Why is there always a can of worms?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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