mental health

Diagnosis vs difference

I read a recent editorial on LinkedIn about the way that the diagnostic criteria for neurodiversity require “impairment” in functioning for a person to reach the diagnostic threshold. It was an interesting topic for a paper, and raised a set of broader interlinked questions in my mind about whether diagnosis is a recognition of difference-from-the-norm in the way some people’s brain or body functions, or whether it is about recognising something that is harmful (like a disease), or whether it causes distress or impairment / difficulties in functioning (like a disability or mental health condition). In particular it is interesting to think about how neurodiversity fits into that framework, compared to mental health conditions or physical health conditions. It opens questions about the purpose of diagnosis and whether that is about recognition of difference and understanding ourselves, or for gatekeeping access to certain types of support. It also raises questions about terminology – whether we acknowledge that many patterns of need or difference fall on a spectrum, and what we call a disorder or condition.

As it stands, in the current diagnostic rules (DSM 5 or ICD 11) each diagnosis has a minimum set of symptoms described. For example, in the DSM for a diagnosis of autism the individual must have “persistent deficits in social communication and social interaction across multiple contexts” and two or more areas in which they show “restricted, repetitive patterns of behavior, interests, or activities”. These difficulties must have emerged early in development, and not be “better explained by intellectual disability or global developmental delay”. However, to be diagnosed, the person doesn’t just need to have the neurotype of autism or ADHD but to struggle significantly with work, life, mental health or relationships because of it. Symptoms must cause “clinically significant impairment in social, occupational, or other important areas of current functioning”.

On first glance it seems a pretty clear description that could be consistently applied, but the more I’ve thought about it the more problems I see. First of all, the impairment criteria mean that people could waver in and out of the diagnostic category according to how well they are doing in their lives at that point, how well their environment and network support their needs, or their developmental stage. For example, a person could be autistic as a child, but then find a lifestyle, job, community or other niche in which they are happy and successful, and therefore fall below the diagnostic threshold – until a change or stressful life event means that they become distressed, when they would be diagnosable once again. Or they could have very subtle challenges that would not meet the criteria in primary school, but increasingly struggle during secondary school and meet the criteria for diagnosis, but then escape the sensory overload and/or social demands of that setting and no longer meet the criteria again.

That doesn’t make much sense given that autism, ADHD and other forms of neurodiversity are currently conceptualised as lifelong, inate differences in how people process information and interact with the world, rather than conditions that come and go. Neurodiversity isn’t a disease that temporarily disrupts a person’s normal functioning and can be treated to return them to normal. Neurodiversity is normal for that person; it is intrinsic to the way they experience and interact with the world for the whole of their lifespan. A neurodiverse brain is set up with a much wider focus of attention, or more attention to detail, or more propensity for sensory overload than a neurotypical one. A person doesn’t stop being autistic or having ADHD or a learning disability even if they learn strategies to fit in better with other people’s expectations or cope better cope at school or in the workplace any more than a person who is colourblind stops being colourblind if someone provides glasses that increase the red-green contrast.

For that reason, neurodiversity doesn’t fit into the medical model of diagnosis in the same way as mental health problems that may come and go, where a diagnosis may be helpful during the period when a person is experiencing depression or anxiety or psychosis, but may cease to be relevant at a later point – as for many people the symptoms will entirely resolve (spontaneously or with treatment) and no longer impact them. In the case of a mental health condition it wouldn’t be relevant to continue to use the diagnostic label after their symptoms resolve, as the individual may return to population-normative ways of experiencing the world. If we retained the diagnosis it would lose all meaning, as about half the population would end up with it, but most of those would have no symptoms that differentiate them from those without the diagnosis.

I also wondered how the idea of impairment fits with masking. In some cases a diagnosis could be withheld from a person who subjectively feels like they are struggling enormously if they were able to mask their difficulties enough for them to not impair their ability to function in their workplace or relationships during the assessment period. Or could it be considered a signficant impairment that it is exhausting to mask difficulties? Or that the effort of masking or coping with sensory overload all day at school or work means the person then struggles to function at home, withdrawing or becoming dysregulated in a way that might on first inspection suggest the difficulty is located within the home.

However, despite all the reservations I have raised, it is possible to think about diagnosis as only being meaningful when it applies to functioning, and a label for a degree of symptoms that is outside of the normative range. Many conditions are not binary variables that are either present or absent. Illness is quite often a matter of degree rather than the presence or absence of a condition. For example, a person’s glucose metabolism can indicate that they are becoming insulin resistant, but it is only above a certain threshold that the diagnostic label of diabetes would be applied, and certain treatments would be considered. Likewise our blood pressure or weight can be in the healthy range, or below or above that, but a diagnosis is only given if it is sufficiently high to cause significant health risks. There are numerous variables where we can be tested to see whether we fall into the typical range, or whether further investigation or treatment would be benficial – from our levels of white and red blood cells, iron, vitamin D, cholesterol, hormones, to the functioning of our liver and kidneys, markers of inflammation, infection or tumours. The threshold at which doctors diagnose conditions is typically the point at which symptoms start interfering with functioning and/or the pattern identified is known to cause harm, risk or distress to the individual.

Sometimes medics have to determine appropriate treatment without a diagnostic test being available, or where there is not a direct relationship between symptoms and the scores from blood tests or scans. For example, calcific tendonitis can affect the shoulder joint causing pain, reduced movement or even functional paralysis. However, sometimes people with scans that show a lot of calcification don’t report any symptoms, and sometimes people with very little visible in the scans have a lot of functional impairment. Physiotherapy and/or steroid injections seem equally effective at treating symptoms regardless of what shows in the scans. So treatment is typically determined by impairment alone. Likewise, a woman might have lower levels of oestrogen during or after menopause, and this might be associated with certain symptoms like brain fog, anxiety, hot sweats or disrupted sleep. But there is a degree of variation in what level of oestrogen the woman’s body is used to, and the effect she will experience from it dropping that means some women glide though menopause naturally without much ill-effect, whilst others (myself included) would find it entirely disabling without HRT – and this doesn’t map directly onto the level of oestrogen detected in blood tests. For this reason, it is the pattern of symptoms rather than the blood test results that should guide treatment.

Likewise, depression is something that ocurs along a spectrum from very mild to totally disabling symptoms. As is anxiety. There are even levels of the unusual beliefs or sensory experiences that occur in psychosis that would be considered normative – such as thinking you’ve seen a person who has recently died, hearing an internal voice giving you advice, or having strange or intrusive thoughts that you are able to quickly dismiss. In the same way, arguably we are all neurodiverse to some degree – we each have different patterns of cognitive strengths and weaknesses, different ways of processing sensory information, and subjective experiences of the world. But some of us are able to function in the world more successfully than others, with some people constantly feeling discomfort, distress or having to put in huge amounts of effort to do things that others find effortless. It therefore seems logical that it is the level of impairment rather than the neurotype that determines whether a diagnostic label is appropriate – even though this brings both a level of subjectivity to the judgement of whether the label is appropriate and an acknowlegement that the degree of impairment reflects not just the qualities of the individual, but also the qualities of the environment and network that they function within.

It might be that like height or hair colour, sexuality or personality traits, our strengths and weaknesses, there are ways in which we all vary that are not “conditions” that need to be diagnosed but simply differences between individuals. If we conceptualise neurodiversity as this kind of difference, then recognising it can still be a helpful way to understand ourselves, and how we differ from others. It can also help us find our tribe – the people that share our struggles or our interests and talents.

However, all this theoretical debate misses the elephant in the room of how widening the diagnostic range helps people with more subtle impairment recognise their neurotype, at the cost of negating the experience of those with more profound impairment who had historically been able to convey their needs with a label that now gives most people a false impression of much subtler difficulties. What terminology do parents or carers of people with the “autism” described by Kanner (or at the more impaired end of the spectrum described by Wing and Gould) use to describe their pattern of needs? These individuals may be non-verbal, with significant developmental delay, very atypical ways of interacting with others, and obvious stims/stereotypies that instantly mark them out as different to members of the public. This group includes people with autism who are profoundly disabled to the point that they will need signficant financial and practical support across their lifespan – attending special schools, not being able to communicate their needs except through their behaviour, unable to reach independent living, or have the capacity to make decisions about their lives. Having an appropriate diagnostic label functions as a gatekeeper to accessing this kind of financial and practical support.

The problem being that whilst this group have used the label “autism” to describe their needs for eight decades, this is not the same population as now use the word “autism” to describe themselves on social media, to friends or in the workplace. As the diagnostic threshold has lowered to recognise more subtle impairments the label of autism has been claimed by many quite “high functioning” people to self-describe their struggles in a neurotypical world, and – because this group is more articulate and able to speak for themselves – they have come to dominate the discourse about autism, overshadowing the smaller numbers of people with more profound disabilities who had previously been described by this label. The larger number of people who are now included in the same diagnostic category but were previously given the diagnosis of Asperger Syndrome or High Functioning Autism, or seen as having difficulties that were below the diagnostic threshold, typically don’t have the moderate to profound learning disabilities, or need for support in their daily living skills as those who were diagnosed with Autism a few decades earlier. This population group might be independent, articulate, intellectually able, employed, and/or involved in interpersonal relationships including friendships and romantic/intimate relationships. Whilst it is evident that they do find some elements of life harder than neurotypical people, and it is a very helpful and affirming label that lets many people understand why they have felt different to the norm and have struggled with elements of their life, the level of support they require is not equivalent – despite the diagnosis on paper now being the same. A parallel process of widening the diagnosis has happened with ADHD and other elements of neurodiversity, to the point that 10-15% of people now identify with at least one element of neurodiversity, when historically only 1-2% of people were given these diagnostic labels.

This mismatch has therefore become the grain of truth that underlies some very toxic discussions about the growing rate of diagnosis, and the expanding numbers of people claiming disability benefits and adjustments or support within education and the workplace. With larger, more articulate and more powerful groups of voices advocating for the needs of the able end of the spectrum (who often object to any implication of there being a spectrum or such a thing as high vs low functioning or find such labels pejorative), it is hard for the voices of those representing more disabled individuals to be heard. I can understand that we need to respect the voices of lived experience about what terminology they are comfortable with. But some people don’t have voices in this conversation. And it wouldn’t be honest or fair to pretend that the needs of everyone with autism are equal.

