenging the rules and processes of the legal system for the benefit of ordinary people, including challenging corporations and government policies and holding them to account. And he has done so without seeking personal glory, or making a reputation as a troublemaker. Whilst I really like Jess Phillips, I think she is too marmite to gain mass support and bring the country back together. Emily Thornberry seems nice, but very much a part of the north London bubble, and I don’t think the other candidates have the public profile or despatch box clout of Starmer,and we will at least get Angela Rayner as deputy leader.

Picking yet another white man from London for a political leadership role feels frustrating, as it plays into all the stereotypes of what a leader looks like. But I’m prepared to make compromise to get greater influence for progressive policies that will make the biggest impact on diversity in the long term. Plus we can only choose the most credible candidate standing. And for me that’s Keir Starmer. Hopefully he can bring the party together, tackle the scourge of antisemitism, and speak out in a way that appeals to a much wider demographic and geographic population than his predecessor.

I sincerely believe that if we all work together to encourage compromise and collaboration hopefully a more effective opposition can rise from the ashes that is more willing to be welcoming to a broad range of voters and more able to articulate how the current government continues to benefit the richest few at the cost of the rest of us, and particularly the most vulnerable in society. We need to show that the choices that Johnson and his remarkably homogeneous new pack of white male cronies are making are directly responsible for harming the welfare of large numbers of Brits. Current Conservative MPs being only 24% women and 6% BME is pathetic, and the greater diversity of candidates on the left should bring us a plurality of ideas and allow us to appeal to a wider demographic and opinion range amongst voters, if we get out of the silo mentality.

But more than that, we need to take on the issues. We need to campaign for environmental action nationally and internationally, strengthening of the legal system, an end to racism, xenophobia, antisemitism, islamophobia and discrimination, and the important task of electoral reform, so that we don’t end up with scumbags in power or people who lose elections being given cabinet roles via the House of Lords. And we need to grasp the nettle with proper regulation of social media as a publisher. But they will only take action if enough of us insist on it. As I said earlier, the million dollar question is whether we want things to change enough to take action, and to find common ground. I’ll end with the wise words of Jo Cox, “we are far more united and have far more in common than that which divides us”. So let’s act like it!

16/2/2020: Lisa Nandy just made a really good speech about anti semitism that has really raised my opinion of her, so maybe there is a woman from the north that can do the job after all!

The rise of the bad guy

Trigger warning: first two paragraphs mention paedophiles, middle section is about racism and sexism, later content is political

The first time I met a paedophile I had no idea. He didn’t wear white towelling socks that showed below his slightly-too-short trousers, he didn’t wear a dirty trench coat, and he wasn’t a socially awkward man with greasy hair, unflattering glasses and a slight squint. Quite the contrary. He was a well-groomed, educated, articulate, middle-class man. He attended appointments to express concern about his grandchildren, and appeared supportive to his children in trying to sort out their problems. He was polite to professionals, and always thanked us for our time and expertise. I later found out that he had sexually and physically abused several members of the family. Looking back, our only clue (beyond the fact the children referred to us were evidently troubled and failing to thrive) was that the receptionist in one clinic said that she didn’t like the way he spoke to his wife in the waiting room, saying “I wouldn’t talk to a dog that way”. But we didn’t know how you could appropriately record that in the notes, given only the children were open to the service. So we didn’t record it.

The next time I met a paedophile he didn’t fit my stereotype of a creep or bad guy either. In fact, he tried to be my friend and find areas of common ground. If I hadn’t met him in my professional capacity and known of his conviction in advance, but instead had met him socially under different circumstances, I suspect we would have found some. Perhaps we would have had a pleasant conversation about politics, video games or running internet forums, and I’d have left thinking he seemed like a nice person. He was young, outgoing and wore a colourful T-shirt referencing a slightly crude meme. He was charismatic, informal and irreverent, and he flirted with the admin staff. However, I might have picked up on something when I found out his partner’s IQ was more than 60 points lower than his, that she had a serious trauma history, and they had met on a dating app for single parents where his profile bragged of how much he loved children. But I doubt his attraction to vulnerable single mothers is something apparent to most people that meet him, at least until they know him well.

The opposite face of this coin, where people assume they can judge a person’s character accurately from superficial appearances, almost certainly contributes to a lot of prejudice and discrimination. So many people from specific population groups are assumed to be aggressive, untrustworthy, or unacceptably different because of their culture or religion – but whether people experience these prejudices or not doesn’t reflect their behaviour or beliefs (or even whether they actually belong to the assumed demographic). Think of the prejudice about gypsies and travellers, or Muslims, or young black men, for example. Likewise the stereotypes about gender, or age. As I mentioned in another blog post, women in the public eye get judged for how well they conform to societal expectations of women – to look decorative at all times, to not be perceived as “aggressive” and to look after others. Any emotional expression is seen as a weakness compared to the perceived standard of cold logic that is perceived as more masculine and therefore preferable. There is a whole lexicon of words used to put women down when they step up to the plate.

Again, most of us are blind to our prejudices and we are also blind to our privilege. We assume an equal playing field when we congratulate ourselves for our achievements, and we don’t see the constant attrition that marks facing prejudice that contextualises individual incidents. This forum conversation (from post by mr0860 near the bottom of page 2 onwards), this twitter thread and this twitter thread show exactly what happens when the recipient flags sexism or racism, but those in the audience who have not experienced it do not pick up the same cues. You end up with a split between those who think it is legitimate behaviour/debate and those who are fed up with it (the recipients of the behaviour). The former group are disproportionately white men who have never been on the receiving end of the issue they cast doubt on. In fact they often haven’t even witnessed the issue first hand, giving them the false impression that it is rare, due to the false belief we all hold to some extent that our own experience is universal. The latter group are then branded as over-sensitive snowflakes stifling debate (though ironically it is those bandying those terms about who cry the loudest if they feel they are being criticised or their voice isn’t being given enough credit, see Stephen Yaxley Lennon or Milo Yiannopoulos).

Meghan Markle has been a particular victim of this pattern, as a mixed race woman that has used her platform to speak up for feminism and against racism and inequality, so it is no surprise that the vested interests of the British tabloid press dislike her and want to put her in her place. Yet there are still those who claim it isn’t racism, or that she brought the problems on herself in some way. In this brilliant clip Dr Shola Mos-Shogbamimu calls it out perfectly. The emotional labour of explaining or performing inequality is exhausting, and falls disproportionately on those who are subject to the prejudice in the first place, who already have additional burdens to carry.

My point is that we all make assumptions about other people, and often we aren’t as good as we think we are at picking out people’s true character from their appearance or what we get to see of them before we know them well. In fact sometimes we can know people very well and still miss huge facets of them, as is often evident in the terrible guilt and grief post-mortem when someone dies by suicide. The same thing might also contribute to why people enter relationships with partners who later become abusive toward them. Yet we are often blind to what we don’t know – I had someone on twitter recently claim to be certain that nobody in her extended network of over 100 friends and family members has ever experienced mental health problems. Statistically that’s as probable as a lottery win on a day you get struck by lightning, unless her family deviates very far from the rest of the world population in some way.

That isn’t to say there aren’t horrible people who are outwardly and obviously bad. There are. And I’ve met plenty of them, both personally and professionally. But I don’t think we can always pick them out from a line-up. And even when we can, it doesn’t seem to always hold them back. After all, we’ve had some very popular and powerful men come to light after many years of sexually abusing people on a massive scale (eg Weinstein, Epstein, Savile). There are also more than a few repugnant men in prominent political positions at the moment. Somehow being a division-stoking, lying, philanderer who will take whatever political position is expedient to him or his far-right paymasters, or a hate-mongering, tax-dodging, cheating, sex-pest who has asked foreign powers to interfere in his country’s elections hasn’t blocked two rich, overweight, blond men from some of the most powerful offices of power in the world. Far from it. Instead of their moral character being a barrier to office it is a selling point. Rather than denying or attempting to mask their true nature, they have started to double down in the knowledge that it isn’t reducing their popularity. Perhaps their carefully constructed persona of being harmlessly dim keeps them filed under ‘amusing oaf’ rather than ‘dangerous autocrat’. It is clear that their simplistic slogans have appealed to populations fed up of being ignored or talked down to, and made them seem more down to earth, whilst their decisions (no matter how hypocritical or founded on lies) make them seem like men of action.

