Spectator sports

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

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

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

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

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

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

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

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

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

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

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

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

 

 

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

Why is there always a can of worms?

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

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

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

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

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