The changing use of the diagnostic label doesn’t necessarily relate to the type or degree of support people require, and therefore it may no longer be able to function as a gatekeeper of services. That might still have to rely on an understanding of impairment – the areas in which we are struggling or require more support than the rest of the population. We can’t support everyone equally, that just isn’t viable. We also can’t allow resource rationing to lead the decisions about terminology or diagnosis. But it will have to be consideration of impairment that helps systems to differentiate what levels of support are appropriate – even if that involves subjective judgements, of functional states that are impacted by the environment, and will need to be regularly reviewed over time. Because without us evolving the right language to accurately reflect levels of need, the most disadvantaged will struggle to get their needs met at all – with tragic consequences for them, their caregivers, and the public purse. And, as Mahatma Gandhi is believed to have said, “the true measure of any society can be found in how it treats its most vulnerable members.”

Why I dislike the concept of resilience

The way people talk about increasing the resilience of children who have experienced trauma makes me deeply uncomfortable. Likewise the way we talk about people who have lived through traumatic experiences in their work, bullying or coercively controlling relationships needing to “toughen up” or learn skills to “shake it off”. Worse still, the idea of attributing better outcomes to people with a “positive mental attitude”, “determination” or “grit”. It seems to suggest that there is some inner strength that allows some people to weather trauma better than others in a way that implies that anyone who doesn’t manage to do so is somehow weaker or missing skills we need to equip them with, rather than acknowledging that how our brains and bodies respond to trauma is largely out of our control. None of us know how we will cope under adversity, or how it will affect us later down the line.

It feels like saying the outcome from the scenario in the picture above is defined by how well the character can use his shield, not by the size or temperament of the monster, the landscape, the weather, or even the character’s age, size, speed, intelligence or strength.

Resilience is defined as “the capacity to withstand or to recover quickly from difficulties; toughness” (Oxford English Dictionary) or within psychology as “the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility” (APA) and they tell us that “the resources and skills associated with resilience can be cultivated and practiced”.

I’ve got a number of problems with this.

First and foremost, I don’t think it is a helpful way to conceptualise the issue. The responsibility for the impact of trauma should sit with those who perpetrate harm*, not on victims. If you think about other forms of adversity like cancer, car accidents or crime, we work on prevention and recovery; we don’t expect people to be resilient to these things. We broadly understand that the extent of their injuries, the treatment required, the impact on their life, and the time it will take to recover, are largely out of their control. In the same way, we need to understand that there are many types of trauma, with different qualities like duration, severity, numbers of perpetrators and the degree to which it undermines trust. Each trauma is set in a different context, and impacts on different individuals, with different resources and sources of support. But even if we map the type and severity of trauma there is no direct relationship between the nature of the trauma experienced and the symptoms the individual will experience.

Secondly, the individual factors in outcomes from trauma seem to be outside of the person’s control. They are determined by chance (eg being in the wrong place at the wrong time), or our biology and epigenetic factors (eg the length of our telomeres, the protective caps at the end of DNA strands that shorten with each cell division, are impacted by our genes but also shortened by trauma), or related to the quality of our relationships (eg having any one reliable attuned relationship is protective), and our socioeconomic status (eg ability to eat a healthy diet and avoid stress) rather than to do with an individual’s mindset. Research that purports to measure individual differences often appears to measure elements that are impacted by experience. For example, one pop psychology article explains “instead of falling into despair or hiding from issues by using unhealthy coping strategies, resilient people face life’s difficulties head-on. People with resilience do not experience less distress, grief, or anxiety than other people do. Instead, they use healthy coping skills to handle such difficulties in ways that foster strength and growth, often emerging stronger than they were before”. But it seems to me that the ability to use these coping strategies depends on intelligence, relationships and past experience.

In the same way, survivor stories are often framed in terms of perseverence, bravery and determination rather than factors outside their control. I’m not denigrating the value of people with lived experience telling their stories – they are important for other people to hear to understand the nature of problems in society, and important role models that life after trauma is possible for people earlier in that journey. But we need to be careful not to extrapolate that the admirable qualities they now demonstrate were the reason they now seem to be unscathed by their experience (or part of post-traumatic growth). Actually it might have taken immense work to get to the point that their lives are going well and they are able to talk about their experiences. Just like the way the people we see most in the gym are the fittest people, the people able to talk about their experiences of trauma may be those who have the intelligence, reflective capacity, time and support to process their experiences and talk about them in a way that appeals to the audience.

Thirdly, we all tend to attribute too much of many outcomes to individual factors, and too little to external factors that come down to luck. Rich people frequently attribute their success to hard work, without realising that many people who work harder fail to reap the same rewards. Top athletes attribute their success to talent and hard work, but fail to recognise that month of birth and access to facilities play a significant part in their success (people born earlier in the school year tend to be larger and better coordinated, and therefore get more practise and experience of success that leads to greater confidence and opportunity). And it is the success stories that get told to larger audiences and seep into the culture. Was the key factor in the story of a six year old who saved his mother by alerting a delivery driver to her seizure his bravery or was it the stroke of luck that someone was around at the right moment? We like the story with internal locus of control as it gives us hope and makes us feel less powerless in the face of overwhelming or unpredictable threats.

That isn’t to say that there aren’t things that can be done to aid recovery from trauma. Of course learning to be compassionate to yourself, being able to talk about your experiences and having ongoing supportive relationships that help you recognise that what happened was not your fault are all important in aiding recovery. However, these aids to recovery should be focused on how the individual feels, rather than to what degree their distress is visible from the outside. We have learnt from social skills training in neurodiversity that looking normal to others can be performative, and something done at high personal cost to wellbeing. I think there is a risk that in some cases perceived resilience might be just how well a person can mask the impact of trauma.

*and anyone who knows about abuse and has the power to prevent or report it, but fails to do so (from politicians, heads of the church, and powerful figures in each industry through to relatives, colleagues and bystanders).

Our relationship with alcohol

Today an article from WHO about reducing the harm caused by alcohol around the world has got people all fired up on social media. The article has slightly clumsy wording about prevention of harm to unborn babies from alcohol, that some people have interpreted as a recommendation to prevent women of child bearing age from being allowed to drink. In response people have jumped in as much to defend/normalise drinking as to stick up for women’s rights (and to rightly criticise the way certain other types of risks from alcohol are only mentioned by reference to other documents, such as the risk of interpersonal violence, or not mentioned at all, such as the risk of perpetrating or becoming a victim of sexual assault). Having tried to reply on twitter but ended up with a mega-thread, I thought it might be preferable to respond fully in a blog post about our relationship to alcohol, including some links to relevant psychological theory.

Before I begin, I should note that I’m not an unbiased observer on this topic. For the last 30 years or so, I have chosen to drink very little alcohol (typically about 5 units per year) as I don’t particularly like the taste of most alcoholic drinks, or the way I feel after the effects have worn off. I also had a very negative experience of being drunk early in my life (see this blog entry, which comes with a trigger warning about sexual assault). That led me to often choose to be the driver or the person who stayed sober on nights out, which also gave me a rather atypical perspective on alcohol – as I was often the person who was looking after the person who had puked up or passed out, or was vulnerable to sexual assault. Speaking of which, I have previously expressed some strong opinions about whether alcohol is an excuse for behaviour (it isn’t; blog also deals with sexual assualt).

So, I am fully on board with the criticism that any global policy about alcohol needs to mention its association with interpersonal violence and sexual assault. We know that drugs and alcohol are often the source of disinhibition for abusers (and can be a step used in overcoming inhibitions for those who feel guilt or social pressure, such as in Finkelhor’s model of factors neceesary for child sexual abuse to occur). We also know that they are often used to create vulnerability in victims (eg with use of drugs in alcoholic drinks by rapists like John Warboys and Reynhard Sinaga) and that the vulnerability of intoxication is frequently exploited as an opportunity for sexual assault. As BPAS say in their response to the document “In the UK alone, more than a third of sexual assaults, more than 39% of all violent crimes, and nearly 1 in 5 incidents of domestic abuse are committed under the influence of alcohol” and this clearly needs to be mentioned in a document about reducing the harm caused by alcohol around the world, more than by passing references to other WHO documents about violence.

However, I’m also someone that believes in preventative and health promotion interventions like schemes to provide healthy food for pregnant women and young children, or the tax on sugary drinks. So it should come as no surprise that I’m broadly in support of measures to reduce problem/excessive drinking and tackle the culture of binge drinking amongst young people. I think a minimum price per unit of alcohol, and more education about alcohol (and drugs) and their risks and benefits would be a good starting point. This should ideally be part of the national curriculum for children, and something that is revisited at developmentally appropriate levels.

So, with my general opinions laid out, let us return to today’s publication. The WHO document is called “Global alcohol action plan 2022-2030 to strengthen implementation of the Global Strategy to Reduce the Harmful Use of Alcohol” and is clearly marked as a first draft. The statement that has been perceived as controversial is that they recommend we “raise awareness among decision-makers and the general public about the risks and harms associated with alcohol consumption. Appropriate attention should be given to… prevention of drinking among pregnant women and women of childbearing age”.

To state something I hope would be obvious: Taking a literal interpretation of this sentence to mean that all women of fertile age should be prevented from drinking alcohol would be ridiculous and awful. I strongly agree with the critics that women are more than just breeding vessels, and that it would be massively disproportionate and set back women’s rights to prevent all women of fertile age from drinking on the basis of potential harm to a foetus. There are many complex and interwoven issues here, the way that gender and fertility have been conflated ignores the presence of anyone trans, intersex or with any of numerous medical conditions that can create infertility. It also assumes that all women are sexually active and none are using contraception or taking any control over their ability to conceive. Taken literally this therefore extends guidance that is perfectly logical for sexually active women who are fertile and not using contraception to every person identifying as female under the age of 50. However, I hope is a thoughtless omission in their wording rather than the intended meaning. It also assumes that any consumption of alcohol at any stage of the pregnancy is potentially harmful to a foetus, which does not appear to be entirely supported by science (where to the best of my current knowledge it would appear that low consumptions of alcohol have not been associated with harm and there are particular windows during pregnancy in which harm to the developing foetus is more or less likely to occur). Thus advice to avoid excessive or chronic consumption of alcohol during pregnancy appears to have been extrapolated into advice for all women of fertile age to consume no alcohol at all. And that clearly needs to be clarified as this first draft is developed into the final published document.