I can’t be the only person that finds this incredibly frustrating. Surely we need to value truth and honour and block bad people from power? We need to stop it being amusing or acceptable to lie, express prejudice, exploit others, or to foment hatred of vulnerable people, and that means challenging the way that this is reported. Critical in this is the regulation of social media, and the support of journalism that is ethical and independent, rather than being reliant on social media, misleading narratives from biased sources and badly checked hearsay that spreads more rapidly and widely than the corrections that follow. I’m with Carole Cadwalladr that this is key to helping the public understand the truth about key issues and allowing democracy to function. If everyone who wanted progressive values to stand a chance in the world boycotted Facebook and lobbied for better regulation, their advertising revenue would fall and their business model would have to change. The million dollar question is whether we want things to change enough to take action, even if this means we have to find alternate ways to journal and share our lives with our networks*. Otherwise the bad people might tighten their hold on power and lead us in increasingly worrying directions.

 

*If that feels too much of a step, then I’d recommend you take three simple areas:
  1. Increase your privacy. On Facebook change your name and set your privacy settings higher so little or no information is public. Be wary of services with poor privacy and data protection.
  2. Be more data savvy. Watch The Big Hack. Be aware of what data you are giving way. Be mindful of what data your mobile phone and/or internet browser is collecting and what “personalisation” of advertising you are allowing, read what you are consenting to in the user agreement for apps and software
  3. Install apps that block advertising and show who is funding the adverts you do see. I use FB Purity and Who Targets Me?

The misrepresentation of evidence

About a week ago I was involved in a heated twitter debate about this blog post. I felt, as I said on twitter and in my extensive comments about the blog, that it entirely misrepresented the evidence about Adverse Childhood Experiences by implying that because of risk multipliers within particular population groups, certain negative outcomes were almost inevitable for people with multiple ACEs. The author repeatedly asks rhetorical questions like “If 1 in 5 British adults said they were abused in childhood in the last CSEW (2017), why hasn’t our population literally collapsed under the weight of suicides, chronic illness, criminality and serious mental health issues?” Likewise, she asks how anyone can be successful after childhood abuse if the ACEs research is correct. I replied to explain that this simply isn’t what the data tells us or what risk multipliers mean, so the exceptions are expected rather than proof the finding is incorrect. For example the claim that a 1222% increase in the risk of suicide amongst people with 4 or more ACEs meant these people were doomed, in reality means that the odds increase from 1 in 10,000 to 1 in 92, meaning that 91 of every 92 people with 4+ ACEs do not die by suicide.

ACEs are a very useful population screening tool, and have provided incontrovertible evidence of the links between traumatic experiences in childhood and numerous social, psychological and medical outcomes that has been highly informative for those of us designing and delivering services. To me it seems like an example of how a simple piece of research can have a massive impact in the world that benefits hundreds of thousands of people. Yet that blog repeatedly implies ACEs are a harmful methodology that “targets” individuals and to is used to “pathologise and label children, arguing that those kids with the high ACE scores are destined for doom, drugs, prison, illness and early death”. It has been my experience that ACEs are used not to pathologise individuals, but to to highlight increased vulnerability, and to identify where there might be additional need for support. For example, I have used this data to argue for better mental health services for Looked After Children.

I felt that the repeated misrepresentation of the maths involved in interpreting risk multipliers undermined the entire message of the blog, to which I was otherwise sympathetic. (For the record, it is entirely appropriate to highlight bad practice in which it seems certain professionals are applying ACE scores to individuals inappropriately, and making people feel that their life chances are restricted or their parenting under scrutiny purely because of their childhood experiences of trauma). But unfortunately the author took my polite, professional rebuttal of elements of her blog as a personal attack on her – to the extent that she misgendered and blocked me on twitter, and refused to publish my response to her comments about my reply to her on the blog. That’s a shame, as the whole scientific method rests on us publishing our findings and observations, and then learning from the respectful challenge of our ideas by others with knowledge of the topic. But I guess we are all prone to defending opinions that fit with our personal experience, even if they don’t fit with the evidence.

Thinking about how uncomfortable it felt to see someone I considered to be a peer whose expertise I respected misrepresenting the evidence and being unwilling to correct their misconceptions when challenged, but instead trying to discredit or silence those making the challenge, it struck me that this was an example that highlighted a wider issue in the state of the world at the moment. Evidence is being constantly misrepresented all around us. Whether it is the President of the USA saying there is a migrant crisis to justify a wall (or any of the 7644 other false or misleading statements he has made in office) or the claims on the infamous big red bus that Brexit would give the NHS £350 million per week, or Yakult telling us their yoghurt drink is full of “science (not magic)” now that they can’t pretend live cultures are good for digestive health. There are false claims everywhere.

I stumbled into another example just before I started writing this blog, as I (foolishly) booked accommodation again through booking.com, despite the horrible experience I had last time I tried to use them (which remains unresolved despite the assurances from senior managers that they would reimburse all of my costs). The room was terrible*.

So I felt like I should be able to reflect my negative experience in my review. But oh no, Booking.com don’t let you do that. You see, despite seeing that properties appear to have scores out of ten on every page when booking, you can’t score the property out of ten. What you can do is to determine whether you give a smiley that ranges from unhappy to happy for each of their five ratings (which don’t, of course, include quality of sleep or feeling safe). So if you think the location was convenient, the property gets a score above five out of ten, no matter what other qualities mean you would never wish to sleep there again. But worse than that, the Booking.com website forces reviewers to give a minimum length of both positive and negative comments, but only displays the positive comments to potential bookers. So my “It was in a quiet, convenient location” gets shown to clients, but you have to work out how to hover in the section that brings up the review score, then click the score to bring up the averages, then click again to access the full reviews, and then shift them from being ranked by “recommended” to showing them in date order to actually get an objective picture. Then you suddenly see that at least half the guests had terrible experiences there. However, there is no regulator to cover brokers, and fire regulations and legal protections haven’t caught up with private residences being divided up and let out as pseudo-hotel rooms.

But just as Boris has faced no consequences for his bus claims (even though he stretched them further still after the ONS said he had misrepresented the truth), and Trump no consequences for his lies, and the consultants selling contracts worth hundreds of thousands of pounds of public funds to children’s social care departments proudly told me they didn’t care about evidencing their claims, so the world carries on with little more than a tut of disapproval towards people and businesses who intentionally mislead others. Maybe I’m in the minority to even care. But I do care. I feel like it is the responsibility of intelligent people and critical thinkers, people in positions of power, in the professions and particularly in the sciences, to ensure that we are genuinely led by the evidence, even if that makes the picture more complicated, or doesn’t confirm our pre-existing beliefs. To counteract this age of misinformation, we all need to be willing to play our part. That is why I have always placed such a focus on evaluations and research, and have developed my screening tools so slowly and thoroughly, despite the fact that potential customers probably don’t see this as necessary. I believe that as much as possible, we should be promoting the value of evidence, educating the public (including children) to be able to think critically and evaluate the evidence for claims, and stepping up to challenge misleading claims when we see them.

