science

Heart and Head

It is an interesting fact that most people make decisions based on their emotional “gut feeling” but then justify them logically in retrospect. So you pick a house or a car that feels right, but tell people you chose it because of the miles per gallon or the lovely neighbourhood. Maya Angelou put it rather perfectly when she said

I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.

However, if you ask me why I think BERRI can benefit a placement provider or a local authority, then my first port of call is facts and explanation, rather than finding the emotional hook that will persuade people that it feels like the right thing to do. Maybe its the scientist-practitioner thing showing through, but I feel like it is more valid or legitimate to make the case in the language of logic and facts, than to try to pull on people’s heart strings, and I am very loathe to make any claims I can’t prove with quantitative evidence.

I think that is partly because of my personal style. I have previously blogged about how I am not a typical clinical psychologist in terms of not seeing myself as primarily a therapist. I wonder whether that is because I tend to start with a more intellectual approach, and address the language of emotions less than many people in my profession. For example, I like to operationalise how I conduct assessments, or the information I like to share in consultations, so that it can be replicated more easily, and to evaluate everything I deliver to check that it is effective. It doesn’t mean I’m not mindful of feelings that arise for people I interact with, or in myself, or that I’m emotionally closed off. In fact, quite the opposite, as I quite often find myself becoming tearful when discussing the stories of the children and families that I’ve worked with (or when reading the news or discussing the current political situation, and even when watching films or reading novels for that matter). I’m likewise prone to a giggle or a belly laugh, sometimes about entirely inappropriate things. I’d say I’m pretty comfortable expressing both positive and negative feelings, and responding to those in others. But when communicating information to others, particularly in writing or as a presentation, science is my starting point.

Maybe it comes from eight years of academic study and writing before I qualified as a clinical psychologist, or maybe it is because I am used to presenting to my professional peers through journal articles and conference presentations. But ask me to explain about a topic or project and my first instinct is to tell a summary of the context and then share my methods, results and conclusions. However, I am mindful that to be an effective salesperson I need to be able to pick out the message that will be emotionally resonant with the listener to focus on, and to capture hearts as well as heads.

To that end, I’ve been working on how we communicate the impact of BERRI on individual children, as well as its benefits for organisations and commissioners. To do this we have started to capture some stories from cases where BERRI has made a difference, and then to anonymise these enough to present them in the materials that I present at conferences and on social media. I had always thought that the lovely animation that Midlands Psychology commissioned to show how they had changed the autism service was a brilliant example of this. I felt like they managed to tell the important elements of their story in an engaging way, and that this couldn’t help but make people see the improvements they had achieved. We didn’t have their budget, but I wanted to capture something similar in our case study animations.

Luckily for me, I had recently reconnected with an old school friend, Joe Jones, who is brilliant at this kind of thing. His “explanimations” for the renewable energy sector had been great at simplifying complex ideas, and he knew all about my business, as he had been helping us to look at our comms. We talked about what I wanted from an animation, the tone we wanted to convey, and the stories that we could tell about different case examples. Joe showed me how The Girl Effect had been able to capture an emotionally compelling story in very simple graphics, where the character created represented every girl, because she was effectively anonymous and culture free.

The result is a short animation that I think captures what we are trying to achieve with BERRI. Obviously, there is more information that will set the simple story into context, which I can tell people in the rest of my presentation, or as they enquire. But as a hook that helps people to see the impact it can make, I think he has done a great job.

BERRI Case Study – Daniel from Joe Jones, Archipelago.co.uk on Vimeo.

What do you think? Does it explain what we are offering? Does it appeal to both heart and head?

I am not a therapist

I’ve always been someone that likes to keep busy, and has a lot of ideas about places where psychological thinking can make a positive impact. The aspect of my character that I now identify as entrepreneurial and put to good use in my business has always led me to want to try new things and create innovative solutions to problems. I like a lot of things about being a clinical psychologist, and particularly our ability to turn our hand to multiple types and levels of work. However, unlike many other clinical psychologists, I don’t really see myself as a therapist. In fact, I haven’t seen more than a handful of clients for individual therapy over the last decade, and even before that it was a pretty small proportion of my qualified jobs. I’ve always had more of a focus on the other facets of being a clinical psychologist. I think the picture of a clinical psychologist as a therapist is so strong that a lot of people will now be wondering how I fill my time!