However, I genuinely don’t think that is the intended meaning here. The document doesn’t mention the rights of the foetus being more important than those of the mother as some critics have inferred (in fact it doesn’t even use the word foetus). Nor does it call for bans on the sale of alcohol to women (in fact it doesn’t even expand on the topic of female alcohol use at all). It only uses the word “women” four times, twice in that sentence, once in relation to mortality and once when talking about the incidence of alcohol use disorders. It literally just says the one sentence I quoted above.

I can see that the wording of the relevant sentence is slightly clumsy, perhaps because of international authors, but It is my belief having read the full guidance that this document is not advocating an unreasonable curtailment of the freedoms of women. Whilst it mentions “prevention” of women drinking, this is in a section entitled “Advocacy, awareness and commitment”. It is written in the context of preventing harm by reducing the social pressures encouraging excessive drinking and providing information about risks that would lead to informational campaigns discouraging children and pregnant women from drinking. It is not an assault on feminism or suggesting that states increase authoritarianism.

And importantly, this isn’t a personal message to individual female readers. It isn’t some jumped up know-it-all judging you for having glass of wine or two in the evening to unwind. It is a draft policy statement proposing educating people around the world about the risks of drinking whilst pregnant in the hope that more women choose to abstain. If you are past menopause, or not sexually active, or use contraception, or drink little/no alcohol, or for any of a myriad of other reasons aren’t going to end up binge drinking before realising you are pregnant, this message to reduce or cease alcohol consumption is not for you. You can let go the anticipated reproach and stand down.

Whilst the tabloids are trying to make this into a big deal, this fits with their xenophobic British exceptionalism agenda, whereby they are dismissive of international bodies, experts and science and try to frame them as limiting personal freedom and autonomy. So when they use stories like this to fuel the “nanny state curtails our rights, its political correctness gone mad” narrative, remember that each of these little fires is built to distract from the way the government are slowly attacking our rights and the safeguards over their power like the right to call for judicial review of government actions, GDPR and the protection of our data from commercial exploitation. Like the fantasy that conservative voices are being cancelled/silenced by an oversensitive generation of woke snowflakes rather than that market forces mean racists and sexists are increasingly feeling the rightful consequences of their repugnant views, or the way that taking the knee to acknowledge racism exists and needs to be tackled has become some unpatriotic politicising of football, this is just a distraction technique. These stories distract from the unlawful crony contracts that have funnelled public funds to friends of cabinet members, the way politicians no longer resign when they are found to have been dishonest, the failure of Brexit, growing inequality, the mess they have made of the pandemic and all the other ways the Overton window has shifted right and the current pack of corrupt incompetents are making a mess of governing the nation.

I think the best way to look objectively at the issue here is to let go of the wording and look at the overall tone of the message. WHO advisors are trying to reduce rates of death, disability and children harmed by foetal alcohol exposure. Surely that is a good thing? It is directly parallel to trying to prevent cancers/disease and harm to others from smoking (including during pregnancy or around young children) – something that was socially acceptable until surprisingly recently. Smoking is (or at least was) another choice that some people find enjoyable, but scientific studies associated with excess mortality. If we saw a publication warning women about smoking harming an unborn child it would probably not immediately make people want to post “oh just reading this makes me want to smoke a whole box of cigarettes”. So I wonder, objectively, why a twitter post replying to the report saying “I’m not sure where to start with this. Maybe by opening a bottle of wine?” has received so many likes?

For context: Alcohol causes 3 million premature deaths a year – that is more than tuberculosis, HIV/AIDS and diabetes. This includes 13.5% of all deaths among 20 to 39-year-olds in the world. In Russia and eastern Europe, nearly a third of people’s lives are shortened by alcohol use, though the rate in the UK is about 3.4%. In the USA research shows that alcohol contributes to about 18.5 percent of emergency room visits and 22.1 percent of overdose deaths related to prescription opioids. Around the world about 1.4% of people are considered to have an alcohol use disorder, with the highest prevalence in Russia and neighbouring states, where it is about 5%, and Brazil and Greenland, where it is about 3%. In America the diagnostic rate is higher (at about 5%), but it is unclear whether the prevalence is higher or the thresholds for diagnosis are lower. Globally, alcohol use disorders lead to 185,000 deaths per year, with around 2300 in the UK. This number has increased considerably since the 1990s, but has been fairly steady for the past 15 years. Few of these people receive formal treatment, with only 5-6% getting treatment in the UK. The incidence of alcohol use disorders increases significantly for those with mental health problems, showing that either the same stressors can lead to both outcomes, or that mental health problems can increase the risk of alcoholism or vice versa.

Problematic alcohol use can either take the form of binge drinking – where the drinking is excessive in quantity, but happens intermittently, perhaps once or twice a week, or on particular occasions or where the individual gets together with a particular social group – or chronic and excessive consumption (where the individual drinks every or almost every day over a protracted period of time). Both patterns are surprisingly common.

About 25% of the population meet the criteria for binge drinking on surveys about alcohol consumption, whilst around 7% report heavy drinking (5 or more units per day on 5 or more days during the last month). Even within geographic regions, there is a high level of variation between countries: in Italy, only 6 percent of drinkers had a heavy episode of drinking during the past month in contrast to nearly half in Ireland; 42 percent in Belgium one-third in the UK and France; and 20 percent in Spain. Binge drinking is particularly common amongst students and young adults, with around 50% of those who have ever drunk alcohol reporting in surveys they had drunk to the point of blacking out at least once, and 10% reporting a blackout associated with drinking in the prior two weeks. If some of those young women are becoming pregnant (perhaps due to sexual encounters when intoxicated), that level of drinking could potentially be a significant risk factor for the unborn babies.

Drinking alcohol to excess can also lead to other additional risks for the drinker. Whilst the immediate effects of alcohol are usually perceived as pleasant, and resolve fairly quickly when drinking stops, they can lead to memory lapses, poor judgements and an increased risk of accident and injury (as well an increased risk of sexual assault). Blackouts can involve potentially dangerous behaviour and loss of consciousness. Binge drinking is known to increase the risk of medical crises, and is a significant contributor to the number of people who present at A&E. Studies show that compared with people who did not binge drink, people who drank alcohol at twice the recommended thresholds were 70 times more likely to have an alcohol-related A&E visit, and those who drank three times as much as the recommended limit were 93 times more likely to present there.

Alcohol also presents other less acute risks of harm. The effects of alcohol on the body become more severe with larger volumes consumed over extended periods of time – with particular risk to the liver, heart and brain. Changes to the brain can eventually disrupt memory and lead to Korsakoff’s syndrome. Alcohol is also physically addictive, with greater risks associated with sudden withdrawal than most drugs.

There are no hard and fast rules, but chronic excessive use appears to follow a different pattern to binge drinking, which is typically social – perhaps because the cost of alcohol in quantity soon prohibits this being consumed at pubs and clubs, or because of the pattern of drinking, or the impact of the level of intoxication on social functioning. The reality of problem drinking is, like most things in life, a bit more complicated than simply being the upper section of a spectrum of consumption. It seems to have some biological components, marked social components (eg when alcohol is used to cope with social situations or fit with peers) and is often cumulative over time. As with most addictions serious alcohol issues are often rooted in combinations of learnt behaviour and exposure to trauma. Impoverished or abusive relationships in childhood set a harmful template that can lead to dysfunctional coping strategies and relationships later on. These can create patterns that reinforce problem drinking, and masking the drinking can disrupt supportive relationships.

However, it is not just in the context of alcohol misuse disorders that alcohol causes harm and excess mortality. Alcohol also increases mortality via road traffic accidents. In South Africa and Papua New Guinea more than half of all traffic deaths are attributable to alcohol consumption. In the US, Canada, Australia, New Zealand, Argentina, and many European countries alcohol is responsible for around a third of all traffic deaths. Alcohol is also implicated in more than half of all crimes in the UK – either because the crime involves alcohol (eg drink driving, drunk and disorderly, theft of alcohol) or because the person committing the crime had consumed alcohol (eg in violent crime, assault or criminal damage). This is higher than elsewhere in the world where this has been studied.

Alcohol also causes Foetal Alcohol conditions that can have a lifelong impact on the brain. NICE say the exact incidence is unknown, but it was thought that about 7.7 people per 1,000 worldwide are affected, and 32.4 per 1,000 population in the UK. A study following up a cohort of births looking at possible symptoms suggested the prevalence could be as much as 6 to 17% of the population. The official UK advice is that the safest approach for women who are pregnant is not to drink alcohol to minimise risks to a baby. However, multiple sources suggest that 41% of pregnant women in the UK consume alcohol, and research shows women are not universally given information about the risks of alcohol during pregnancy (with 30% of those who drank before pregnancy reporting getting no information on this topic from maternity services, and only 29% of midwives saying they routinely share this information). The messages about how much alcohol is safe are unclear. There is a consensus from the stakeholders that NICE consulted that education and raising awareness of the risks of drinking alcohol in pregnancy is necessary, and 91% of alcohol bottles sold in the UK now warn against drinking during pregnancy. So it should be no surprise that the WHO also feel that women around the world who are pregnant or who may become pregnant (because they are of fertile age and are having sex without contraception) need to be aware of the risk posed to a baby by excessive alcohol consumption. Reducing alcohol consumption in these groups will reduce harm.

Yet as soon as reduced consumption of alcohol is mentioned, it brings out an almost reflexive response. I think some of that is “anticipated reproach” – the defensive (but often antagonistic) response people have to anyone they feel may judge them negatively, which can sometimes be combined with “do-gooder derogation” the feeling that anyone taking the higher moral ground about an issue personally, or taking action to resolve it, must be pompous and judgemental. Anticipated reproach has been studied by Benoit Monin, who has shown the effect in relation to everything from vegans to racism. We can see that playing out in the response to this WHO report. People want to speak out for their right to consume alcohol, and don’t perceive it as harmful (except in others with obviously excessive drinking).

The pandemic has also conflated unrestricted access to alcohol with the idea of personal freedom and agency. Closing pubs has been seen as more of an imposition on our rights than closing schools – particularly for the vocal anti-mask/anti-vax brigade (I wonder if there is some overlap between views about pub-drinking and a rejection of broader progressive values? It certainly seems to be associated with covid denial, Brexit-voting, and dismissal of expert advice, which I associate with a kind of disenchanted malaise that comes from underachievement and a feeling of being cheated by the changing social contract that makes people vulnerable to alt-right propaganda).