*I booked a room in a property in London which they have euphemistically called “Chancery Hub Rooms” to stay over whilst I delivered some training in Holburn. It wasn’t a hostel or a hotel, but just a small terraced house. This time it had keypad entry to the property and to the individual room, which is a system that I have used successfully several times in Cambridge. Unfortunately it didn’t work so well in London, as they changed the codes twice without informing me. Once this resulted in locking me out of the room on the night of my arrival (and meaning that the beeping on the door as I tried the various codes they sent me woke the lady in the neighbouring room, due to the total lack of sound insulation in the property) and then by locking me out of the property the following evening, when all my stuff was locked inside. It also had glass inserts above the room doors that meant your room lit up like Times Square when anyone turned the landing light on. I then discovered that the building (which I already recognised to be small, overcrowded and not complying with fire regulations) had walls like cardboard, when the couple in the next room had noisy sex, followed by noisy conversation and then a full blown argument that lasted from 3am to 4am – despite me eventually in desperation asking them quite loudly whether they could possibly save it for a time that wasn’t keeping everyone else in the building awake. Of course Booking.com didn’t see it as their problem, and the property management company just blamed the other guests for being inconsiderate.

The attraction of small rewards

I went to the Y Not Festival last month. It was a bit of a mixed bag because of the weather, and the terrible app that was supposed to function as a map and timetable was a daft idea on a site with limited mobile in the first place and totally useless in practice as it wasn’t updated when things changed. But we saw some good bands, and ate some good food, and it was only half an hour from home so we also slept in our own beds! But the reason I mention it was because of a trivial but unexpected thing: They had an incentive to recycle the plastic pint glasses that were being used and dropped on the floor. They offered 10p per glass to take them to a recycling point in sets of five. For the most part that wasn’t enough for people drinking to bother keeping and pooling their glasses to cash in. But a small economy developed amongst people who found it worthwhile to go around collecting the dropped cups. There were some sets of kids excitedly supplementing their pocket money by collecting piles of cups during the day, and also a few adults who increased in numbers in the evenings.

At £5 per pint the beer was not cheap, and I joked with my husband that I’d see if I could collect 10 cups to offset the cost each time he drank one. But as soon as we started collecting cups, we realised that there were loads of them, and it was easy to make quite good money from them. In three hour-long collecting binges, and whilst listening to bands I enjoyed, I stacked and recycled well over 500 cups. That was enough to pay for all our food over the weekend, and the couple of drinks my husband had. Of course my legs ached like crazy the next day, after all that walking around punctuated by 500 bodyweight squats. But I felt good about being part of the efforts to clear up the site and recycle the cups.

Of course I’d much rather they used reusable cups as they did at Timber festival, or ones that are biodegradable as they did at Woodside. And it doesn’t really make much sense to pay random people more per hour than they pay their bar staff or rubbish pickers, let alone to pay the people who were simply emptying out the plastic recycling bins, stacking up the plastic cups and taking them to the recycling point like their own little black market scheme. And I wasn’t persuaded that they were actually going to recycle the cups at the end of the weekend. But I was interested in the fact that I somehow found it fun to do a dirty, smelly, physically demanding job earning way less than I can earn from work. Apart from the novelty and fact it filled in the gaps between artists, the reason was as obvious as those demonstrated in Pavlov and Skinner’s seminal experiments: The small but proximal rewards were enough to reinforce the behaviour, and make me want to repeat it over and over again. In fact it became quite addictive. The small payments made it feel like a game in which I was succeeding and earning five to ten pounds per trip to the recycling point made it really tangible that I was being rewarded. I could have spent the entire weekend picking up those crushed and broken plastic cups and straightening them out into stacks to cash in, and my kids were jealous that they’d missed out on the opportunity to earn cash because they had chosen to go to their grandparents rather than the festival.

In another example, I’ve been playing a really rubbish game on my iPad called Hidden City. It is a hidden object game, where you have to find items within a picture of a scene before the time limit runs out. For example, there might be a picture of a greenhouse full of caged birds and exotic plants, and you will then be asked to find a pair of binoculars, a fan, an oil lamp, a walking cane, a string of rosary beads, a bunch of chilli peppers, a pair of shoes, a turtle, and various other objects to click on and collect. Each will be visible within the scene, some in plain sight and others tucked away or masked by being in front of similarly coloured items. In certain quests there are also keys to find in the scene that are smaller and better hidden. Whilst this has some inherent mental challenge and novelty, it really is a very simple premise for a game, and quickly becomes repetitive, so you’d think the game would be very boring – in fact it seems boring to have explained it in writing, so I hope I haven’t sent you off to sleep! You would therefore assume that people would drop out of the game very quickly, but that doesn’t appear to be the case. In fact, the makers are so confident that players won’t be bored enough to drop out that they make you search each scene for objects selected from the same list and placed in the same range of places in the scene many times. In fact, to complete some quests you search the same scene over a hundred times. The task becomes more difficult because you are expected to find more objects in a shorter time interval, and the scene becomes more cluttered so it is harder to pick out the specified items, and you have to alternative with searching other scenes to get the tokens required to go back to the main scene. To compound that, there are multiple locations in the game, and each needs to be searched a large number of times, so to complete the whole game you probably have to complete about ten thousand search quests.

It sounds like an enormous and monotonous task, and the game itself is full of bugs, glitches and poor translations, yet it is the most popular hidden object game in the world. More than half a million people have played it, and there are tens or maybe hundreds of thousands of players active at any one time. They are not only signing up to play in huge numbers, they are choosing to pay for the optional purchases to assist their searching, making this game and the multiple other games by the same company, and the multitude of similar games available, highly profitable.  Estimates suggest that over £3 million of in game payments have been made since the game launched four years ago, and tens of millions of pounds are being spent in in-game micro-payments across all the games by this maker each year. It seems illogical, but many players spend way more than they’d need to pay to purchase a really good game to play this glitchy game that is constantly interrupted by advertising for in-game purchases and other games by the same company.

So why do people keep playing, and why do some of them keep paying? I think it is the same idea of reinforcement through small rewards. As a player you experience a lot of small successes. They make the first few searches really easy. Then each time you search and don’t find all the items you are told to try again. If you find them all you are rewarded by a random selection of small icons, and you can collect these items in sets. Completing the set gets you a rarer icon, with some bonus points or magical powers to boost your energy or increase your ability to find other bonus items. In the bigger quests you might also get tokens to unwrap gift boxes containing more icons. You also get overnight bonuses, daily bonuses and components of a magical piece of jewellery each time you play again after more than 8 hours but less than 24 hours. They compound so an unbroken chain of about a month gets you the finished item, and 12% more items to find for a 10 day period. If you break the chain you either have to use or buy in game currency to restore it, or you lose the components you gained. Something about our psyche likes gaining these pseudo possessions and dislikes missing out or losing them, enough that these games are quite addictive. But they are all just small pictures of random things. Why should I care if I have a magical tuning fork in my collection, or whether I get the apple strudel icon that completes the huntsman set that gives me the Austrian clock? There is no intrinsic value in the drawing of the clock, or the strudel or the tuning fork. They bear little relation to the scenes I search, or to the token plot about the magical city trapping people, or the candy-crush style mini-games. My life is not better in any tangible way if I collect 75 keys and open the golden chest to receive 6 bonus items, or if I play the scene 100 times and get a new avatar of the lady of the manor, or the Samuri, or the gardener. Being at a higher level on the game doesn’t convey any greater skill that would garner respect from other players, let alone in the real world, nor does it teach me anything I can generalise outside the game.

So why is a badly made game with such a simple and repetitive premise so popular? I’d suggest that is intentionally designed to be rewarding to play, and to tap into what we know about reinforcement with the number of small rewards it offers. Our brains are set up to love rewards, no matter how meaningless they are, or what the longer-term cost is. Like scratching an itch, or eating something tasty but unhealthy, using drugs or smoking cigarettes, the immediate rewards are often much more effective as an incentive than the longer-term consequences are as a deterrent. The logical decisions we make about changing our behaviour struggle against these proximal sources of gratification. It doesn’t feel like a big effort or commitment, because we are only playing a three-minute mini-game. We are tempted to take the small action to sample the reward, but this then lures us in to take the next step with another small effort, and the result is that we repeat that for far longer than we planned. Even if this means losing out on sleep, or getting things we objectively rate as more beneficial or necessary done.