So I will answer that question: I have done loads of highly specialist assessments (of neurodevelopmental concerns, attachment, parenting capacity, mental health, life skills, self-esteem, wellbeing etc) and lots of formulating and report-writing – some in collaboration with psychiatric or medical colleagues or within a wider MDT, but more as an external expert or second opinion. I have advised the family courts as an expert in care proceedings and complex custody disputes, and completed numerous pre-court assessments for local authorities to help inform their care planning. I’ve managed teams and services, and supervised from 2-20 other staff at a time, along with sitting in various organisational/management structures. I have designed and delivered training to parents, carers and professionals, and I have done lots of consultancy to various organisations and professionals (mainly those providing health and social care services, or involved in the family courts), and help placement providers to improve their services. I design and deliver group programs (eg Managing behaviour with attachment in mind), but then rapidly cascade train other staff to continue to deliver them. I wrote a book about attachment/developmental trauma, and lots of papers and policy documents about Looked After children, and acting as an expert witness to the family court. I sat on a BPS committee and I contributed to NICE and SCIE guidelines. I’ve designed, managed and evaluated therapy services (but employed others at lower bands to deliver the therapy). I’ve been an expert advisor to the HCPC in a fitness to practice case and to the team investigating a death in public care. I’ve done loads of practice-led research about each client group I’ve worked with, from looking at the psychological and health economic impacts of offering brief therapy to hospital users with diabetes, to commissioned evaluations of other services. So I have plenty to fill my days despite not having a therapy caseload!

I have reflected on why it is that I don’t feel drawn to therapy, and reached the conclusion that, whilst I see it as a very worthwhile endeavour, I don’t really have the patience for resolving difficulties one person at a time over sessions spanning many months. I’m always more interested in grappling with the bigger questions of why people are in distress, and what we can do to most effectively prevent or ameliorate those difficulties. When I’ve solved the riddle (or at least, reached a plan that improves upon existing solutions) I like to evaluate its efficacy, modify it if necessary and then disseminate the learning and/or train others to replicate the solution. I try to step outwards from the individual issue to the broader themes and ways that we can intervene on a wider scale. To use a visual metaphor, if dealing with mental health problems is like bailing out a ship, then rather than scooping out water one cup at a time, I am trying to work out how to plug the leaks, and to design boats that won’t have the same vulnerabilities to leakage in the future. It also helps me to avoid feeling hopeless about factors outside my control and demand exceeding supply, or burned out by an accumulation of traumatic stories.

Jenny Taylor, a past chair of the Division of Clinical Psychology, once described our profession as the structural engineers of the therapy world. Unlike a therapist trained in a single modality of therapy, we can survey the landscape and assess the need, then design the intervention that best meets that need – even if we are not always best placed to deliver it. We can base that recommendation on our knowledge of the current evidence base, which can change as new information comes to light.  If we consider the challenges people face as a river they need to cross, a therapist trained in a single model of therapy might be a bridge-maker. A psychodynamic therapist might be a mason who can build traditional stone bridges and claims that this design best stands the test of time. A CBT therapist might be a carpenter with a set of designs for wooden arched bridges that he claims are cheaper and quicker to erect. Each sees their own skill as either suitable to solve the challenge or not, but also has some incentive to sustain their own livelihood by continuing their tradition. A clinical psychologist can survey the land either side of the river, the span length required to cross it, and the materials available in the locality. They can then advise on the various options, including the relative costs and the evidence of how they fare in different conditions. They may or may not feel that bridge required is within their own skill-set to erect, but have a reasonable overview of other bridgebuilders in the area to recommend. If new designs of metal suspension bridges are developed, this is not threatening to the structural engineer, who can adjust their recommendations to incorporate the emerging evidence base.