But I think this positive and normalising view of alcohol long predates the more recent changes to the socio-political environment, and the increasing polarisation of society. Alcohol has been embedded in our culture for thousands of years, and it holds an important role in social engagement and special occasions. So for most people it has positive associations. It is also an example of something where many people use the substance, yet comparatively few are harmed by it (the same could be said of illegal drugs like cannabis). So (as with the “just say no” campaigns that portrayed illegal drugs in entirely negative terms) dramatic warnings about potential harms don’t tend to chime with personal experience, which may be another reason for the defensive response.

The annual global average alcohol consumption is equivalent to 6.4 litres of 100% proof alcohol per adult per year. This is equivalent to 53 bottles of wine or 225 pints of beer (a bottle of wine or 4.5 pints of beer per week). In the Middle East and north Africa (which contain many Muslim nations where alcohol is frequently prohibited for religious reasons), consumption is much lower than average and often close to zero. In eastern Europe (and Nigeria) consumption is typically double the global average, and western Europe is not far behind. The UK, Russia and Australia are also well above the global average. However the type of alcohol, age and gender of drinkers, and the patterns of consumption vary from place to place. Broadly beer is quite widely consumed outside of the middle east, wine is most popular in Europe, Australia and southern South American nations, whilst spirits are most popular in Asia and Russia. In the UK the consumption of wine has increased steadily over the past three decades, whilst consumption of beer has reduced. The highest percentage of income is spent on alcohol in Europe and Australia – with Ireland being an outlier where around 7% of income is spent on alcohol. In general wealthier individuals drink more, although there is not a higher incidence of problem drinking.

For most people alcohol is a pleasurable mild intoxicant. And most people consume alcohol in moderation, where the impacts on health are more debatable (and in some cases even suggested to be positive – especially when it comes to wine as a component of a Mediterranean diet). So we do have to set the concerns about harm in context with the fact that many people derive pleasure and little or no harm from their alcohol consumption.

However, even when it comes to foods, consumers are increasingly given a warning of the fat, salt and sugar content, so that they can make informed decisions about their health. This balancing of benefits and risks is also something we are familiar with when it comes to the leaflets enclosed with prescribed medications, and has been in the spotlight in relation to the coronavirus vaccinations – where potential harms, like the tiny proportion of people who have had blot clot related complications, have dominated the discourse, despite the fact that for the vast majority of people it is protective and side effects are relatively trivial. Perhaps it is a good precedent that the benefits and risks of something have to be clearly explained even when there is widespread consumption?

After all, alcohol gets lots of positive messages to the public every day. There are numerous adverts showing beautiful, healthy, happy people engaging in social drinking. But on top of this, alcohol gets advertised from peer to peer. I see lots of social media posts about drinking, and almost all have a positive or light-hearted tone. Research corroborates this – surveys of social media show that posts which picture or talk about alcohol use show happy social occasions, groups of people interacting, romantic settings and chilled nights in. They talk about fun and exciting experiences, celebrating, dancing, dating. Posts rarely show risks or consequences. There are numerous memes like “wine o’clock” or “just a little glass” with a picture of an enormous glass of wine, as well as many references to alcohol as a survival strategy or a means to cope with parenting. Comedians joke about binge drinking and Irish weddings. I’m not sure people think about the impact before sharing posts or memes that feature alcohol, but studies show that exposure to alcohol posts on social media leads to increased alcohol consumption (why else would alcohol companies spend billions on advertising?). This means that seemingly harmless posts can potentially have negative impacts on others. This might particularly be an issue for those who have a problematic relationship with alcohol. Studies have also shown that people who post about alcohol consume more of it.

Yet it seems we each normalise our own consumption. Alcohol consumption and related risk is influenced by how the person perceives they compare to others in the population (if they believe others drink as much/more than they do, they believe their drinking is less risky). This is compounded by overestimating norms. So the more we drink, the more we assume others drink to subconsciously justify our own drinking (the same pattern also appears to be true of drug use, or sexual behaviours). The influence of social norms is a whole field of psychological research.

But I think that this can also happen at the societal as well as the interpersonal level. There has long been a tendency to encourage/normalise drinking in the UK that leads to people not recognising excessive/harmful use. Perception of alcohol use varies by drink, context, time and characteristics of the drinker. Adults typically regard themselves as moderate drinkers and disapprove of excessive drinking by others. We are not very good at judging the threshold at which alcohol use can be harmful, particularly when we are amongst others who consume alcohol in large quantities. I’ve met many who normalise drinking vast amounts (eg >40 units in a day). So maybe, like smoking and sugar consumption, and our lack of physical activity and increasing obesity, we do need to think more about harm minimisation?

Alcohol causes 24,000 deaths and over 1.1m hospital admissions each year in England, at a cost of £3.5bn to the NHS. Yet at the moment, the only labelling of alcohol to indicate risks is voluntary, as is the industry funded Drink Aware campaign (which sprung from the Campaign for Smarter Drinking instigated by my business mentor and NED Richard Evans before he left the drinks industry). Like the similar Gamble Aware campaign, the aim springs from corporate social responsibility and is intended to maintain profits and consumption whilst reducing harm – which could be considered to be competing interests. Experts say that the drinks industry would lose 38% of their income if drinkers kept to recommended guidelines, losing £13 billion per year of sales, which is why they are so reluctant to promote accurate information about the risks involved. So once again, there is a weighing up of corporate profits against public health. A minimum price per unit of alcohol and increased duty to subsidise costs to the NHS and the impact of alcohol-fuelled crime (eg police, services for sexual assault, refuges for survivors escaping domestic violence) might seem to be appropriate steps towards getting that balance right, but the public really don’t seem to like the idea of raising the cost of their simple pleasures….

The elephant in the room: Mental health and children’s social care services

I heard a few months ago that the Housing, Communities and Local Government Select Committee were undertaking an inquiry to look at the funding of local authorities’ children’s services, and thought that sounded like an interesting topic that might relate to my areas of interest. I therefore met with a local MP about the topic, contributed to the BPS response to the inquiry, and (on the request of the committee) submitted my own response in relation to my innovative work with BERRI. I have subsequently been called to give evidence in person to the enquiry in a few weeks time.

Given I’ve been so immersed in this issue it seemed a good topic for a blog. I’m going to start with the evidence that this sector is in crisis, before thinking more about what a clinical psychologist like myself can contribute to addressing elements of this need. Hopefully I can then write another blog in a few weeks time to talk about my experience of giving evidence, and report back about whether the politicians grasp the issues and appear motivated to do something about it.

It didn’t surprise me that this was an issue that the government wished to give more scrutiny, given the steep increase in need in this area over the last decade, whilst funding for local authorities has been substantially reduced by the government’s austerity agenda. Human distress and unmet need rarely seems to gain political attention unless it is in such a crisis that the public are aware of the issues, or it has financial implications for the public purse, and children’s social care has suddenly hit both of those thresholds in the last year or so. 

A number of factors have combined to increase need in children’s services. This includes growing awareness of child abuse and its impact (particularly emotional abuse which has long lagged behind the more tangible forms of abuse), along with reduced stigma in disclosing having been abused (due, for example, to the publicity surrounding the Jimmy Saville scandal, the various institutional abuse enquiries, and the #metoo movement) and a reduced tolerance for forms of abuse that had been normalised or ignored in the past (due to cases like Baby P and the Rotherham child sexual exploitation trials, and subsequent prosecutions in many other areas). A lot of teenagers who had been allowed to remain in unsuitable living circumstances because of the belief that they would “vote with their feet” if removed are now appropriately protected and brought into Care, perhaps because of some precedent setting cases in which people have taken successful legal action against local authorities and have been compensated for failures to protect them in childhood. This includes an enormous legal settlement for two Care leavers from Jersey, who have received tens of millions of pounds compensation.

Children in Care are also entitled to stay in their foster placements up to the age of 21 where they want to and it would be beneficial for them, and to have support after leaving Care from a personal advisor until the age of 25. Another pressure is the reduced use of secure units on welfare grounds, and a reduced willingness to incarcerate children in institutions for recurrent minor offending. The increased stress, shame and social hardship of benefit changes and increases to cost of living has led to move children growing up in poverty, and more families developing the risk factors that can cause harm to children, such as drug or alcohol use, mental health problems, domestic violence and family breakdown. This has had a particularly negative impact in families in lower socioeconomic groups.

It is therefore unsurprising that over the same period of time the demands for social care services have risen steeply. Over the last decade there has been a 9% increase in referrals to social care and numbers of children considered in need, but there has been a 84% rise in child protection cases, and 26% more children are in Care. This creates a lot of additional workload for children’s services, with a 122% increase in demand for section 47 enquiries, and a 125% increase in Care Proceedings (as less children are now informally Accommodated with parental consent). Yet the budgets have shrunk, so there is no resource available to meet this need.

The financial picture is genuinely shocking, and yet it has hardly made the news (perhaps because looking at the numbers is considered too technical or boring for the lay public, and the political and news agenda has been hijacked by the continuing debacle of Brexit). But reviewing the figures makes sobering reading. The cuts to local authorities since 2010 are unprecedented. The National Audit Office highlighted the extent of the shortfall in their report on the financial sustainability of local authorities published last year. They point out that central government spending on social care has halved. This has been masked by changes in how funding is delivered, and some additional funds from council tax being made available to spend locally, but the cuts are still enormous and amount to a real terms reduction of nearly one third of the entire budget for local authorities, but the burden is again being disproportionately felt in more deprived areas.

Such cuts are unrealistic and unsustainable, as they make the total budget too small to cover anything other than statutory services, which are legally protected. This means that councils have no means to make ends meet without dipping into their savings. The report shows that two thirds of local authorities had drawn from their reserves by 2016-17, so there is an ever decreasing amount left in the pot for contingencies, and the audit office predicted that 11% of authorities will empty that pot by the end of this financial year. Councils are having to sell off properties and come up with increasingly radical plans to try to fulfil their minimum duties. Recently Northamptonshire County Council had to declare themselves bankrupt as they had no means to cover statutory services from the available budget.