The same is true of our online behaviour. We chain from one news article to another, or one social media post to another, or one youtube video to another until whole evenings disappear into a black hole. Even when we are going about our daily lives, we constantly check for the small rewards of messages, likes or responses on social media. For many people this becomes something done obsessively, to the detriment of other activities in our lives. As well as hitting our reinforcement pathways, these small social connections also fire up our desire to feel belonging and acceptance in a group, and to gain the approval and/or attention of others. I’ve blogged before about the toxic aspects of social media. Studies have shown that stopping using social media, whether for a couple of hours per day, a day per week, a longer block of time, or permanently, makes people happier (journal articleanecdotes, article citing studies, more anecdotes, even more). Yet for most of us, we are enticed by the sense of connection (albeit often a much more distant and less authentic connection than we make in real life) and the promise of these small rewards.

It makes me think how despite all the progress of technology, we really are quite primitive creatures in some ways, tied to the way our biology has evolved to reward behaviours that had some adaptive function that had evolutionary benefits. So can we make a conscious choice to use these inherent reward systems for more positive purpose? Possibly. For example, we can benefit by building chains of positive behaviours that we don’t want to break – like a colleague who told me he hasn’t drunk alcohol for 92 days after realising he was drinking almost every night. That challenge of having a dry month, or to do without meat, or caffeine, or cigarettes for a set time period seems an effective way to change behavioural habits. It is less final and impossible sounding to have a break from something than to give it up permanently, but it can give you a chance to see what life is like without it, find alternatives that fill that gap and build up some of these rewards for going without. It then becomes easier to continue that pattern, and there can be a reluctance to break the chain, particularly if there have been social or financial or health rewards for the change.

Likewise we can gamify exercise. When I used to weight lift I would share my achievements with a group of other weightlifters online. This gives a sense of a peer group who can reinforce your behaviour and some social pressure to sustain the pattern (though I was never one to post every gym visit on facebook the way that many runners/cyclists use their apps to, or to post lots of philosophy and photos the way that yoga fans seem to – I just posted to a weightlifters group when I made gains, and could compare my progress to others in the group). But even without this online support I had a sense of achievement each time I went to the gym, or completed my routine, or increased the weight I could lift in a specific exercise. I liked to record my weights in a journal and to feel that I was making measurable small gains. I also liked confounding expectations by being an overweight middle-aged woman who had hidden physical strength. I’ve mentioned my joy in having “ninja muscles” before. I’d like to get back to it, and I’m sure my core strength would return. I’ve still got surprisingly muscular legs, though I wouldn’t risk picking up an 18 stone barbell these days!

So I guess the knack is working out how to make our innate reward systems work for us in a modern world. I’m certainly far from achieving that. Change is hard. But maybe I can at least recognise the patterns better now I’ve thought about it more. Maybe I’ll come back to that theme in a future blog.

 

 

Drama vultures: Some comments on social media

For young people, social media can be a very significant part of their social life. As Mark Brown put it, “Social media went big at the same point that austerity did. We lost our libraries, youth clubs and schools funding but we got smartphones and snapchat instead.” It has also been a means of connection for people who were technologically savvy but socially isolated. This is a surprisingly broad group, including both “geeks” (with subgroups of angry young men who have been radicalised by anti-feminism and the alt-right), those with social communication deficits (who like entirely written communication, as it means that they no longer feel excluded by the pace and non-verbal elements of real life social interactions) and people who are socially isolated because of their geography, disabilities, sexuality, gender identity, culture or more introverted personality, as well as an increasingly broad demographic who have simply discovered the convenience of social media as a means to connect with likeminded others. It can be enticing as a way to gain some social validation, either through “likes” of your content or photographs, or through a sense of belonging to a community of people with shared values or interests. And with so many different platforms, there can be many different qualities to this interaction, and functions that social media serves in people’s lives.

With niche communities, pockets of self-referencing and self-reinforcing cultural norms appear. Whether it is the sensitive niche sexualities of tumblr, or the offensive-as-possible culture on 4chan, the visual memes of imgur, the glamorous selfies of instagram, the endless stream of headlines from twitter, the business focus of linkedin, the many facets of reddit, videos on youtube, livestreaming on twitch or periscope, various blog platforms, an almost endless variety of podcasts, massive web forums on every topic imaginable, or even the comments sections of various publications, each has a different personality and norms. Some are ephemeral, with content disappearing after a certain time. Others stand as searchable archive with a long-term record of past content. Some allow people to broadcast outwards and collect followers, whilst others are focused on more reciprocal relationships. Some allow privacy restrictions that mean you can limit access to friends and family. But most have some means for others to indicate their approval or disapproval. And that means that there can be a sense of being judged or rewarded according to what you post. Sometimes this is based on the quality of the content, but it can also be based on political/group affiliation or appearance – with attractive young women who post photographs or video in particular getting a lot of attention. Some sites allow interesting or amusing content to float to the top where more people will see it, allowing particular posts to be read by remarkably large numbers of people. These can include inspiring content like non-zero days or unintentionally hilarious content like the penis dunking thread on mumsnet (mildly NSFW) that had me failing to contain my laughter during a BPS committee meeting. Some people seek out notoriety by writing controversial or entertaining content. Others who feel they don’t get enough positive attention seek out more negative peer groups, or seek attention in less functional ways. There are also less healthy pockets of social interaction on the internet. There are pro-anorexia communities, and sites that discuss and even encourage self-harm and suicide. There are bullies and trolls, and even people who fake being bullied in order to seek sympathy or justify introspective disclosures*.

One of the great advantages, and problems, with social media is the potential to be anonymous. This is a great leveller because it makes other users blind to your gender, age, race, appearance, physical ability/disability, sexuality, wealth, social class or other sources of prejudice – although many people choose to display these characteristics anyway and seek out similar people for a sense of belonging within specific online communities. However, the very anonymity and ability to create a character for yourself online can be problematic, as anybody can pretend to be anything. As well as the proverbial middle-aged lorry driver pretending to be a teenage girl, there are people pretending to be of different social demographics to infiltrate or undermine these communities. For example, many alt-right trolls attempting to fuel the gamergate conflict signed up “sock puppet” accounts as women and people of colour to pretend that their movement was more diverse or to defend them from criticism for sexism and racism. More obviously there are trolls, who use the anonymity to bully, harass and try to get a rise out of others, safe in the knowledge that social media is functionally a lawless zone, where only the very most serious of attackers, who challenge national security or make repeated overt threats towards targets in the public eye ever see any attempt at identification or prosecution.

By contrast, if you slip up on social media and say something stupid or embarrassing it can be shared with hundreds of thousands of people, your identity can be outed, and the impact can spill out into your real life in unpredictable ways leading to a roulette of inequality in which an ill-judged racist or sexist joke having more consequences than a year-long campaign of rape and death threats.  Or, you can become a target whose personal details are released on the internet (known as doxxing) by someone who dislikes your opinion or feels slighted by you, or subject to “revenge porn” where intimate photographs are published by an ex-partner without the consent of the subject. In America you can even become the target of hoax calls intending to send in an armed response team (known as swatting). And (as in many things) it is women and people of colour who always end up being disproportionately punished.

Having been on the internet since the 1990s, I’ve had an interesting personal history on social media. I was part of the eBay forums around the launch of eBay.co.uk for several years. As well as giving advice about scams and using eBay to buy and sell, there were lively off-topic discussion, running jokes and fundraising activities. But even within a seemingly diverse and healthy community of strangers there were many interesting signs of dysfunction. There were cliques and factions with marked animosity between them. There were people who claimed to be things they were not, including a “detective” and a “vet” (who was so desperate to uphold the facade she tried to get the Royal College of Veterinary Surgeons to amend a register entry for a genuine vet to match her name). There was a lady who faked her own death and posted as her (supposedly bereaved) husband, but was rumbled by an astute poster spotting contradictions in her story. When I foolishly mentioned being a psychologist in a conversation that only contained four other active users, that information spread much more widely than I had expected. I started to receive disclosures and allegations, messages about distressing feelings and even what appeared to be a suicide note (with the help of moderators I alerted authorities, and the suicide was not completed) so I soon learnt to be much more private and anonymous.