I really like this metaphor and strongly identify with the role of structural engineer rather than bridgebuilder. I had always thought that this was instilled in me by my first graduate job, where I was an assistant psychologist on a research project about improving quality of life in residential care homes for older people, and I could see how the research and clinical work were closely tied together and built on each other reciprocally. But now I think my love of data and the scientific method runs deeper than that and I can see it infused throughout my whole approach to life since childhood. When it comes to my work I am a scientist practitioner down to my bones, as I always collect data as I go along. Where I don’t feel like I understand the situation well enough, I first look to the literature and then to gathering data and doing my own analysis to try to gain insight. When I develop something new to try, wherever possible I try to evaluate what we are doing, and refine it through an iterative process until we can prove maximum efficacy. I see that process as being part of the USP of a clinical psychologist – that we think like scientists and gather data to inform our interventions.

But I’m not sure that we communicate this mindset well enough, or that it is universal amongst the profession. It certainly isn’t what draws people into the profession in my experience. Too many clinical course application forms I review could be paraphrased as “I want to learn to be a good therapist” with an afterthought of “and do/use research” because they think that is what selectors want to hear – but in my view therapy can be done by lots of cheaper professionals, who might do an equally if not better job of it. I believe that clinical psychologists should be more than well paid therapists. We should know the evidence base and be able to take on the most complex assessments and formulations (even if others then deliver part or all of the treatment) but also to be able to develop, refine and evaluate novel therapeutic interventions, supervise other staff, improve services, consult, train and manage – things that extend beyond the skillset of most therapists. I’m sure it is clear by now that this is where my own interests lie. And I think it shows through in everything I do.

For example, when I was asked to lead the CAMHS service providing neurodevelopmental assessments I started with a literature review and current policy and best practice guidance. I then conducted an audit of the existing pathways, then tried to make things better. We set up a new clinic system with more rapid throughput and more thorough assessments, and then re-audited showing a reduction from an average of 18 months of input to five, with increased clinician confidence in the service and higher client satisfaction. I also wrote a booklet to help provide the information to parents whose child received a diagnosis of an Autistic Spectrum Condition. Although it required dedicated clinician time for the multi-disciplinary clinic and for the psychometric assessments generated, overall the new pathway freed up capacity because less cases were being held open by other clinicians whilst waiting for assessment, or kept open for prolonged periods afterwards to help the family understand the diagnosis and connect up to local sources of support.  I also sat on a multiagency strategy group to look at establishing best practice standards for the county.

I had the same approach when I was asked to support the adoption and permanence service. I initially set up a consultancy clinic, where social workers could bring cases to discuss or book in families to see jointly. I found that I was explaining similar information about attachment, trauma and neuroscience to multiple professionals, parents and carers in the consultations. So I designed a group to share this content. I called it “Managing Behaviour with Attachment in Mind”, and developed some “doodles” I would draw on flipchart paper to explain the concepts more accessibly. I evaluated the impact and showed it to be an effective format for supporting parents in this situation. The groups were popular and over-subscribed, so I trained others to deliver the group to keep up with demand, first in my service and then more widely. Many people in the groups liked to photograph the doodles to remind them of the topic, so I decided to write a book to share them and Attachment: In Common Sense and Doodles was born.

But I also wanted to know about how we could achieve permanence for more children. I started by looking at the literature about what makes effective adoptive matches. Very little information was available, so I systematically audited the paperwork from 116 adoptive matches and followed them up over 7 years to see what factors influenced the placement outcomes. I was able to look at whether the innovative adoption project to place children with more complex needs had better or worse outcomes, and was able to explore the impact of different motivations for adopting. Whilst to me this was just a natural process of answering the question as an evidence based practitioner, it transpired that these studies of adoption risk and resilience factors were amongst the largest ever done, and I have discovered unique findings that I really should publish*.

You could argue that I was using a sledgehammer to crack a nut by doing all this research and trying to change process when organisations are notoriously slow to change, and that I could have spent my time more productively working with more individual adoptive families. But that’s not how I’d see it. The research I did helped me to understand what the key variables are when considering whether a child can achieve permanence, what kind of family we need to look for to place them successfully, and what kinds of support might ensure that the placement succeeds. I hope that I have fed that knowledge back through my court work, and into various organisational and policy work over the last decade. I have also disseminated it at conferences. However, I would still like to spread it further, because it is my belief that such knowledge can have positive impact at multiple levels – it can help to inform individual placement decisions, service-wide strategies for helping optimal numbers of children to access permanence, and national policy about adoption.