This mismatch between demand and resourcing has led to enormous cuts to non-statutory services, with two thirds of the spend on preventative and community children’s services disappearing. This means that, as with mental health, there is a minimal set of brief services delivered for milder or less entrenched difficulties, but that there is then an abyss in which no services are available until they reach the threshold for the crisis-focused specialist services – which are expensive and time-consuming to deliver and can’t keep up with demand. The focus has moved from collaborative work to assessments and interventions that are perceived as the end of the line, despite the absence of the precursor interventions that might have enabled change.

To me, the elephant in the room when it comes to children’s social care is mental health need. I don’t just mean the clean single-condition, diagnosable treatable mental health need that gets through the doors to CAMHS. That’s the need up on the sterile concrete plains of mental health research that Prof Miranda Wolpert describes so well. I mean the real messy need down in what Miranda calls the swampy lowlands where real complex people live in varied circumstances, where numerous issues intersect to create barriers in their lives that are not straightforward to address, and do not fall into the simple diagnosis to treatment pathway that currently gets through the doors to CAMHS. That’s the need that determines the outcomes for these children, and the pathway on which they leave Care and try to negotiate adulthood. It is that need which determines whether they can go on to happiness, employment and family life or whether they become one of the Care leavers who end up facing prison, homelessness, mental health problems, addiction, conflict and/or their own children going into Care.

So what are these broader mental health needs? In my experience, a complex and interwoven picture of trauma, adversity, behaviour problems, attachment difficulties, developmental disorders or delay and mental health needs is typical of children in Care or receiving social care services. As well as the traditional “mental health” needs of anxiety and depression I see a much broader picture that is expressed in a variety of ways. Some children act out with their behaviour, others withdraw and show signs of emotional difficulties (including low mood, poor self-esteem, and a lack of positive identity or perception of belonging). They often struggle to form healthy relationships/attachments to others, and can present a risk to themselves and others. They have an increased prevalence of conditions like Learning Disability, Autism, ADHD, or psychosis that add an additional layer of challenge in standard services effectively meeting their needs. That is why my BERRI assessment system attempts to cover all of these areas.

Seen as a group, children who are Looked After have high levels of mental health difficulties (45% have a diagnosable condition, and over two thirds have significant mental health need), so it would be easy to blame the Care system. However, this extraordinary level of need is predominantly caused prior to them coming into Care. It is well established that Adverse Childhood Experiences lead to multiple layers of vulnerability, and these are very prevalent for Looked After Children (my own research suggests an average of 4 historic ACEs per child, along with 2 current vulnerability factors at the point they come into care, such as involvement in gangs, sexual exploitation, school exclusion or the criminal justice system). Looked After Children are in the vast majority traumatised children, who have experienced abuse and/or neglect. But these problems don’t occur in isolation. They are contextually embedded. Children in Care come disproportionately from families that experience the adversities of poverty, crime, family breakdown, and poor housing. They are more likely to be born to parents who have lower education, higher risks of unemployment, and a higher incidence of mental health problems, substance misuse, domestic violence and a history of abuse or neglect in their own childhoods. As a result, their parents are less able to provide safe and stable care. Patterns of difficulty often carry through many generations of the family, and the problems they face are a symptom of our increasing social inequality. 

However, CAMHS are not really set up to meet these complex and interwoven needs, and cut off at 18 years of age, whilst children can stay in care until they are 21 and receive leaving care services until the age of 25. They also have ongoing needs that will need to be revisited over time as they develop or different themes emerge as they enter different life stages or face different challenges. It might be that a dental care model, in which there is long-term oversight but with responsive services as and when they emerge works better than the time-limited episodic care that is currently on offer. Likewise services need to be embedded so that they collaborate with placements and other support services, rather than stand in isolation.

The wider context of the underlying contextual and vulnerability factors mean that treating symptoms or even specific conditions might be an ineffective model of intervention. We need to think back to Maslow’s hierarchy. These children first and foremost need their basic needs met, and to have reliable food, shelter and warmth. They need safety and security, medical care and an environment that doesn’t contain ongoing risks. They need opportunities for identity and belonging, such as education, employment, hobbies, peer relationships, and family. They need intimacy and trust in their friendships, sexual/romantic relationships and relationships with carers. When that is reliably in place they need opportunities for achievement and being valued, so that they can gain self-esteem, confidence, status, responsibility and individuality. The icing on the cake is then self-actualisation, the chance to explore creativity, set goals, reflect on morals and values, and feel purpose and fulfilment. Mental health needs only fit in mid-way up that pyramid. We cannot expect a child to have a positive outlook and good coping strategies and social skills if they are not in a safe environment, don’t have their basic needs met, or cannot trust those around them. To see the point of going along to a therapist takes enough self-esteem to believe you deserve to feel happier, and you then need the organisation and social skills to get there, and the trust to confide your story, or a carer who will advocate for you and help you to achieve these steps. There are many building blocks that need to be put in place by the caregiver and environment before therapeutic interventions are possible, and it may be that when we get these other elements right, the child is able to recover using their own resources and that of their caregivers, without ever seeing a therapist.

My perspective is that if we can help to identify needs of children as early as possible and skill up the caregivers and the systems around the child, we can make the most impact. That is why I have increasingly moved from working with individual children to working with their caregivers and the systems that surround them, and have developed the BERRI system to identify needs and help carers understand them, as well as developing and delivering training to help carers and professionals understand the needs of the children and young people better. It doesn’t have the depth of working psychologically with a single individual, but it has the scope to make impact on a much wider scale, and it fits better with my personal strengths and interests. As I’ve said before, I’m not the most patient therapist to walk a long journey of recovery or personal development with a client, but I do have strengths with assessment and evidence-based practice.

My aims have always been to address human needs. I believe that Clinical Psychology in its simplest form is an attempt to make people happier and more able to lead fulfilling lives, and that is what drew me to this profession. And within that broader mission, my focus is to work with the most vulnerable members of society at the earliest possible point in the lifecycle, which has brought me to working with Looked After Children and the broader population of children and families receiving (or in need of) social care services. Recognising the mismatch between the level of need and the resources available to meet that need has increasingly led me to focus on systemic and population level interventions. Rather than drowning in the burnout that comes with trying to solve an overwhelming problem, I’ve tried to find a niche where my skills can make an impact. Having looked at this population group from multiple perspectives, and tested out projects in various settings, I have become increasingly persuaded that there is scope to make positive changes through the use of better systems to identify need, and increased clinical governance over the choice of placements and interventions. 

I have tried to develop practical, cost-effective ways to make a difference, and to gather evidence of their efficacy. I have then tried to share my findings, and what is already known from research, with the widest and most influential possible audience. That is why I have given so much of my time over to writing best practice papers and contributing to policy. Through these experiences I have gradually learnt to shape the messages I share to make them relevant and understandable to various audiences. After all, whilst most of psychology seems common sense to those of us working in the profession, once you have learnt about the main findings and the methodologies for gathering knowledge, to lay people (and professionals, commissioners and politicians) it might seem very complex and unfamiliar. Over time I have learnt that being able to articulate the financial benefits of improving people’s lives helps to get decision makers on board. So my goal in responding to the enquiry was to explain both the human and financial case for greater psychological input for children receiving social care services. I don’t know how well I have achieved that, but I’d be interested in your thoughts and feedback.

Sticking plasters

I realise that this title won’t mean much to Americans or people outside the UK, so let me share a small anecdote by way of explanation before I get into the topic I want to discuss. I was on an American airlines flight back from New York in 2003, having done a lot of walking around the city over the preceding week. When I removed my shoes and straightened my socks it transpired that a burst blister had adhered to my sock, and it started to bleed surprisingly profusely. I asked a member of cabin crew for a sticking plaster, and got entirely blank looks in response. When I explained the situation, a steward showed a sudden look of recognition and sighed “oh, a Band Aid! I keep one of those in my wallet for my kids” and provided what I needed. So yes, a sticking plaster is a Band Aid – an adherent protective dressing for a small wound.

I found it quite an insight into American marketing, as I had also tried to buy antihistamine cream in a drug store to utterly blank looks, until someone realised I wanted “Benadryl”. I had also seen the TV advertising persuading people they had adult ADHD (with a symptom list that seemed to encourage false positives, and a link to a small quiz online that seemed to classify almost anyone as having ADHD), or that they needed Viagra (with the almost comical warnings that “erections lasting more than two hours can be dangerous and require medical attention”). Disease mongering is a pretty interesting phenomenon, and well worth reading about – Did you know that the vast majority of viagra prescriptions are “off label” and written for groups in which there is no evidence of efficacy (including women, when there is not a single study showing evidence of efficacy in this population)? And that the pharmaceutical companies are trying to medicalise “Female Sexual Dysfunction” to create mass markets to address lack of desire or lack of pleasure, with minimal consideration of the context or wider issues, because of the success of such marketing with men? Or that “restless legs” has been marketed to the public as a common condition requiring medication? It made me quite glad for our generics, and lack of medication marketing targeting the public.

But the reason I wanted to talk about sticking plasters is that they are a response after the event. A means of short-term management, and covering up of an injury, rather than preventing it. Like my blisters adhering to my sock, there were many stages at which that bleeding could have been prevented – by covering the blister earlier, or better still by taking the subway more and/or wearing more sensible shoes to explore New York. The problem is that if we become overwhelmed by demand for the reactive response, we lose the capacity to look at what underlies the demand. And if we spend too much time reacting to distress in health services, it can mean that we fail to do the preventative work that would reduce the need for such services. With austerity politics ensuring that the health and social care sector are too underfunded to be proactive, I think that is where the NHS is heading, along with most of the public sector.

Every single day I seem to read about travesties of social justice, and the lack of thought about the people that bear the brunt of them. Time and time again the most vulnerable members of society are being abused and neglected at a national and global scale. Whether it is the man who has paid UK taxes for 40 years who is being denied essential cancer treatment because he doesn’t have a British passport (due to a paperwork oversight when he arrived as a child with his parents from the Caribbean 44 years ago), or the deportation of a humanitarian/academic couple who are being told to leave because they went abroad for too many days – to complete a government study. Or how about the person that tweeted about having waited for over a year for support after a sexual assault, with rape crisis waiting lists closed for most of London for more than a year due to the scale at which demand exceeds supply?