On clinpsy we have also had our fair share of tea-cup sized dramas, despite having very little need to intervene as moderators compared to the large volume of members and posts. I blogged about some examples two years ago, and I can only think of two people we have banned since then (although I did block someone from registering after they were very antagonistic and inappropriate on facebook after we failed to activate their registration between 10pm one night and 4am the following morning). I did recently have the interesting experience of having someone apply to work for me who had been banned from the forum. They didn’t seem to think I’d know about that, despite the fact that they used the same email address in their application as they had when they had been banned. They withdrew their application when I said that I knew and we’d need to have a conversation about it if they wished to progress their application.

It is an interesting thing that social media crosses the boundaries of communication that we are familiar with. The written form seems somehow impersonal and emotionless compared to forms of communication that contain the non-verbals, and yet somehow emotions are conveyed and evoked. The nature of speaking to strangers who may or may not be conveying the truth, and where we know little about them except for what is posted, involves a lot of extrapolation and ambiguity. It is hard to judge the response of the audience or how far information will spread, and deceptive safe feeling that we are posting in our own homes and usually under pseudonyms, yet it can suddenly become very personal and intrusive. On the clinpsy forum we monitor usage quite closely, and have zero tolerance of personal abuse or inappropriate content. In order to avoid knee-jerk responses or being hooked into unhelpful patterns, and to help us keep on top of maintenance and development tasks on the clinpsy forum, we work as a team. We keep a log of moderator discussions, user reports of concerns and reasons for banning users in a hidden moderators area on the forum. We tend to have quite a rapid response time for removing content for moderator consideration, and quite consistent views about where to draw the line, which has made clinpsy relatively drama free.

That isn’t the case on other forums, where much more banter and jokes are let fly, and these can be quite offensive, particularly if the dominant demographic is young white men. Racism, sexism and misogyny are quite prevalent in some online communities. Many women hide their gender to avoid quips about getting back in the kitchen, or banter about rape (which can be a term used in video gaming communities to refer to trouncing another player). But in some places it can even go a step further than that. 4chan, for example, used to ask for topless photos if anyone mentioned being female with the delightful phrasing “tits or GTFO”, and provoked many young women (at least one of whom appeared to be below the age of consent) to share sexually explicit images of themselves. 4chan also had links to child pornography (although I believe that this was eventually prohibited and split off onto another forum). Reddit has subreddits for misogynist men’s rights activists, pick-up artists, and incels (men who consider themselves to be involuntarily celibate – that is, they are too unpleasant to attract consenting female partners but do not recognise this, and turn the blame onto the women instead, with extreme examples like Elliot Rogers and the man behind the recent Toronto van attack), although again some attempts at prohibition and moderation are creeping in after bad publicity following the recent school shooting.

As a female poster in some male-dominated communities it was initially quite a culture-shock, but it is good to socialise outside the same narrow bubble, and there are also very positive aspects of being part of an online community. There is a hive mind of information on every topic that means you can gain immediate and often highly skilled advice on everything from how to rewire a light fitting, or how to distinguish a wasp from a mortar bee, to which model of television has the best features within a certain price bracket, or how to complain if a parcel doesn’t arrive. The community might be a rapid source of news, or entertaining new memes. There can be reviews of films, music, events or games that lead you to try new things, and erudite discussion about politics, current affairs, history, different cultures, religion, sports, science, religion, mental health, relationships and any topic that takes your interest. There can also be mutual concern and support when things are not going well, and shared delight when people experience unexpected success. So there are definite positives. The problem is that they can come at a price, and some people are more likely to pay the price than others.

Anyone who has been part of an online community knows about how they seem to inevitably create remarkable interpersonal dramas. These are like road traffic accidents – as a neutral spectator they both repulse you and make compulsive viewing, but as a participant they have the ability to cause genuine harm. When a person starts posting erratically or there is public conflict, or even when a person or group is bullying a vulnerable member if they do so in a way that is seem as amusing, it is viewed as entertainment or public spectacle. And, like a fight in a school playground, they inevitably attract a circle of spectators who both encourage and influence the unfolding drama, both joining in to sub-conflicts in the audience, and throwing in more fuel if it seems to be petering out. I’ve been in that circle a few times for different reasons, and it isn’t a fun experience. And as it starts feeling more personal and more antagonistic emotions start showing in how you post, and that seems to fuel the aggressor to go in for the kill, and other posters to join in. Our ability to reason and to predict the way that others will interpret and react to our posts reduces, and the stakes start to feel higher, and yet it somehow becomes harder to leave the conversation whilst feeling threatened or misunderstood. So you get drawn in to the battle, trying to clarify your intended meaning, defend yourself from perceived attack, or persuade others to see your point of view. Perhaps you criticise the other person, who then becomes more antagonistic or defensive. By the time you are in the thick of things there isn’t an obvious exit without either victory or shame.

Walking away from an online community because you don’t like how you are treated feels a lot like social exclusion and can have a significant impact on your sense of self, but to stay once you have attracted negative attention can mean the slow attrition of insults and snide digs that someone once described as “death by a thousand paper cuts” (a less severe/more protracted version of the Chinese torture method death by a thousand cuts, in which it is hard to criticise any individual action as being unduly aggressive or breaking any rules). Frustratingly these can often be the kind of microaggressions that align with real life experiences reflecting the casual degradation of disempowered/minority groups. And, as ever, women and minority groups seem to be disproportionately the target for them. Even a phrase like “calm down love” is loaded with patronising layers of meaning about women being ruled by their emotions and lacking the calm logical analysis of men. It implies that caring about anything enough to show some emotion about it is already losing the battle.

There is little time for compassion or reflection online, and it is hard for an onlooker to intervene in a way that is helpful to diffuse conflict. Thus vulnerable people may end up re-victimised, and people with dysfunctional ways of relating often play these out over and over online. I can particularly recall one poster who had a distinct cycle of debate, feeling criticised, rage and then burning out to a final phase of being shamed and apologetic, trying to make amends to avoid rejection – and the community becoming increasingly intolerant of these emotional extremes. At times it felt like observing a digital version of a disorganised attachment relationship, with the forum community functioning as the inconsistent/abusive parent. It came as no surprise to read disclosures about an abusive childhood, use of crisis mental health services and a personality disorder diagnosis. But s/he was far from alone in having dysfunctional ways of relating to others online. In fact it seems that many people with such difficulties are strongly attracted to the accessibility and 24 hour nature of online communication, and can find significant support from strangers there. But it often comes at a high cost, or with significant risk, because of the prevalence of trolls and the way dramas are amplified by having an audience, and the way social media can serve as a written record of whatever unfolds that is hard to erase. There might be the right to be forgotten under GDPR, but how does this actually work in practise when comments are quoted and replied to, or captured in screenshots and posted elsewhere?