That work led naturally on to developing our services for Looked After Children when I left the NHS and set up my own company, LifePsychol Ltd. We provide training and consulting to foster carers and residential care staff, the social care organisations that support them, and the wider professional networks surrounding them, including education and health staff, police, lawyers, magistrates and judges. As I started to get more immersed in working with children in and on the edge of Care, it led me to recognise that there was a lack of validated and reliable tools to identify the needs in these populations, no outcome measurement tools that could reliably measure change over time in a way that was sensitive to the context and type of life events these young people experience, and a dearth of clinical governance in terms of the efficacy of both placements and interventions for this group of children. That seemed shocking to me, given their highly complex needs, and massively elevated incidence of mental health problems, challenging behaviour, risk to self and others, and prevalence of intellectual or neurodevelopmental difficulties.

As well as the human cost of not being able to identify the best choices for people, it seemed unacceptable that huge amounts of money were being spent on placements and specialist services for this group without any evidence of them changing their wellbeing or life course for the better. Placements seemed to struggle to identify what to work on and how, and there was little objective indication of what defined a successful placement, beyond annual visits from Ofsted (who were predominantly focused on process and procedure). The high level of need and the lack of clinical governance in the sector has allowed various specialist therapists and services to spring up that are virtually unregulated, and many placements have adopted terms like “therapeutic” without these having a consistent definition or meaning. So I wanted to see whether I could make any headway in changing that.

Meanwhile there is pressure from the government to improve outcomes for children in public Care, because they are seen to fare badly compared to the general population of children the same age. The difficulty is that this isn’t comparing like for like – children in care have many more adversities to face, both organic and in terms of their life experiences, that mean they often deviate from the norm. For example, I found that there was a 20 point skew downwards in IQ distribution in children in residential care compared to population norms, meaning that 20-25% of children in this setting had a learning disability, compared to 2% in the general population. Likewise the incidence of Autistic Spectrum Conditions and other neurodevelopmental difficulties amongst children in Care is more than triple that in the wider population. The same is true of young offenders. If we don’t acknowledge that, then the sector is being asked to seek impossible goals and will inevitably be seen as failing, even if placements and services are performing optimally and adding a lot of value to the lives of the children they work with.

To state the obvious, children in care are not just randomly drawn from the population – by definition their needs have not been met, and this can mean both the presence of additional challenges and exposure to harm or deficits in care. I believe that to look at the needs of this population and the degree to which these are met by placements or interventions, we need to either compare them to carefully matched controls or ensure that outcomes are always considered relative to baseline. The latter seems more pragmatic. Scores for young people also need to be considered in the context of what is going on in their lives – as changes in placement, daily routine, contact arrangements, or the arrival or departure of other children from the home can make big impacts on the child’s functioning.

So I’ve been beavering away exploring these issues and developing systems to measure needs and make the data meaningful for those providing care and services. The impact might not be as obvious as delivering psychological therapy directly, but I’d like to think that over time it can improve services for thousands (or even tens of thousands) of children, and make a greater net change in the world.

 

*Maybe I’ll write more about this in a future blog. But the short version is that I have been trying to secure some funding to complete the statistical analysis and disseminate this information, and would still like to do so, so if you have any ideas or useful connections to assist with this please let me know. Failing that I hope I’ll find enough time to write a book on making better adoptive matches at some point in the future.

Wisdom, sycophants and advice that won’t work

I have been watching and reading a lot of Brene Brown stuff recently, and for the most part I feel like she has been able to identify and tap into some important concepts that chime true with my own understanding of attachment, shame, perfectionism and self-compassion, but there is a part of me that is a bit uncomfortable. When I’ve watched recent interviews, such as this one with Oprah I find myself responding to the comments like “that is so powerful”, “right, right, right” and “there are so many things I love about you” with a bit of a cringe. I think it is partly that it feels like a sycophantic mutual love-in amongst a particular group who have formed their own self-improvement echo chamber, and partly that the whole American over-the-top-ness of it makes it come across as less than sincere.

