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.

Video games and violence

The relationship between playing video games and violent behaviour isn’t as black and white as most people assume. There is neither the causal evidence that would support the tabloid alarmist headlines that blame Mass Effect, Call of Duty or World of Warcraft for mass shootings nor the evidence that video games are entirely benign.

We know from research that trauma has a significant and lasting impact on the brain, a pattern widely accepted across numerous studies. For those who have already been traumatised and/or have maladaptive social skills, that increase in arousal sensitises the brain to further threat. It also makes them more likely to respond with anger or fear to a neutral stimulus, perceiving it as a threat. We also know from research that when the threat sensor in the the brain is activated (the amygdala and limbic system) the prefrontal cortex pretty much goes off-line until the threat is resolved. That significantly reduces the person’s capacity for empathy, complex reasoning, social skills and ability to be aware of the impact of your own behaviour on others. This effect is amplified where there is an absence of healthy real life relationships and/or physical exercise (which produce oxytocin, and help to mediate cortisol and adrenaline). And of course we know that people who have raised arousal levels deliberately seek out experiences that match or use that level of arousal, so they are often much more interested in violence and gore than their peers.

That’s all well established neuroscience. We also know that these brain changes can be perpetuated by exposure to violence or the representations of violence in our daily lives or the media we consume. Exposure to violence is an unseen public health epidemic. We also know that this pattern of being over-sensitised to threat and in a heightened state of physiological arousal gets ‘stuck’ for a proportion of maltreated children, particularly where there is an absence of secure attachment figures, and that ‘acting out’ with violence in this group is much more common. The neurological basis for moral reasoning and antisocial behaviour implicate similar brain regionsSimilar areas are also implicated in violent behaviour when this is related to a lesion, dementia or atrophy.

Having reviewed the evidence, I think it is clear that video games do not in themselves cause violence. But playing violent video games increases physiological arousal levels (readiness for fight or flight) just as we know is the case for exposure to real life conflict such as domestic violence within the family. This can create a lasting effect which shows in MRI scans. But the effect is quite specific. We know that MRI studies show differences in the brain when people play violent video games but not when the video games do not involve aggression. We also know that it is dependent on the social acceptability of the behaviours chosen in the game.

It seems likely that watching films or TV can similarly cause an increase in physiological arousal, but this would only be the case with a high level of violence/action/drama, something which is not normally sustained for hours upon end the way it can be in some video games. Also, video games are more immersive because they are interactive, and I suspect you don’t become as habituated to them because of the fact that there is variation on every presentation of the stimulus, whereas rewatching the same film gets dull and predictable and no longer gives us that visceral response. Thus I think that it is reasonable to consider violent video games as a particularly concentrated form of this stimulus.

It seems from the meta-analysis that a small scale shift towards higher readiness for fight or flight and lower empathy/insight/reasoning is happening all over the place amongst people who play a large volume of violent video games with the result of small but measureable increases in the risk of aggressive behaviour. I’d extrapolate from this to what is currently happening with the threats and harrassments towards women and minorities in the gaming space, to suggest that this combination of lack of nurture and exposure to violent material may be contributing to the lack of empathy and insight into the impact of their behaviour amongst people involved. But I suspect that the impact of video game play on real life aggressive behaviour is only a significant issue at the individual level where this is combined with the presence of trauma and/or the absence of nurture. After all, the move from enacting violence in a video game to doing so over social media is much smaller than the move to take actions outside of home technology where you can see the impact on the recipient.

It is only in the extreme examples, where you combine violent video game use with people with horrendous histories, a lack of secure attachment relationships and/or who have entrenched extreme views (eg about women), nothing else in their lives to constrain them, an echo-chamber of harmful views including incitement to violence, and perhaps mental health problems on top that the mixture becomes truly toxic. Amongst this group a small proportion take the threat-talk that is so prolific online and in video game spaces into horrific real life actions.

I can’t see that being so different to the proposed mechanism for lots of other phenomena. As with the relationship between cannabis use and psychosis, or alcohol consumption and suicide, the former is something most people consume without harm so it cannot be causal in isolation, but for a much smaller number of  people with increased vulnerability (genetic, epigenetic or experiential) it can be a contributory factor towards a more negative outcome.