Wisdom, sycophants and advice that won’t work

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

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

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

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

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

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

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

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

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

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

The double bind of trying to do research as a clinician

In my first job after university I was an Assistant Psychologist on an applied research project evaluating the impact of staff training on the quality of care in old people’s homes. It wasn’t my natural client group, but I loved the fact that we were measuring whether all our fancy psychology ideas actually made a difference to people when applied in practice. My supervisor, Esme Moniz-Cook was an inspiration in this regard, and set a pattern I have aimed to maintain to this day: innovate, evaluate, disseminate. We wrote lots of papers, and each one worked through many iterations in which Esme would cut up a print out of my latest hopeful draft and stick it back together and/or annotate it in different coloured pens. I developed a ritual to overcome the frustration: I would look at the result, take a few deep breaths and then set it aside. Then I’d move the text around on screen to match the arrows and sellotape. Then set it aside. Then do a few of the suggested edits that felt too trivial to argue about and set it aside. Then I’d look at the reduced number of suggestions that was left and decide which were worth disputing and do the rest. Then I’d send it back to Esme and the process would repeat. It was a challenging process, but the papers were always better as a result, and meant I started training with a set of publications on my CV. My doctoral research felt like a piece of cake by comparison. I developed and evaluated a computer based training tool to help people (especially those on the autistic spectrum) learn to recognise facial expressions of emotions and predict how people would feel in different situations. I published a paper from it, of course.

As a newly qualified clinical psychologist in 2000, I was all fired up about continuing to do research. I put in a bid to two charitable funds to expand my doctoral research to a larger population and to follow up the effects after a period of time. It took me a long time to complete the proposal document and to get all the signatures, references and endorsements from both academic and clinical hosts. Both were declined. The first said the bid was so strong that it didn’t need autism specific funding, the latter said that we hadn’t accounted for poor uptake or drop-out because they didn’t know how keen the kids with ASD had been to have extra computer time. It felt like a Catch 22. In retrospect I should have researched the potential funders better; the former probably wanted research that would relate to their patented use of pig secretin in autistic children, they focused on medical interventions and were not interested in something as ‘soft’ as psychology. I was gutted. In the time I had spent preparing the two bids I could have made significant inroads into the study, but I hadn’t got off the starting blocks.

In my next job, I applied my learning to undertaking small bits of research myself by juggling my clinical time. I explored what it was that defined the young people who challenged multiple agencies. I evaluated how social workers in the adoption support team reacted to having the opportunity for consultations with a psychologist. I measured the Theory of Mind skills of Looked After Children and compared them to children with ASD and a control group. I assessed the cognitive ability and mental health of the children in residential care homes within the catchment. Most importantly, when asked to advise on how to improve adoptive matching, I undertook an audit of factors affecting adoptive outcomes across 116 families. This turned out to be the largest study of risk and resilience factors in adoptive matching ever undertaken in the UK.

I found the answers to my questions, and I learnt a lot of new things that other people need to know. But I had no funded time or academic support to disseminate the results. With the smaller projects, I let my Assistants write up the results for publication in professional newsletters and present them with me at conferences. But with the larger studies I wanted to do them justice, and my NHS role never gave me an opportunity to do so.

Once I left the NHS, I followed up my adoption audit 5 years after the initial data collection because I was determined not to let such interesting findings disappear into the ether. Then I made another bid for research funding, and by fluke or serendipity secured a £75,000 Shine Award from the Health Foundation to complete a one year study of the impact of adding brief psychological input into the local diabetes service (something I have previously blogged about). We reached the end of the year and applied for further funds to spread the impact, but were told that they do not fund follow-up data collection, or time to write up results for publication as this should be done in the course of your employment in the NHS. Of course we don’t work in the NHS, and have no funded time as part of a bigger contract or our contract of employment. So the Assistant Psychologist who was doing our data collection and analysis was only funded for the duration of the project, and has since moved on. The £2500 they did offer towards a editing our service user feedback into a short video, revamping our website, a press release and a small local event, requires a long report to release which is now overdue. I’m still trying to work out how to complete and submit the academic papers, but this takes time and means it has to compete against all the other demands of running a business.

Herein lies the big double bind: you need funded time to write bids and to write up papers to give the credibility to future bids, but unless you have academic tenure this time is not funded. For a clinician it competes with more immediate clinical demands, and for someone self-employed it competes with the tasks that actually pay the bills (in my case training, consulting, and up to 4 court assessments per month). There are also other things that demand my time and mental energy (committees, other forms of writing, http://www.clinpsy.org.uk, etc) and I sometimes even have a life outside work. Not everything can fit into the evenings and weekends, even if I allow work to expand into the rest of my life like gap-fill foam.

But I am not defeated. I am determined that the diabetes results will be submitted to peer reviewed journals by the end of the year. And I’m even more determined that what I have learnt about risk and resilience factors in adoptive matching will make its way into social work practice. I’ve considered all kinds of options including writing it up as a PhD, or a book, or a series of papers, or all of these things seeking funding as a grant, or a stipend, or a fellowship. I’ve tried to use my network to find potential funders. But nothing seems to come to fruition in a way that would allow me to have funded time to write it up with input from a statistician, whilst still having at least half my working week to run my company. Perhaps that is just asking the impossible, no matter how close to fruition the research is or how it will impact on people’s lives. I don’t know.

Meanwhile I keep asking the questions and gathering the data that will answer them, even if I can’t share the results. Innovate, evaluate, disseminate is simply part of what I do. I’ve got grand plans for what the next project will be, but I’ll save them for another blog.

BTW, if you have any ideas where I can secure funding, or want to collaborate with me I’d love to hear from you. Likewise if you can offer an overloaded clinician with big ideas a nominal NHS and/or university home, that would also be very welcome. It is twice as hard to bid for funds when you work in a small company that nobody has heard of!