Obviously Oprah is in herself an incredibly impressive person: She is self-made despite horrible early life experiences and someone who adds welcome diversity to the line-up of bland white males and slim, magazine-beautiful young women that populate American TV, she has popularised acceptance of LGBT people and been empathic about a wide variety of life experiences and mental health problems. Plus she is a significant philanthropist (albeit that her charitable activity in itself is not entirely without criticism). However, Oprah and her ilk are so non-critical of patent nonsense from self-help books about spirituality and positive vibrations to dodgy hormone treatments that it feels like a huge missed opportunity to have not put a threshold of scientific scrutiny (or at least critical thinking) to claims when she has such an enormously influential platform.

Likewise it is hard for me to reconcile why a credible researcher like Brene Brown would be prepared to be thrown in that mix and start marketing self-help courses for Oprah watchers. It doesn’t seem to make sense without attributing a financial motivation for accessing the wider audience that is more powerful than professional ethics.

I’m going to read all her books and then I’ll be in a better place to comment, but I’d like to think I’m not being naive or rigidly judgemental here. I’m sure if I felt that I had an important message to share and Oprah offered access to her audience of millions, and I felt that would help to change the world I would make compromises too, both to get the message out and to get the book sales, raised profile and funds that would enable further work. And I fully accept that there have to be coffee table books that are accessible to wider segments of the population than the referenced texts of scientists and clinicians that are more closely tied to the evidence base from which they are drawn. But something still feels uncomfortable.

So, is it just a cultural divide or my own hatred of insincere praise, or is it something deeper that is rotten about the self-help culture?

I’ve started to think that the self-help world, like the diet industry, is rotten at the core because it is invested in failure. I don’t mean the books often recommended by mental health services as ‘bibliotherapy’ that address mental health problems based on well-evidenced psychological techniques like CBT here, which are predominantly helpful. I mean the 2000+ books per year of home-brew wisdom about how to be happier, grasp control of your destiny, be more successful, fix your marriage in a week, get more energy, unlock your chains! Most of these have no evidence base whatsoever, and the authors often have no scientific or mental health credentials. A cynic might say they are selling false hope. Yet the same unhappy people try again and again to change their lives by reading the next book, spending more and more money to make changes presented as easy that are actually unsuccessful for the vast majority of those that try them out.

Just like the diet industry, self help is an industry that has had meteoric growth. Yet little of that is based on any evidence of either the underlying principles or the efficacy of outcomes. There is minimal evaluation, and what there is isn’t promising. In fact, recent research (albeit on a very small sample) has shown that reading self-help literature actually makes people more depressed and anxious!

“The sale of self-help books generated over $10 billion in profits in 2009 in the US, which is a good reason to find out if they have a real impact on readers,” said Sonia Lupien, Director of the Centre of Studies on Human Stress (CSHS). The results of the study showed that consumers of problem-focused self-help books presented greater depressive symptoms and that growth oriented self-help books consumers presented increased stress reactivity compared to non-consumers. No difference was found in any variable according to whether people had read self-help books or not, suggesting they have little impact on functioning. In fact “the best predictor of purchasing a self-help book is having bought one in the past year” suggesting that the same group of people repeatedly buy self-help books but aren’t actually changed by reading them.

In the same way, every new year consumers with weight-loss resolutions in the UK spend £335 million, yet a month later for more than half of them there is no measurable impact on their weight or fitness. Overall the diet industry has an incredible failure rate: 95% of people re-gain the weight they lose. Yet the consumers keep on spending. In the USA consumers spend more on diet-related purchases than the combined value of the government’s budget for health, education and social care. And yet a little basic knowledge of the subject could inform them that most of the things they try won’t work, and that there are very well established links between diet and health.

It seems I am not alone in this discomfort, and Brene Brown herself has felt it and responded. I still think she is one of the good guys, and clearly there are gender politics and marketing influences she struggles to counter, but it remains a fact that there is little to distinguish the good from the bad in the self-help field. I wonder if it is time for those of us who write from an evidence base to respond to that and to start a website to evaluate claims from self-help literature?