Perhaps we should look at the rapid rise in mortality in the UK so far this year, falling life expectancy (especially in lower socioeconomic groups) or the rise in deaths amongst mental health patients – despite the falls in smoking and improved outcomes in many health treatments. A man/woman in an impoverished estate in the north of England can now expect to enjoy 32/35 fewer years of life in good health, compared with a counterpart in a wealthy suburb in London or the Home Counties. Or perhaps we can look at the impact of cuts to NHS funding (albeit masked by fake claims of record wage rises) record waits for A&E, the cancellations of operations, and the burnout of NHS staff.

Or look at the increase in homelessness over the last few years (it went up 16% in 2016 alone, with almost 50 000 families living in bed and breakfast accommodation and many more “hidden homeless” living on floors and sofas of friends and acquaintances) with the knowledge that being homeless can worse than halve your remaining life expectancy (homeless women die on average at 43 and homeless men at 47, compared with 77 for the rest of us). As the author of the BMJ article puts it “Homelessness is not an episodic event, but something systemic. It is a neon sign that something is fundamentally wrong with policy across health and housing”. This lack of provision doesn’t even save money as the cost to the NHS of society’s failure to deal with homelessness and other examples of inequality has been estimated at £4.8bn (€5.4bn; $6.7bn) annually.

These same austerity policies have a wider impact on mental health. Psychologists for Social Change have identified five ways austerity policies impact on mental health: 1. Humiliation and shame 2. Fear and distrust 3. Instability and insecurity 4. Isolation and loneliness 5. Being trapped and powerless. They remind us that “These experiences have been shown to increase mental health problems. Prolonged humiliation following a severe loss trebles the chance of being diagnosed with clinical depression. Job insecurity is as damaging for mental health as unemployment. Feeling trapped over the long term nearly trebles the chances of being diagnosed with anxiety and depression. Low levels of trust increase the chance of being diagnosed with depression by nearly 50 per cent”.

So we can’t see mental health in isolation. Whether it is the individual context (for example in the power threat meaning framework I discussed in a prior blog) or in the wider sociopolitical context, we are not brains in a jar, but socially connected beings with experiences that impact on our wellbeing. When we talk about the shortfall in mental health services, too often we are saying that in the context of demand for services exceeding supply, and feeling strongly pulled as psychologists to provide more of the same. That makes sense in at the coal face, where it is hard to have the energy, time or resilience to look at the wider picture beyond the demands hammering on our own door. However, it means that we are discussing the lack of sufficient reactive responses to a problem that could have been dealt with more effectively further up the timeline with proper proactive and early intervention work, and in a lot of cases could have even been prevented with better social policy and provision for vulnerable population groups.

Of course, doing preventative or early intervention work also takes resources, and we can’t take them away from the people currently in need/distress now. But instead of us constantly asking for a little bit more of the same to deaf ears who reply with excuses about finite pots and efficiency savings (and sarcasm about magic money trees), maybe we need to think more creatively about intervening at different levels and in different ways to the set up of existing services. I’d rather be providing sign-posts to avoid hazards than doling out sticking plasters when people trip over them – and best of all I’d rather be fixing the hazards, and helping vulnerable people identify routes that are less risky.

I’ll give Psychologists for Social Change the last word: “Mental health isn’t just an individual issue. To create resilience and promote wellbeing, we need to look at the entirety of the social and economic conditions in which people live”.

Nature versus nurture revisited

This week I have been reading the Power Threat Meaning Framework published by Lucy Johnstone and colleagues. This document is an attempt to challenge the dominant medical model in adult mental health with a more functional framework for formulation, based on the person’s experiences and circumstances. It is an interesting and challenging read, because it tries to cover the political and philosophical context of challenging the medical model, and input from service recipients about the benefits and challenges of different ways of conceptualising their difficulties. But at the core it rests on a pretty simple and (I’d like to think by now) well-established concept – that the adverse childhood experiences a person has prime them to use survival strategies that make them vulnerable to difficulties later in their life. Those early templates for dysfunctional relationships and the sense of self created by inconsistency and maltreatment also mean that people are more likely than others without those experiences to go on to have other relationships and experiences that are traumatic/harmful as they grow older, which compound the strategies and narratives with which they navigate adult life. The survival strategies which made perfect sense in response to their experiences at the time, have a lasting impact on the brain, body and behaviour. They change the way the person perceives themselves, understands the world and relates to others, and go on to have detrimental effects long after the initial trigger is gone.

As I have mentioned in previous blogs, a person exposed to high levels of trauma or adversity, especially if lacking protective relationships, will become more vigilant to signs of threat, less able to focus on the tasks that help us attain educationally and in the workplace. Where their early relationships have been dysfunctional, they are likely to struggle with forming healthy later relationships, and are more likely to express needs indirectly and in ways that cannot be ignored – including in ways that lead to negative societal responses, such as rejection and/or pejorative judgements by others, involvement with mental health services (and being given diagnostic labels), involvement of criminal justice systems. This leads to an increased risk of socioeconomic adversity, lower social connectedness and a greater chance of a range of adverse outcomes.

In short, thinking about adversity in both the person’s childhood experiences and current context, not only gives us insight into the biggest variable in personality disorder, attachment disorder and other specific conditions. It also explains a lot of the risk factors for wider issues with physical and mental health, challenging behaviour, addiction, violence, crime, homelessness, harmful relationship patterns and helps determine our sense of self and our ability to make healthy social connections. Adverse childhood experiences increase the risk of a very wide range of  physical and mental health problems, for a range of reasons including lower self-care and poor lifestyle choices, a lack of self-monitoring and seeking of appropriate care in the early stages of problems, and what seems to be increased propensity for ill-health mediated by the stress messengers in the body.

I’d go so far as to say that getting child protection and parenting right is the biggest task facing humanity, and the area where I believe we can make most difference for the future – hence dedicating my career to working with the kids who have experienced the most adversity and trying to improve their outcomes. But as I have explained above, it doesn’t just stop there, because the ripples of that early adversity continue to spread out into the lifespan for many people, forming a barrier to the protective factors of education and employment, establishing social networks, and the means to access pleasurable activities. This can then be compounded by financial hardship, hostile systems (such as benefits sanctions and fitness for work tests) and lack of access to resources (including finding it hard to identify and navigate access to social care and health services, to know and assert their rights, or appeal against decisions made by organisations). So the same people who experienced chronic developmental trauma and have unresolved psychological consequences from that are often struggling with their personal relationships, as well as practical issues like debt, homelessness and crime. In that context, dysfunctional coping strategies like substance abuse or presenting with challenging behaviour or mental health symptoms make more sense as attempts to obtain escape or safety.

There are also vulnerability factors such as being in a disempowered/minority population group, that also bring compounding adversity such as sexism, racism/xenophobia, homophobia, transphobia, ableism, ageism, religious intolerance, etc. These can impact at all life stages. For example, a child with physical or intellectual disabilities is more likely to be the victim of abuse, to experience bullying, and (perhaps increasingly as they grow up) to struggle to access community resources, financial independence or a supportive social network. For people from cultures outside of the majority in the country where they live, there can be language and cultural barriers, prejudice and political/economic challenges, as well as exposure to poverty, war, terrorism and other threats to survival that are outside the experience of the majority of lifetime residents of developed nations. Certain population groups such as asylum seekers find things particularly challenging in terms of finding safety, housing, financial security, after already experiencing multiple traumas in the country they have left and during their journey to find safety. Each individual is unique and their story, current situation and past experiences are a huge influence on the way that they experience and interact with the world.

As Johann Hari rightly points out in his recent article to promote his new book, everybody knows that our experiences, relationships and living conditions impact on our state of mind. If a loved one such as a partner or child dies, you are likely to be sad (and perhaps angry, or relieved if they were suffering, or many other complex feelings). Likewise, if you are given a warning of impending missile attack most people would feel anxious, and become hypervigilant for signs of threat. Therefore, most people would not think of grief after a bereavement or loss, or anxiety when in an acutely threatening situation as pathological. Which makes it somewhat curious that the medical model has been applied to mental health in the way that it has. Why has it become that depression or anxiety or even addiction is seen as a disease, a neurochemical imbalance that needs to be treated with medication?

Perhaps the advances of modern science studying genes and neurochemicals made us think of ourselves as complex biological machines that could be understood at a physical level. Perhaps there is wishful thinking about biological models leading to potential cures. Perhaps the fact that brain injuries, tumours, dementias and neurodevelopmental conditions can make an impact on our feelings and behaviours made it seem that all feelings and behaviours could be attributed to brain changes. Perhaps the idea of massive numbers of people suffering is too distressing to think about and it is a common defence to depersonalise that, and to other the person suffering. Perhaps the narrative of mental illness has sustained the power and income of the medical profession as experts and gatekeepers to such treatments. Perhaps it was clever marketing propaganda by the pharmaceutical companies to sell more of their products. Perhaps it was so persuasive because it fits with the neoconservative narrative to think of individual failure rather than individuals showing the symptoms of societal problems (and therefore our collective responsibility to solve these problems and look after each other, rather than just thinking of ourselves). Or, more likely, it was a combination of these and many other factors.

Of course, we don’t want to throw the baby out with the bath water. There are certainly people for whom psychiatric medication has made a massive positive difference. People who feel more able to concentrate and gain attainments when on stimulant medication, or who feel less hopeless, anxious or angry when on antidepressants, or people whose distress, confusion or aggression is reduced by neuroleptics. But we can’t work backwards from positive impact to considering that proof of a neurochemical deficit or imbalance. After all, the evidence for analgesics is very strong, but I doubt anybody thinks a headache is a symptom of lack of aspirin! We need good unbiased data to understand what is going on, not the cherry-picked examples that currently make it into the public domain. Alltrials is a good step in the right direction in this regard, but there is still bias in what research gets funded and what gets published, with bias towards the sexier topics of new technology, genetics, scans and hard science, and less towards the sociopolitical aspects affecting individual and population wellbeing.