There are plenty of examples of how vulnerable people are enticed by the sense of belonging in a group, or the superficial success of social media influencers, but harmed by the messages they are given. This can range from unhealthy roles models such as the one I blogged about previously to being encouraged to harm others or given advice on how to harm themselves or commit suicide (the Daily Mail recently ran a scare piece on a “Blue Whale” game that culminates in telling children to commit suicide, though snopes felt there was little evidence to substantiate this). It would seem to me that the bigger concern is the indoctrination of larger numbers of young, socially isolated people in toxic beliefs such as alt-right ideologies, through writing that blames others for their ills. Whether it is “psychologist” Jordan B Peterson whose 12 rules for life serve as an introduction to his regressive beliefs including “enforced monogamy” in which he appears to advocate that to prevent male violence women should be allocated to partners and forced to remain monogamous to them (which is rightly being called out as sexist/stupid/victim blaming). It might have sold 1.1 million copies, and he might make £80k/month in patronage, but this isn’t a new enlightenment. Enticing simplistic sexist answers are not the cure for angry young men who feel left behind by progress, I would argue they are the very fuel that will convert them into the school shooters, rapists and perpetrators of future violence and harassment. But it is hard to offer up an alternative perspective or contradictory evidence when an angry mob descends on any divergent opinion, claiming that they are the true victims and that the sexist/racist drivel they promote is being censored by sensitive snowflakes (the new version of “its political correctness gone mad”). Ironically, these repugnant views that are allegedly suppressed/unspeakable are getting lots of airtime, whilst stifling free expression of opposing/alternative views** as progressive voices fear becoming a target of the mob.

In short, its a messy and unregulated space, and there are both interpersonal conflicts and large scale culture wars playing out in it. How to protect people in a digital age needs a lot more thought, both at the level of educating children about critical thinking and empathy, and in terms of regulation of social media, and enforcement of crimes committed via digital media. But with middle aged and older politicians doing the legislating it is hard to see how that is going to happen.

*if you find this surprising, consider the bug chasing community, who are people actively seeking HIV infection in order to gain care, sympathy and a sense of belonging
**including me, as I avoid using certain terms on social media or in the tags and category labels for this blog, as I dislike the surge of abusive/antifeminist responses they trigger

Spectator sports

We are in the age of the internet. Adele’s Hello has been viewed 1.8 billion times, yet there are five other music videos on YouTube with more hits, culminating in Gangnam Style’s 2.7 billion view parody of the western status symbols rich south Koreans aspire to. Viral memes emerge and hit millions of page views in a day or two. Websites full of recycled content and filler with clickbait titles make up news stories to profit from the advertising revenue. False news engineered for the most gullible audiences makes tens of thousands of dollars a month. False news created by vested interests including foreign governments sways election results. Trivial stories that involve popular vloggers make headline news. Swedish video game blogger Pewdiepie reached 50 million followers last week and reportedly earns $12 million per year. His empty threats to delete his channel made headlines around the world. The top ten YouTube channels each make in excess of $5 million per year in revenue. Yet many people above the age of 40 have never heard of any of them. Part of what they have in common is what image-hosting site Imgur calls step 1: “Be good looking” although, as has always been the case even prior to the internet, that rules doesn’t seem to apply if the content is funny.

This new class of creators and media is packaged into bite-size content that doesn’t require any critical thinking, often with a catchy title and thumbnail that oversell the contents. Clicking from item to item across quick videos, memes, images and articles seems to make a time-sink trap that captures internet surfers in their millions. Amongst the new population of content creators are people with various different personalities, histories and views about the world, ranging from the ordinary to the extreme. And just as in the responses to any feminist video online, there are then vloggers whose content is made up of critiques of more famous vloggers and their content.

As Katie Hopkins has worked out, being sufficiently unpleasant and controversial generates clicks. It then creates responses that drives more traffic to the original content, and perpetuates discussion. There is then meta-debate about the creator themselves, attempts to shame them, and debate about what to do about them. Even publicising her embarrassing apology and substantial payment of damages for making false racist allegations of terrorist links against a muslim family gives her more notoriety and more clicks.

So it has been with the media rubbernecking the car crash of Eugenia Cooney’s weightloss, from a slim but attractive young woman into an emaciated role model of anorexia (weighing an estimated 4-5 stone) whilst denying she has a problem. A petition to ask YouTube to block her videos until she has sought help reached 18,000 signatures before being removed as inappropriate, and this has created a media circus with numerous vlogs and articles about her weight and whether this represents anorexia or not. Some have commented on the obesity of her mother and brother, and her childlike demeanour and role.

Because she has chosen to put herself in the public eye, and to make money from her audience, she is considered fair game for discussion. Yet if she does indeed have anorexia (and from the little I know of the case that does not seem an unreasonable assumption) she is very vulnerable and likely to have very distorted thinking. In the UK, there might well be a case to section her under the mental health act for treatment if there was not an alternative explanation for her weight loss, because of the lack of insight and high morbidity characteristic of this condition. So there appears to be a dangerous incentive of clicks (and the cash from advertising that follows) for being controversial, and in this case, seemingly putting her own life at risk.

Let us not underestimate the seriousness of eating disorders. One in five people with an eating disorder will die prematurely as a consequence of the condition, making it the mental health condition with the highest level of mortality. There is an increased risk of suicide, and an average duration of eight years for anorexia or five for bulimia, with less than half of all of those diagnosed making a complete recovery to the point they no longer meet the diagnostic criteria for an eating disorder. This is significantly more dangerous for your health than all but the most severe levels of obesity, and yet being too thin is often viewed as a positive characteristic and aspirational. The internet term “thinspiration” has nearly 4 million hits, with the top sites being pro-anorexia websites, with young women sharing tips and setting dangerously unhealthy weight loss goals.

Teenage online model Essana O’Neill bravely exposed the truth behind her instagram profile, which had half a million followers, before quitting social media to focus on real life. She later posted about her insecurity, depression and body dysmorphia. But she was far from alone. Photoshopping of images in magazines has become ubiquitous. Various surveys have shown that half to two thirds of selfies shared by adults or young people on social media have now been edited.

The fact that there are now dangerously thin vloggers denying that they have a problem and giving fashion and lifestyle tips to their followers must be considered concerning. It gives a new set of easily accessible role models that parents and clinicians may be unaware of, with very large audiences of young girls. Eugenia Cooney for example has 900,000 subscribers, who are predominantly teenage girls. There are several anecdotal examples of how this has been a trigger for eating disorders in girls trying to emulate them, and given 6.4% of the population has traits of an eating disorder, with most starting in this age range, that is highly concerning.

On the positive side, there have been growing moves to prevent overly thin models being used in catwalk shows and magazines and to indicate when images used in magazines have been photoshopped (something I would strongly support), so some progress appeared to have been made to present healthier role models to young women. There are many positive messages about health and fitness out there too (personally, I particularly like the goal of being stronger rather than thinner). However, there is a huge challenge when it comes to legislation on the internet, because of the many countries that the vlogger, hosting company and viewer can be situated in. Whilst these logistical pitfalls fail to prevent propagation of eating disordered messages (or other forms of toxic content) on the internet, there is little that we can do to prevent more and more young people normalising or idealising unhealthy role models.

Exploiting the ignorant: From quack cures to the rise of Trump

I was reading today about a man called Braco (pronounced Bratzoh) who is the centre of a personality cult that believes his “gaze” (looking out into a crowd and not speaking for 5-7 minutes) can heal health problems and have a positive impact on people’s lives and the lives of their loved ones. He does free online gaze sessions, and cheap or free local events all around the world in order to market books, DVDs and items of jewellery containing his golden “sun symbol” (many for $500+ each). I see nothing more than a man who learnt how profitable it was to be a fake healer from a mentor in a similar line of work, and took on his audience and methodologies (but without the stress of having to give any advice, or the risks of making any claims about himself that could be proven false).

Yet, nonetheless he has a plentiful audience of believers. People claim remarkably diverse experiences and attribute all kinds of random positive events in their lives to his gaze. One contributor believes that Braco cured the hearing loss of a newborn whose parent and grandparents went and gazed (and bought the $500+ trinket). Unknown to them, 13% of children identified with newborn hearing loss spontaneously recover, without any superstitious interventions. It reminds me of Tim Minchin’s fantastic song Thank You God [link contains swearing] that describes alternative explanations for a “miracle” in which a lady’s cataracts are “cured by prayer”. These include spontaneous remission, misdiagnosis, a record-keeping glitch, a lie or misunderstanding. He mentions the power of confirmation bias, groupthink, and simplistic ideas of causality based on temporal correlation (as was the case with autism and MMR). On the internet there is also the significant possibility that the review is fabricated.