High on scare, low on science: a tale of charity, politics and dodgy neuroscience

In 2011 when I took a voluntary redundancy from the NHS I was asked to help set up a parenting charity* focusing on the period from conception to age 2. I agreed to be the founding Clinical Director and to help them set policies, sort out pathways of treatment and recruit staff. I worked for them one day per week. After less than six months it was clear that there was a divergence between what I felt was most clinically helpful to say about supporting parents in this critical period and the primary goals of the charity**. This was particularly evident in what was being said to promote the launch event of the charity. The title of the launch conference was the dramatic and pessimistic pronouncement, “Two is too late”. This title was cast in stone despite my repeated protests that parents would feel blamed and might think that there was nothing they could do beyond the age of two if they had not had a perfect attachment relationship before this point (when the evidence suggests that there are in fact many effective strategies for enhancing attachment relationships beyond this point, and many therapies for helping children and even adults to learn to emotionally regulate, mentalise and have successful relationships, even where there has been poor attachments, neglect or maltreatment).

The media were given soundbites to promote the event that suggested a baby is born with only one third of their brain active, and the rest relies on the quality of parenting received to grow. The news coverage in the Telegraph*** said that “a failure to help troubled mothers bond with their babies can stunt the development of the children’s brains”. The BBC coverage*** stated “a growing body of research suggests that the amount a baby is loved in the first few months of its life determines to a large extent its future chances” (when love and the quality of the attachment a parent is able to provide are quite different things, the most critical period is usually cited as 6-18 months of age, and the change in prognosis is most impacted by significant maltreatment).

Although our tiny pilot had kept 5 children out of 6 at home with parents successfully, despite them being referred on the edge of care, I had some misgivings about the marketing messages. We had feedback from service users and user groups that they felt stigmatised by some of these messages, but the organisation was unwilling to hear that. I am passionate about the value of improving attachment relationships and I had written a brief literature review on the impact of poor early care to ensure that the project was informed by the evidence. I was also writing a book about attachment and the impact of maltreatment, but I couldn’t match my views up with the politics of the organisation. I felt that to stay would conflict with my professional ethics, and my desire to honour the evidence base and respect the people who needed the service, so I quit before the launch. My colleague decided it would be unsafe to practise in my absence and left at the same time, leaving the charity with no clinical staff. Nonetheless, they decided to make a very big launch event, that I could only describe as one third professional conference, one third stately home wedding and one third party political broadcast for the blue party. It sold 500 tickets to health professionals and other interested parties, and I went along to see the show.

The speakers included a Conservative Peer, Ian Duncan Smith and Andrea Leadsom, along with Dr Amanda Jones (who shared a case study of parent infant psychotherapy). The fantastic Camilla Batmanghelidjh was also present (and made a good job of challenging the lack of empathy from politicians for the people they serve and quipping that this reflects their avoidant attachment styles). I had invited Dr Michael Galbraith (a Consultant Clinical Psychologist who has run community children’s services in Liverpool for many years) to talk about the health economics of early intervention. He did so persuasively and he also challenged the politics that came before his talk (with genuine zeal, as his entire service had been closed in a cost-saving ‘reorganisation’ a few weeks prior to the conference). But the biggest draw was that Baroness Susan Greenfield was invited to talk about the epigenetic effects of early attachment experience on the infant’s developing brain****. As I had not heard of her work prior to this event I was intrigued.

The talk that Prof Greenfield gave was baffling from the off. It massively overran her time-slot, and the program was rearranged to give her a second slot in the afternoon to complete what she wanted to say. My recollection was of a chaotic set of shock images and headlines, with provocative statements which appeared to contradict my knowledge of the literature, despite the fact she claimed they were scientifically founded in hard neuroscience research. Thankfully the pdf of the PowerPoint she used was circulated after the event, so you can see the content for yourself (zip file to download here).

Her title was “The mind of the 21st Century Infant” overlaid on a stock photograph of a baby using a computer. She immediately moved on to dramatic images of a youth celebrating in front of a fire during the recent riots, blaming the riots on the lack of attachment young people have grown up with, which she said had been replaced by technology. She then showed scary images of “artificial intelligence” before trying to define the mind. Then she made a knight’s move to demonstrate that “environment trumps genes” through a single study of rats given genes that cause Huntingdon’s Chorea which had less symptoms if they lived in a more stimulating environment. Then back to human babies, and images of how neurones proliferate during the first 2 years of life. Then a study showing that the Hippocampi of taxi drivers are enhanced, and then some blobs designed to indicate that mental practise of piano also activates the brain like physical practise. Then back to rats, showing more neural connections in a richer environment than when rats are isolated in boring cages. Then a description of how the mind shifts during development, from sensory processing to cognitive experience and gives greater meaning over time, with the view this is driven by experience.