I’m not saying that nature isn’t important. It seems likely that various medical/biological factors do mediate the impact of experience. For example, some conditions like autism, intellectual disability, and dementia do appear to have predominantly biological causes, whilst having impact on thoughts and feelings. Brain injuries and diseases can affect personality, mood and behaviour, and various hormonal and physical conditions can affect brain function and impact on mental health. There seem to be genetic differences (eg to telomeres) that make some individuals more resilient to adverse experiences than others. And some twin studies show genetic factors influence the incidence of conditions like schizophrenia and bipolar disorder, although again the epigenetic factors seem important, it is not clear whether the biological differences are a cause or a symptom of the condition, and the role of biology is not large enough on its own to explain who gets these conditions without also considering experience. Like most of these debates, the answer isn’t going to be one extreme or the other. I am glad that the pendulum has swung back towards considering nurture and experience more, and not exclusively the high tech science of genes, psychopharmacology and brain scans. It seems likely that who we are and how we feel and function in the world is affected by both our biology, our experiences, our circumstances and our relationships both now and in the past.

So, whilst Christine Courtois and Bessel van der Kolk’s efforts in the adult and child spheres respectively to get the impact of complex and multiple traumas and damaged attachment relationships recognised as a better way to understand attachment disorder and personality disorder than a neurobiological disease model (and their challenges to the DSM) have not yet been successful, I am heartened if this way of understanding the impact of experience is gaining more credibility in the field. I think the power-threat-meaning framework might be helpful for some clients, and the questions that they advise asking are certainly good way of starting a clinical assessment.

“What is your story?” Specifically:

1) What has happened to you? (How is Power operating in your life?)

2) How did it affect you? (What kind of Threats does this pose?)

3) What sense did you make of it? (What is the Meaning of these situations and experiences to you?)

4) What did you have to do to survive? (What kinds of Threat Response are you using?) and are you still doing this?

5) What are your strengths? (What access to Power resources do you have?)

It certainly resonates for me, and I wrote about a lot of this stuff in my book, Attachment in Common Sense and Doodles in relation to children who don’t live with their family of origin. I wanted to make information about attachment and the impact of trauma more accessible to carers, legal professionals and social care staff and other profesionals in the child’s network. It isn’t novel content, as it was based on themes that had been researched, written and spoken about by others before me, but I have tried to present it in an accessible and engaging way.

I am heartened that in the last few weeks the idea of experiences and nurture being important in mental health seems to be reaching the public consciousness. It seems to be being promoted more vocally by a lot more clinical psychologists, and to have reached me in various different ways. I’m glad if it is gaining traction and a wider audience, but it might be that’s wishful thinking on my part, and merely a product of my unrepresentative sampling. In light of how horrible a lot of the news is since the Brexit vote, Tory election win and Trump victory, I’m trying to be more selective about what I read and the social media I engage with, so it could be I’m in more of a bubble of like minded thinkers these days, and that is the explanation for hearing more about models that fit my own thinking!

What is wellbeing?

A typical GP appointment is 7-10 minutes long. Therefore it was no surprise to me that when I started talking to my GP about my blood pressure a couple of months ago and diverted to talk about my lack of energy, I was referred to the “wellbeing worker” linked with the practise. There was a five week wait for an appointment. I sat in the waiting room at the designated time wondering if this was a new name for a practise counsellor, or an offshoot of IAPT linked to physical health, or whether it was a specific scheme designed to get people eating better and doing more exercise. When she invited me in the wellbeing worker introduced herself and said her remit was to work with people about “diet, exercise, smoking, drug use or to improve your wellbeing”. She asked me to rate my wellbeing on a likert scale for six variables.

So I diligently explained that since being rear-ended by a lorry 2 years ago, I have not been able to make a full range of movement with my left shoulder. This meant I had been unable to continue weight lifting. I also had to have 3 teeth removed and then had a very severe ear infection, causing some other health complications I detailed in an earlier blog. I told her that I have had intermittent earache, headaches, and a feeling of being underwater, which are exacerbated by changes in pressure or getting my ears wet so I had stopped swimming. I have also had ripples in my peripheral vision and a general lack of energy and motivation. I explained that the combination has meant that I had stopped my three times a week gym-and-swim habit and reduced to a fairly sedentary lifestyle with occasional longer walks.

I mentioned that been overweight for my whole adult life, and I had drawn some psychological links to the root of this. I explained that I am fairly comfortable with the idea of being overweight but that stress may have contributed to my more recent problems. I was of the opinion that there is clearly a significant physical component to my health issues, as it has transpired I am anaemic and vitamin D deficient as well as having high blood pressure. But I acknowledged that there is also a lifestyle component, as I had reduced activity and gained weight over the preceding months, and I acknowledged a substantial stress component too.

I noticed that the wellbeing worker had not taken any notes beyond “weight” and “exercise”, so I paused and tried to clarify her role. I asked what professional background she came from, expecting to hear she was a nurse, health worker or psychology graduate. “I’m an admin” she said, and explained that she had taken the job during a reorganisation, having been told that it was predominantly administrative. She said she had initially worried about what she would do if told about problems she didn’t know the answer to, but her manager had been reassuring that it wasn’t her job to solve everything and she could report any concerns to the appropriate person.

It turned out that her job was to identify which pathway to put people onto, from a choice of weight management, exercise, smoking cessation, drugs or alcohol and then fill in the paperwork to make it happen. She booked me in for the weight management group, and gave me a referral to the local council run leisure centre for 12 weeks free membership.

Don’t get me wrong, those things are good low-level interventions. The weight management group is friendly and non-shaming, even though it is pitched at a simplistic level, and I completely endorse exercise on prescription schemes for improving physical and psychological wellbeing. But where was the space to actually talk about what was going on my life? The website for the wellbeing service says:

‘Wellbeing’ means feeling happy, healthy and content in life. Our wellbeing can be affected by our physical and mental health, the people around us, the place that we live, the money that we have and how we spend our time. Our Wellbeing Workers can help you to identify and prioritise changes you might want to make to improve your overall health and wellbeing. They offer lots of support to help inform, motivate and empower you [including through] … Support with confidence issues and to improve self esteem

They offer services to reduce social isolation and assistance to address issues such as debt, housing and education (though this branch appears to prioritise people who have an intellectual disability or socio-economic deprivation) but the only mention of mental health or psychology is in relation to the specialist branch of the weight management pathway for people with BMI over 45 and those considering bariatric surgery. There are also leaflets linked from the weight loss section of the website which talk about “finding happiness” (helpful habits) and “mastering your thoughts” (basic CBT intro) and “relaxation and stress relief” (mindfulness, visualisation/anchoring, breathing exercises). But I was never even told these existed, and even when on the website I had to use the search feature to find them, and as far as I could tell there was no connection to the local IAPT service.

Six weeks later the wellbeing worker rang me up again, to see how I was doing. But again, she didn’t really want to know how I was doing psychologically in any meaningful sense. She wanted to know if I had followed the pathways she had offered. She asked me to give the six ratings again. It felt pretty hollow giving more positive scores, as I didn’t feel like the services provided by the wellbeing service were responsible for the changes – I had lost 10lb in weight before I joined the weight management group (and 2lb since), and feel better because I have more iron, more vitamin D, lower blood pressure, more energy and less pain.

So I was left feeling that it was a service that I was glad existed, but it seemed to tackle symptoms in isolation to their causes, and didn’t seem to connect physical and mental health. I’m guessing that is because public health is still local authority commissioned, whilst mental health is within the NHS. Wouldn’t it be nice if there was a single point of entry to this kind of wellbeing service and IAPT? Surely that would reduce stigma and mean that both symptoms and cause could be addressed, and patients would be able to tackle the interwoven issues of mental and physical health together.

 

Sherlock jumped the shark

Warning: Contains plot spoilers for series 3 (and for August Rush)

I think Benedict Cumberbatch and Matin Freeman are great actors, and the BBC have made a very stylish production of Sherlock with complex and nuanced characters. Both Sherlock’s use of drugs and the relationship between the two men has been portrayed in an interesting and convincing way. I particularly enjoyed the hint of Asperger’s in the way that Sherlock can use his visual observation skills and visual memory to reason in a way that seems almost impossible to a layperson, whilst struggling with interpersonal relationships. So it was with high expectations that I watched the latest set of episodes, and found them sorely disappointing.

I should say that it isn’t the first time I’ve built up my expectations of a film or show only for the reality to not live up to them. I have long identified a pattern I call “the Total Recall effect” whereby films seem to vary in their quality according to my expectations. The first time I watched Total Recall (the 1990 original, starring Arnold Schwarzenegger) I thought it sounded like a weak premise with a wooden actor, but was pleasantly surprised. The second time I watched it, some years later, I remembered it as a good film and was sorely disappointed. The third time I watched it, after several more years,  I nearly turned it off, remembering it to be dire. However, it wasn’t that bad and I enjoyed it enough to stick with it until the end. I learnt that my expectations influenced my subjective experience; hence naming the Total Recall effect.

I also hate films that mix realism with implausibility. I’m fine with suspending belief entirely for a fantastical tale, or for enjoying the interplay of characters in a different time or place (eg I love Firefly’s futuristic western set in space) but I hate it when stories that are designed to seem within a stretch of reality suddenly take a leap into the impossible. In the film August Rush, for example, I had that experience of a semi-plausible plot jumping the shark. It was a stretch I could just about tolerate for the boy to reject family placements and stay in the care system in the hope of finding his real parents, and to then run away in search of them (despite the fact he’d have been adopted as an infant, would never have known anything but the love and belonging of his adoptive family, and wouldn’t have felt quite the same yearning). His relationship with music was beautifully captured and was the highlight of the film. But the grand finale where everything fell into place, and his parents were both seeking him and each other, and were present in the right place at the right time to hear the concert and recognised it calling to them, then recognised each other and him, made it all fall apart.

That accounts for some aspects of my disappointment with Sherlock but not all. To be honest, whilst I applaud the idea of also including female characters and narrative as a general aspiration for all media, I wasn’t a fan of Watson’s wife being an international espionage expert (it felt a bit like the second series of Heroes, where everyone got superpowers). Likewise I didn’t buy Sherlock having a sister. They felt like a step away from the source material that wasn’t in keeping with the rest. I also found it frustrating that each episode spent three quarters of its time laying out a riddle, and then wrapped it up far too quickly and neatly in the final quarter. I also felt cheated that unlike earlier shows, we didn’t see how Sherlock put together the clues to reach his conclusion. It was presented in an abstract way, a bit like magic. Viewers were left to assume that the song combined with some numbers in the graveyard could be rearranged to lead to a sentence that unlocked the location of the well. But why those graves, and how did it unlock the location – we were short-changed in the explanation.