The same story repeats all over the world. People are paying something for nothing more than woo in numerous seances, palm readings, psychics, mediums, crystal therapies, quack nutritionists, chiropractors, reiki, all energy therapies, coffee enemas, homeopathy, reflexology, magical weight loss products, Bach flower remedies, most vitamin supplements, magnetic items making health claims and anything that promises to “detox”. In fact, any one of us could invent our own snake-oil or novel form of quackery. And then we could invent some titles and qualifications and go on TV as an “expert” to promote them. The trade is worth in excess of £500 million per year in the UK alone. Quackwatch is a good reference point – I check doubtful health claims there, just as I check doubtful internet stories on Snopes.

We are 250 years past the enlightenment in which the ideas of reason and science supposedly gained supremacy over superstition and liberty progress and tolerance gained traction over dogma. Yet here we are in so many ways believing in magic and witch hunts. The public doesn’t understand science, is wedded to superstition, or simply has overwhelming credulity and a lack of critical thinking. This is the same culture that created plausibility for Andrew Wakefield’s weird “measles immunisation” recipe that contained his own blood and goat colostrum and that pushed an appropriately skeptical professor of complimentary and alternative medicine into early retirement because he wouldn’t endorse homeopathy and reflexology on the NHS.

No wonder in the Brexit campaign and in Trump’s electoral campaign there has been such wide deviation from the facts. The public have been told to disregard experts and go with their gut feelings, or with the guy who they could imagine meeting in the pub. That is a very poor way to judge the evidence base, and (as we have discovered with Brexit) a very easy way to be sold a pup. I can’t understand why it is not a crime, or even a disgrace, to lie to the public. Why were there not enquiries and reprimands for people who knowingly lied about the £350 million pounds a week extra that was supposed to go to the NHS if we left Europe? The answer is because we have better protections against a drink being sold with false weight loss claims than we do over vote-changing political claims.

It is interesting to explore why people don’t trust experts, and here it seems that there are a few dimensions that are important. Knowledge is only trusted if it is coupled with a perception of benevolence, and presented in words that people understand and don’t feel patronised by. It is all too easy for people with expertise to use jargon or technical terminology that makes sense in their field, for readers of the journals they publish in or in conversation with their peers, but that makes the content inaccessible to lay people, who then think of the expert as being part of an intellectual elite who are sneering down at them from a position of superiority.

And some people seem to deliberately manipulate any show of expertise to make it seem that particular commentators are not connected with the experience of ‘the man on the street’. Michael Gove (linked above) was probably the pinnacle of this, but Trump also directly appeals to this distrust of experts, and seems to bank on his audience not caring about his content being proved to be factually incorrect later down the line. Tim Minchin captured my feelings and frustrations about this rising anti-intellectualism (and Brexit and even Donald Trump in passing) here [contains swearing, I’d recommend watching from 24 to 35 mins in].

But it is becoming more and more common. I was listening to the radio earlier this week and flicked over from Radio 4 to Radio 2 to hear the host Vanessa Feltz tell a labour party spokesman that the word “narrative” when used in context, with four repetitions of the word “story”, was jargon that was beyond her and her listeners and proudly proclaimed that it was similar to the teaching that went over her head at university (listen at 15:00 for just over a minute). She seemed to want him to pitch his vocabulary lower, whilst showing her own insecurity about wanting to be clever by using the word “elucidate” herself in her instruction to him to do so! It was particularly notable in contrast to Radio 4, where the words that she criticised, such as “managerial”, “technocratic” and “narrative” would not stand out in the discussion or require definition. Maybe it is just a mark of my age and changing listening preferences, but I would always prefer to have conversation pitched at the level that I learn from, than patronisingly dumbed down.

It is also a reminder that, despite a natural tendency to consider ourselves pretty much average at everything, very often we fail to recognise our own levels of skew within the population. My politics are left of average, my income and intellect above average, just as my physical fitness is below average. But this deviation from the norm does not stand out to me as I have sought out a peer group of other professional, intellectual lefties. In my peer group, the remain preference was so strong that the vote to leave the EU was quite a shock!

Similarly, despite having written a book to try to make the scientific knowledge around attachment and developmental trauma accessible to care givers and professionals from other fields, and working hard to make psychological knowledge available through this blog and various forum posts, not everyone finds my writing accessible. For every ten positive views of the book there is one person who feels I pitched it too high. I’m sure I’m as guilty as the next person of knowing the meaning I intend to convey, and therefore not always recognising when I have not communicated this effectively. So please do point it out to me!

 

 

How do we know what we need: differentiating evidence based treatments for the public

I am interested in making a website to help direct people at the right kind of sources of support when they are hitting a block or feeling unhappy with their lives. So I started to look at what was out there. I found lots of small silos full of professional jargon that would help people to identify a counsellor, psychotherapist or psychologist if they knew that was what they needed. But I also found lots of sites that point people at all kinds of snake oil that has no evidence of efficacy at all. For example, Findatherapy.org lists the following categories as “therapies”:

Abdominal-Sacral Massage
Acupressure
Acupuncture
Alexander Technique
Allergy Therapy
Aromatherapy
Arts Therapy
Autogenic Training
Ayurveda
Biofeedback
Bioresonance Therapy
Body Stress Release
Bowen Technique
Chiropody
Chiropractic Treatment
Clinical Pilates
Cognitive Behavioural Therapy
Colon Hydrotherapy
Colour Therapy
Counselling
Craniosacral Therapy
Crystal Therapy
EMDR
Emmett Technique
Emotional Freedom Technique
Energy Medicine
Flower Essences Therapy
Foot Health
Havening Techniques
Healing
Herbal Medicine
Homeopathy
Homotoxicology
Hydrotherapy
Hydrotherm Massage
Hypnotherapy
Indian Head Massage
Kinesiology
Life Coaching
Manual Lymphatic Drainage
Massage Therapy
Matrix Reimprinting
Maya Abdominal Therapy
Meditation
Microsuction
Mindfulness
Myofascial Release
Naturopathy
NLP
Nutritional Therapy
Osteopathy
Physiotherapy
Pilates
Psych-K
Psychotherapy
Reflexology
Regression Therapy
Reiki
Relationship Therapy
Rolfing
Sex Therapy
Shiatsu
Speech Therapy
Sports Therapy
Structural Integration
Tension and Trauma Releasing
Thai Massage
Thought Field Therapy
Yoga Therapy
Zero Balancing

That’s a list of 70 “therapies” of which at least 40 are obvious quackery, and very few could be said to have any form of persuasive evidence base for efficacy*. But the practitioners of each are persuasive, and the websites use pseudoscientific rationales that might fool those who are not as cynical or conversant with the scientific method as we are. So how do the public know what kind of help to seek out? How does someone who is feeling miserable, has a job they hate, financial difficulties and problems in their relationship know whether to get financial advice, careers advice, life coaching or therapy? And if they pick “therapy” how do they know whether to get CBT, psychoanalysis, art-therapy or non-directive counselling? And how do they know whether to get it from a therapist or a psychologist or a counsellor or a mental health specialist or any of a hundred other job titles? And within psychology, how do they know when to seek a clinical psychologist, a health psychologist, a counselling psychologist or any of the job titles that the HCPC don’t register?

I think apart from word of mouth and google, they don’t. Most people ask their GP or their friends for recommendations, and then go with something available locally within their price range. They don’t read the NICE guidance or understand the various professional bodies or regulatory systems. They trust that they’ll get a gut feeling as to whether it is going to help or not from the first session, and most of that “gut feel” is probably based on personality and charisma, and whether or not they feel listened to. The decision then rests on whether the therapist wants to work with them and has the capacity to take them on, and the price they ask for (assuming the service is in the private domain rather than the NHS).