She then claimed the mind might be “changing in unprecedented ways” due to interaction with technology, and showed alarming headlines circled in red, and book titles reflecting her view that internet use is changing our brains.

Prof Greenfield then showed a study counting children’s hours of screen time reported by parents, according to the child’s age. The source cited turns out to be a report saying that children have always used whatever media is current, mostly watching TV (which has been on for 7 hours per day since the 1970s) and although digital media is rapidly proliferating including learning toys, music and phones, total media use by white children had only increased by 38 minutes between 2004 and 2010, though it was more prevalent in low income families and had increased more in BME families. It states there is no evidence yet about how much is too much when it comes to media consumption but states that “media platforms by themselves are neutral; what matters most are the choices made by parents, educators, educational production companies, and other content providers in order to encourage a balanced pattern of consumption” using the metaphor of needing a balanced diet. This was not reflected in Prof Greenfield’s narrative about this amount of media being harmful, and it is unclear how she extrapolated the figures in her table.

Another leap, and we were onto how dopamine is the reward chemical and behind all addictive behaviour. Prof Greenfield said that it changes neural activity, inhibiting the frontal lobes. This is why children are becoming fat, sedentary and obsessed with technology. They are all addictions, and disrupt our frontal functioning. Then a leap to schizophrenia not having sufficient frontal lobe activity, and reverting the brain to sensory processing which is fragmented and without meaning. Another slide full of brains: The prefrontal cortex is not mature until your 20s. Then a claim that schizophrenia, gambling, over-use of screen technology and over-eating have a common pattern of prioritising our senses over reason, due to dopamine making us mindless rather than able to synthesise meaning. It felt very alarming to have schizophrenia and addictions linked to the same pathways as attachment difficulties and technology use. The implication was that parents could cause these difficulties in how they parented babies, or by allowing children to use digital media. These are claims for which I have never read any scientific evidence, despite being a clinician working in this area and trying to keep abreast of the research literature.

Another leap to social media and how it makes us “alone together”. Prof Greenfield told us how real communication is three dimensional, and little of the meaning is conveyed in the words, whilst 90% is in eye contact, body language, tone of voice, perhaps even touch and pheromones. But online we have only the words. According to her, this is why empathy has dropped over the last 30 years (another newspaper headline, not a scientific study, and with no reflection on the socio-political changes that might explain this). The lack of empathy required is why people with autism are so at home with technology and on the internet. People also have reduced identity, so they have to record their existence online. Prof Greenfield characterised the development of online communication as going from describing your cat sneezing on Blogger, to putting up a photo on Flickr, to a video on YouTube, to live Tweeting the action, saying that such activities reflected the author as a disconnected “nobody” who needs to prove they exist. She postulated that a rise in social networking is the cause of reduced empathy and people having a less robust identity, but it seems to me that even if these two things co-occur the direction of causality could be the reverse.

She then skipped on to the evils of video games, inserting a slide with MRI scans to show reduced listening when looking at something else, before blaming video games for the increase in methylphenidate prescriptions. Prof Greenfield claimed ADHD could be caused by video games because they lead to “fragmented attention, shorter attention span and increased recklessness” because they activate the dopamine system. Another headline in a red circle saying children who love video games have “brains like gamblers”. Then she showed us her own work bringing this together: a proposed cycle of how the intense stimulation and immediate feedback lead to high arousal and dopamine release, reward seeking behaviour and this makes brain changes which cause “conditions of childhood, schizophrenia, obesity” and a drive for sensation over cognition increasing the appeal of screen based stimulation in a continuous cycle. Again, I don’t believe any of these claims have appeared in peer reviewed publications or have any evidence to substantiate them, and even if there was evidence of co-occurrence the direction of causality is far from certain. There is however a growing body of evidence that some symptoms that could be interpreted as ADHD-like are caused by early trauma and maltreatment having an impact on neural development. To end that section, Prof Greenfield juxtaposed the “mindless” brain slide with a shot of World of Warcraft and mocked the lifestyle she believed was typical of those who play the game.