As ever, huge amounts of trauma were included in the plot, without an appropriate scale of emotional response. The repeated prompts to be soldiers wasn’t sufficient to carry the uneven emotional responses (smashing the coffin because he had upset the pathologist, whilst being unmoved by four murders and recovering from feeling responsible for a suicide in less than a minute). Likewise later scenes showed the repair of 221b Baker Street to its former state, indicating that the explosion that would have supposedly killed Mrs Hudson in the flat below, and threw them out of the windows in bursts of flame had not only caused them no injuries, but hadn’t even penetrated the floor boards of the flat.

However, my main grumble was with the character of Eurus and the plot that surrounded her. The actress playing her was good, and the twist of her being several characters was fun, but the story and back story they gave her was appalling. This woman was supposed to have been born a dangerous psychopath, and to have spent her entire life from the age of around seven in solitary confinement as a result. She was supposed to be lonely, anxious and delusional but to express that by doing nothing for two decades and then engineering plots that skipped continents and killed multiple people without emotional response. Well I call bingo on the theme of propagating negative myths about mental health, with zero points for reality.

First, it reinforced the association between mental health problems and risk of committing crime, when people with mental health problems are much more likely to be the victims of crime. Second, it gave the impression that mental health problems are things that you can be born with, and unrelated to your life experience. For example, we didn’t see that Eurus had been emotionally and sexually abused to create her distress and anger. We saw a highly intelligent child in a highly intelligent family that felt a little left out when her brother had a friend, and as a result decided to kill the friend, then burn the house down, and wanted to kill her brother. She was portrayed as a petty and jealous child, whilst presumably nobody in this highly intelligent family was able to show her affection or to help her regulate her emotions. And nobody recognised the risk or tried to intervene in a supportive way.

Eurus was supposedly unable to tell the difference between laughing and screaming, and was portrayed as being entirely without empathy, yet she had the subtle social insight to see (from her minimal observations whilst supposedly secured in a prison island) that her brother was unable to communicate any affection for the woman who was in love with him. Then, despite the lack of normal human interaction for most of her life it transpired that she had developed sufficient mind control to reprogram others within minutes of conversation. She had never done so as a practise, or in a way that was unsuccessful or aroused concern, however. But after 20 years she had suddenly taken over the entire prison/asylum island sufficiently to get people all over the place to transport her to and from the island, to set up her murder scenarios, to dangle three men in front of the window and cut the ropes to make them fall off the cliff to their deaths. No single person in the entire staff of the island failed to fall under her thrall, or had any moral doubts about her plans that were sufficient to breach her conditioning enough to raise an alarm (whilst the prison governor was able to disobey her to commit suicide in his attempt to save his wife). And she was able to set explosives, procure sedative darts and transport Holmes and Watson to an entire set created at her old family home. And this frightened, lonely girl who had supposedly only killed a child once in a failed attempt to play was suddenly killing many as experiments to test her brothers.

Sherlock, despite his intellect and his “mind palace” of perfect visual memories, was supposed to have entirely erased the existence of his best friend being murdered by his sister, or even of having a sister at all. When he spent the evening with the daughter of the famous serial killer, he could notice the drips of water and the line on her dress from her exit from the taxi, but not the fact that she was his own sister in disguise, putting on a false accent. Likewise he could predict that Watson would be at a particular location in two weeks time, but not see anything suspect in his flirtation with the woman on the bus. Meanwhile, despite the whole of MI6 and the intellect of Mycroft being involved in her supervision, Eurus could come and go from her prison island enough to make a therapy practise that both Watson and Holmes thought to be bona fide. And in the finale, Sherlock could believe that the voice of an adult woman he had been interacting with, communicated from an attic in the rain or a prison island, was that of a small girl in a crashing aeroplane.

In short, once you apply any critical thought, this series was a woeful disappointment, despite the stellar cast, impressive budget and stylish delivery.

 

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.

Terrorism revisited

I feel very very sad about the referendum results, but not entirely surprised given the previous election results.

I think the campaign has been fought on dishonest ground that didn’t represent what we were voting for, and the referendum and the Brexit campaign were the culmination of a particular message being pushed by vested interests in the media and politics for many years. It is part of a bigger problem of politics becoming ever more a game of the super-rich, corporate lobbying and propaganda, and less about representing what the majority of the electorate actually want. I think it is a sign of big trouble with the democratic process when two thirds of the cabinet are millionaires, and that demographic represents only 1% of the population, whilst they are supposed to speak for the breadth of the UK.

I’m not convinced that concerns about immigration are the unspoken elephant in the room, so much as one of a number of targets that keep on and on getting vilified and scapegoated for all of society’s ills. To paraphrase the metaphor: An immigrant, a voter and a millionaire politician are sitting at the table with 10 cookies. The politician takes 9 to give to his chums and then tells the voter “watch out, the immigrant is going to steal your cookie”.

What is unspoken is the responses we need to challenge these poisonous messages and to remind us that there but for fortune we could be in the shoes of an economic migrant, an asylum seeker, a single mother, a person with disabilities, a parent of a child with special needs, someone who loved that child that died because we didn’t have proper health and social care services, someone without legal representation, unemployed, the victim of racism/sexism/homophobia, the generation that live through war, etc. We should want to protect human rights and public services, legal aid, benefits and victims of crime, and to prevent war because we are them and they are us.

But somehow the talk was all focused on the money, and the immigrants, and the pointless bureaucracy of the EU. Maybe I am naive or cynical, but I think that a group of people have been actively driving that narrative for a long time, I don’t believe it is an organic grass-roots concern that has spontaneously bubbled up. I think there are vested interests pushing us towards greater income disparity, blaming of the vulnerable, and encouraging prejudice, selfishness and nihilism. I don’t think people are stupid, I think people have been drip fed right-wing propaganda for many many years, that blames all ills on “immigrants” and “benefits scroungers” so that we don’t look too hard at austerity politics and see all the vested interests. If there was a credible alternative, they’d as easily target that rage against the bankers, the corporations dodging tax and using zero hours contracts, and those using tax havens to hide their cash – all of which I consider to be much more legitimate targets.

As this article in the BMJ eloquently explained, the less people feel they have to lose, the more willing they are to take a gamble on a potentially risky outcome. And the results of austerity politics mean that large swathes of people are suffering financially, and feel powerless, hopeless, disenfranchised and exploited. At the same time as the referendum we have seen an even more tragic set of events unfolding that I think have the same underlying cause.

With the Miami mass shooting and the murder of Jo Cox (and longer ago, the shootings in Paris), I think that we have seen the ugly underbelly of what happens when people feel desperate and voiceless, and are radicalised by hearing poisonous messages blaming particular people for their unhappiness or lack of success in life. Both were horrendous acts, targeting people who had done absolutely nothing wrong in order to convey some kind of political message. Both were incredibly distressing to hear about, let alone for those who were personally involved.

Jo Cox was my age to within a fortnight and had a similar family configuration, so it has really hit home that her husband and kids will never see her again, just because she spoke out for compassion and inclusiveness. She is someone I had never heard of before she was attacked, but the more I read about her the more I like and admire her. She was taking action for the good of others, and she was a great example of our democracy. I have donated to the fund in her memory, and the fact it topped a million pounds in just a few days, suggests that I am not alone in wanting to take some kind of positive action in the face of such awful news.

And with that in mind, and the clear indications that this was politically motivated terrorism with a far-right agenda, I wanted to say something about all the references to mental illness. Being mentally ill doesn’t mean you kill people and killing people doesn’t mean you’re mentally ill. Doing something awful that we can’t understand is not the same as being mentally ill. One in four people has a mental illness, a characteristic as widespread as blond hair. The vast majority of them will never hurt anyone, and are at no greater risk of doing something awful than anyone else (although they are disproportionately the victims of violence). It is abhorrent to stigmatise all those people because of the actions of one person, even if he may have had mental health issues. He didn’t kill Jo Cox because he had mental health problems. He killed her because he wanted to promote his repugnant fascist beliefs.

I posted on Facebook about the causes of terrorism earlier in the week when the discussion was about the Miami mass murder, and this is exactly the same. This was what I wrote:

Just a reminder, but mental illness is not a cause of terrorism. There is pretty good research that has disproved this popular myth. People do awful things. We can’t understand that and we want to feel like they are different from us, so we assume their mind is broken. In fact the research says that it is a combination of a strong need to belong, coupled with a sense of marginalisation and injustice, dehumanisation of enemies, group processes where beliefs get hyped up into extreme actions and strong religious beliefs. Intelligent men who underachieve are particularly at risk for this radicalisation. That is, ordinary people with no genetic or mental abnormalities get pulled down a particular path by their experiences and social networks.

From a paper by Silke after 9/11:

“It is very rare to find a terrorist who suffers from a clinically defined ‘personality disorder’ or who could in any other way be regarded as mentally ill or psychologically deviant (Silke, 1998). Ultimately, the overwhelming majority of terrorists (and this significantly even includes suicide bombers) are average, normal individuals who in other circumstances would be quite unremarkable. Their involvement in terrorism is not the result of psychoses, inner traits or aberrant personalities. Rather, in most cases it is an understandable response to a series of life events.

The causes of terrorism need to be focused on – not just the actors. Once you are forced to throw away the ‘terrorists are different’ model, then attention must be given to other areas. An important realisation here is that becoming involved in terrorism is a process. Nobody is born a terrorist. Neither does anyone wake up one morning and decide abruptly that on that day they are going to start planting bombs in public streets. Becoming a terrorist is in the first instance an issue of socialisation. Any given society will possess some minorities or disaffected groups who rightly or wrongly perceive that the world is treating them harshly. In some cases there are genuine and very substantial causes for grievance. Individuals who belong to or identify with such disaffected groups share in a sense of injustice and persecution. It is from such pools that individual terrorists emerge”.

Western politicians will easily condemn muslim extremists, but in America in particular they find it much harder to look at terrorism fueled by prejudice, in this case racism (but previously by homophobia and religion) – because, like the gun lobby, it has so much popular support. I don’t have any solutions for that, but we do need to name the problem, and the problem is the rise of right wing regressive ideas, fueled by prejudice and religion, blaming every vulnerable minority whilst turning a blind eye to the rich and powerful exploiting the rest of us.

I want my country back from all this hatred and fear-mongering. We need to stop blaming the vulnerable, and start looking at the political system that has created an increasingly divisive and selfish society.