Even the NHS itself isn’t very consistent about evidence based practise. For example, the NHS still funds some homeopathy – possibly wasting up to £5million per year on this placebo treatment that is entirely without evidence or credible rationale. Likewise I’ve seen NHS therapists who have done training in models of therapy that are implausible and without evidence (eg ‘energy therapies’ like EFT). Perhaps this is why the majority of clients doubt the efficacy of talking therapies. Yet, despite this scepticism, most would prefer to try therapy than medication yet the use of psychotropic medications has risen much more rapidly than the use of psychological therapies.

So where do we draw the line? If we only deliver fully evaluated treatments and those where we understand exactly how they work, then the amount the NHS can do when it comes to therapy will be much more limited. Lots of therapeutic interventions in practise are derived from other models or by combining aspects of various models. This allows individualisation of care. Similarly, there are many therapies which are being developed that have promising methodologies and are tightly rooted in scientific knowledge, but have not themselves been subjected to RCTs that prove efficacy yet (eg DDP). And many RCTs seem far removed from actual clinical practise where clients have a variety of overlapping conditions and clinicians deviate substantially from the treatment manuals.

The other confounding factor is that when it comes to talk therapy, it turns out that the modality or adherence to the manual matters very little compared to the relationship between the therapist and client. It seems the key ingredients are listening to the client, genuinely caring about them, giving them hope that things could be different, and giving them the confidence to try doing things slightly differently. Whether we have years of training and follow the manual diligently or whether we are newly qualified and muddling through seems to make much less difference than we think. In fact, therapist variables are much more powerful in influencing outcomes than modality, and even than the difference between treatment and placebo. That is no surprise to me as I’ve personally benefited from physiotherapy that included acupuncture – despite having read studies that show it to be no more effective than ‘sham acupuncture’ where random locations are pricked with a cocktail stick!

In the paper I’ve linked above, Scott Miller argues persuasively that we don’t need to focus on understanding how therapy works, or in using the medical model to work out what works for whom with endless RCTs. He shows evidence that experts are defined by having deep domain-specific knowledge, earned by a process of gathering feedback and focusing on improvement. So he argues that in the same way, expert therapists are those who collect and learn from client feedback. So his answer to the issue of evidence-based practise is for us each to collect our own outcome data to show whether our work is effective according to our clients (and by comparison to other options), and to see if we can improve this by using simple ratings within each session that check we are working on the right stuff and that the client feels we understand them, and that the working relationship is good.

So what does this mean for the proliferation of made up therapies? Does it mean that we should leave the public to buy a placebo treatment if they so wish? Or does it mean we need to focus on the modality and evidence base after all? The ideal would obviously be better regulation of anyone purporting to provide therapy of any form, but given the HCPC remit doesn’t even include counselling and psychotherapy, I think we are far from this being the case. To my mind it throws down a gauntlet to those of us providing what we believe are effective and evidence based treatments to collect the outcome measures that demonstrate this is the case. If we are sure that what we offer is better than someone having an imaginary conversation with an imaginary ‘inner physician’ by feeling imaginary differences in the imaginary rhythm of an imaginary fluid on our scalps then surely we ought to be able to prove that?

And what does that mean for my idea of making a website to point people at helpful places to start a self-improvement journey? To me, it shows there is a clear need for simple and accessible ways to identify what might be useful and to allow the public to differentiate between sources of support that have evidence of efficacy, professional regulation, a credible rationale for what they do, reputable professional bodies and/or personal recommendations. Maybe such a website can be one contribution to the conversation, although I’ll need both allies and funding to get it to happen.

 

 

*I’d say EMDR, physiotherapy, speech therapy, CBT and some types of psychotherapy and counselling probably reach that bar. Mindfulness is probably getting there. Art therapy probably suits some people with some issues. Yoga, sports massage, pilates, osteopathy, meditation, life coaching and (controversially) even acupuncture probably have their place even though the evidence for them as therapy modalities is limited. Most of the rest are quackery.

Why is there always a can of worms?

I’ve run http://www.clinpsy.org.uk for 9 years now, and built it up to 6900 members, 600,000 users and nearly 10 million page views per year. I’ve put enough hours into that site to add up to more than two years of full-time work, and I’m proud of what we’ve achieved. It is an informative, welcoming community that allows people to network and ask questions. It also levels the playing field of information and reduces the impact of personal connections within the early stages of the profession, and I hope that this will in the long-term act to increase diversity in the profession. Over those 9 years, members have written upwards of 135,000 posts on the forum, and our wiki of information and answers to frequently asked questions has been viewed millions of times, with some posts about preparing for interviews, the route to qualifying, formulation, writing a reflective journal, and transference proving particularly popular – the latter having been read over 115,000 times.

In all of that time we have had remarkably little need to intervene in the forum as moderators. We remove the occasional bit of spam, and we have sometimes anonymised posts in retrospect on the request of the author, and from time to time we have to explain to service users that this is not an appropriate place to ask for advice, but we rarely have to warn or ban forum users. I think the total to date is seven banned individuals and one banned organisation. Not bad when we’ve had 10,000+ sign-ups, and 135,000 posts! This is perhaps a reflection of our clear guidance about how we expect users to behave on the forum, and also of the large number of regulars who act as a more informal feedback loop. We also have quite a large number of qualified clinical psychologists who log into the forum regularly and often act to provide information and correct misconceptions. This is a very important function, as the pre-qualification arena can often become an anxiety-provoking echo chamber, where rumours are propagated and exaggerated without being confirmed or refuted. It also allows us to have a (hidden) peer consultation forum, which is a very good place to discuss concerns with peers in a safe environment in which every member is an HCPC registered clinical psychologist.

However,  the few times when intervention is necessary always tell an interesting story. And the strange thing is, that every single time somebody has been a persistent concern on the forum, this has opened a can of worms that makes us worried about wider ethical issues for the same individual. We had someone who was very unboundaried, and at times threatening to their colleagues and other members in the LiveChat space, and transpired to have caused concern with aggressive conduct in real life. We had a member who was somewhat grandiose and wanted to be a moderator, who attempted to delete and vandalise site content. They later had issues in their workplace, with a similar theme of acting beyond their level of competence. One poster lied to persuade successful applicants to share their applications for clinical training and plagiarised them, and when we identified them it transpired they had plagiarised site content into a publication without acknowledgement and had been unprofessional in numerous other ways. Another odd poster used the same username to post topless pictures on another website. And most recently we have had an organisation recurrently attempt to circumvent payment for advertising on the forum by signing up stooge accounts to promote their service, where it would appear that the appearance of an ethical non-profit organisation instead covers a profitable privately owned tour operator.

It has made me wonder whether ethics and professionalism are the kind of thing people have or they don’t, and that show in numerous domains of their life. Or, is the seeming anonymity of an internet forum a place where traits are exaggerated and played out. Either way, the association between inappropriate use of the forum and inappropriate professional behaviour in other domains seems too high to be a coincidence.

Yet the ethical and professional guidance for psychologists has little that applies in our context. We have had to work out our own boundaries amongst the moderating team (we now comprise ten qualified psychologists and a lay member, although many joined the team as APs or trainees). It makes me realise how much unique our position is, on the technological frontier, and how we are learning case by case. For example, we have had to interpret the balance between confidentiality and risk to apply to our unique setting. We settled on a position that is broadly consistent with what I’d do with clients in real life; we would identify and report a member if we felt they were at risk or presented a risk to others, but otherwise aim to respect the pseudo anonymity of using a posting ID, where only a minority of people choose to be identifiable as a specific professional, or in a way that could be recognised in their workplace. Likewise, we have learnt to log everything typed into our LiveChat space, so that we are able to review the usage of particular members, or read the content if a report is made of inappropriate behaviour. I’d like to think that we’ve reached a good place, and have always been transparent in how we behave. It has been an interesting process though, so I’m thinking of presenting some of the ethical dilemmas and our process at the CYPF conference later this year.