Then Prof Greenfield turned her attention to search engines, claiming they give fragmented information but nothing about meaning. By way of example she claimed that you can’t possibly understand what honour is from the search engine results produced by that term. Again, she claimed digital media is all fragmented content, lacking metaphor, depth and meaning. She strongly asserted that nobody could care about a character in a video game like you care about characters in a novel. Again, I would disagree with this. Like any media, video games are very diverse in style and quality and you pick ones that fit your taste, just as you would with a book or a film. If you don’t like violence, don’t pick a violent one. You don’t have the same expectations for the latest chick lit/flick as you do a weighty classic. Some examples are also of better quality than others, some focus on special effects over plot, others are low budget and whimsical. In my opinion if you feel immersed and the story is told well it feels like time well spent and you care about the characters and outcomes, whether the media is a video game, a book or a film. Its disingenuous of her to pick a random game she has probably never played and say nobody could care about a character in it as much as one in War and Peace.

Prof Greenfield then talked a little about the benefits for children of reading with a parent, and how we need to “make up our own minds”. She finished by advertising her books, and claiming that “mind change is the new climate change, the biggest issue facing us in the 21st century”. I’d share the comments on this claim raised here.

The whole felt to me like a mishmash of pseudoscience, headlines and speculation that didn’t even address the topic of the conference. Even if there was persuasive scientific research about the impact of using digital media (which I wasn’t persuaded), it wasn’t relevant to the conference as babies don’t use it. Her talk wasn’t about the importance of relationships between conception and two, which was what the conference was designed to highlight. She had come with a single agenda to sell. And it was clear that she was very much an outsider looking in when it comes to technology; judging it with minimal knowledge of social media, the internet, or video games.

As someone fairly immersed in that world, I could pick out numerous examples of violence in TV, film and video games, particularly violence against women and children. I might even be able to make a prima facie case that we are being desensitised to human suffering (and violence and sexism is being normalised). It is possible that the manufacturers of such products are buying into various ‘exciting’ neurochemical pathways that deal with arousal and reward (cortisol, adrenalin, dopamine), over those that deal with relationships, empathy, love and the ability to soothe (oxytocin and the work of the prefrontal cortex). But I think Susan Greenfield is making a huge correlation-causality error when she blames new media for people becoming isolated and lacking social skills and healthy relationships. I think there is much more evidence that real life experiences of maltreatment prime certain brain changes that make people more sensitive to later triggers and confer vulnerability for later mental health problems (see the work of Prof Eamon McCrory, for example) than that digital media is the cause of the problem.

I do think that if people lack templates for how to do real relationships in a healthy way, and haven’t learnt empathy and self-soothing skills, then these kind of media have a stronger attraction and a different effect on their brain, and can perpetuate rather than ameliorate this pattern. However, in the end I figure that people can always fill their time with something that disconnects them from others, or anaesthetises their pain. In other words, it isn’t the availability of the internet or video games that is the problem (any more than the presence of cheap alcohol, or drugs), it is the unhappiness and isolation that creates the void people want to fill with those things. And that has much more complex solutions, though it might generate less click-bait headlines.

* It is now nearly 3 years on, and I am confident that the clinicians recruited after I left have been able to establish a high quality service, so I would not wish to imply any concern about the services they provide.

** I felt, cynically perhaps, that there was a second agenda designed to promote the MP who founded the project and her political party which was of more importance than our clinical goals, although this was never explicit.

*** http://www.telegraph.co.uk/women/mother-tongue/familyvideo/9273569/New-post-natal-depression-charity-will-address-huge-gap-in-provision.html

http://www.bbc.co.uk/news/uk-england-northamptonshire-18117945

****The promotional flyer for the event said “We are honoured to announce that Baroness Susan Greenfield, Professor of Synaptic Pharmacology at Oxford University, whose speciality is physiology of the brain will bring you up to date on the Science, Neuroscience and Epigenetics”.