Is Netflix Doing Enough to Protect Viewers from Harmful Content?

This post was based on an article first published to HuffPost

Controversy over Netflix and one of its latest hit shows was sparked by a study published last month suggesting that teen drama ‘13 Reasons Why’ may have increased suicidal ideation in viewers.

Published in the Journal of the American Medical Association (JAMA), the study found that Google search queries involving suicide increased by 19% during the days following the release of 13 Reasons Why, which centres around a teen suicide.

Members of the media were quick to draw their own conclusions from the paper, with The Telegraph suggesting that the Netflix show “should be withdrawn” due to the possibility that it is “driving young people to consider suicide”. Meanwhile, the journal article’s authors suggested that shows ought to be evaluated before release to identify potential risks, and that troubling scenes ought to be removed retrospectively — something that is done in China.

Before rooting for all-out censorship, it’s worth considering that the study’s findings were not all bad. Search queries following exposure to the show also increasing for ‘suicide hotlines’ and ‘suicide prevention’, indicating “elevated suicide awareness”. While various conclusions could be drawn from this, at the very least it suggests that the show increased interest in suicide-prevention and help-seeking. This fits with the narrative of public health campaigners that advocate openness with young people about challenging issues, such as those concerning sexual health — so long as balanced, good quality information is made available. It might have been interesting, therefore, for the study to have considered which particular resources the search queries led to, and how useful they might have been. Information about this could be used to help funnel search queries (and distressed individuals) towards useful resources – something that Google has shown interest in facilitating since as early as 2010, and that Facebook is beginning to take more seriously.

The authors of the Netflix paper suggest that content producers ought to follow WHO media guidelines on suicide, but these guidelines only refer to news and documentary media — not to fictional content. In fact, of all of the literature that guides news media on how to cover suicide, guidance around fictional content is virtually non-existent.

Some of the non-fiction guidelines remain relevant with fictional content. Before or after the credits, films and dramas can look to provide helpline numbers and appropriate ‘factfiles’ that help balance views and educate the audience (examples of positive moderation). But leaving aside debates about the ‘philosophy of art’, morally dubious ideas and characters that engage in unwise activities (and say untrue things) are often seen as an important feature of artistic, fictional content. This sets it apart from non-fiction.

In developing guidance for fictional content, we might do well to look to parallel cases of other public health concerns, such as smoking. Studies over the past 10 years have linked exposure to smoking in films with increases in adolescent smoking. Subsequently, lobbying groups have been pushing for the film industry to award R ratings to films that feature smoking prominently. While this remains an ongoing struggle, it seems reasonable that impressionable children should be protected by ‘parental guidance’ when it comes to exposure to potentially harmful health behaviours. As for how age restrictions can be enforced with digital devices, this is something for technology companies to figure out, and figure it out they will if regulators pressure them.

There are no easy solutions for content moderation, but it should be clear that rather than panicking and sliding towards Chinese-style censorship, we ought to pursue a pragmatic middle ground based on evidence and compromise; one that champions and balances both emotionally-challenging art, and also protection, guidance and support for those who need it.

Facebook is getting serious about suicide prevention

This article was first published at HuffPost

Those with an interest in online safeguarding and recurring debates about social media moderation might have found an interesting anecdote hidden in the latest Facebook earnings call.

When asked about content moderation efforts, in light of recent incidences of troubling videos being broadcasted live on Facebook, Mark Zuckerberg used the opportunity to discuss the company’s approach to suicide prevention:

“A lot of what we’re trying to do here is not just about getting content off Facebook. Last week there was this case where someone was using Facebook Live to broadcast – or was thinking about suicide. And we saw that video and actually didn’t take it down and helped get in touch with law enforcement who used that live video to communicate with that person and help save their life. So a lot of what we’re trying to do is not just about taking the content down, but also about helping people when they’re in need on the platform, and we take that very, very seriously.”

As Zuckerberg implies, the instinctive approach for administrators dealing with disturbing content has tended to be to remove the content and line of communication immediately. This reduces the number of users exposed to the material, and minimises the risk of a PR crisis. However it doesn’t necessarily help the individual concerned or those already exposed to the content. One of the reasons for this is purely technical. For professionals to be able to de-escalate an incident, they need a direct line of communication with the individual affected, and just as with emergency calls, keeping the affected individual communicating can often help them to be located by emergency services.

This shift away from instinctively shutting down content reflects a more thoughtful, measured approach to safeguarding — one which I wrote about in a postgraduate public health thesis in 2015. Media depictions of the internet have often been marked by hysteria over outlier horror stories that were often as indicative of digital dangers as rare shark attacks are of the dangers of going for a swim. This isn’t to say that there aren’t dangers, but excessive fear doesn’t put us in a good condition to make rational judgments about how to manage the opportunities and risks, let alone prepare for threats should they arise.

If we consider moderation to involve employing a finite set of resources, then, to date, internet administrators have tended to heavily favour forms of what can be termed ‘negative moderation’ (as in subtractive), which is to remove, block, and ban offensive content and users.

Although it might seem intuitive that this prevents users from being exposed to troubling content, blocking content too liberally can just as easily push offensive content or conversations to the shadowy fringes of the internet where troubling behaviour can be normalised. Just as adolescents might discuss risky behaviours after school or in the playground that they were not allowed to discuss in class, the conversations can still take place — just in far murkier settings. A good school will recognise this and allow some issues to be discussed in the classroom so that tutors can monitor conversations and offer forms of ‘positive moderation’ through factual information, supportive resources, and balanced perspective.

Mark Zuckerberg’s anecdote, which he shared despite not being directly asked about suicide prevention, suggests both that Facebook take the issue very seriously, and that they will not be cowed by media sensationalism into taking a simplistic route of trying to block every potentially troubling piece of content irrespective of whether this approach helps or harms users. These are encouraging signs.

Perhaps the simplest example of positive moderation is with efforts by media organisations to provide relevant factfiles and helplines at the end of media content that features potentially upsetting themes (as recommended by Samaritans). In the case of social media and chat rooms, platforms can provide easily accessible links to authoritative content and resources, and also educate users about how to respond to content they find concerning or disagreeable. For example, the youth peer-support platform TalkLife is working to train volunteers to provide forms of peer-support and to signpost to resources.

Where content is deemed necessary for removal, rather than pretending it never existed, administrators can provide forms of follow-up support to those affected and pre-emptive educational material in the event of incidents reoccurring. These are difficult to do at scale, but they will become easier as platforms employ predictive algorithms and machine learning.

In his 1958 inaugural lecture at the University of Oxford, political philosopher Isaiah Berlin introduces the concept of negative liberty to describe freedom from imprisonment and coercion. Negative moderation is the digital antithesis of negative liberty; it interferes with the behaviour of some, but on its own it’s a crude method that can harm as many as it helps. A mature philosophy of the internet must be one that employs a balanced approach towards digital content if it’s to allow individuals to express themselves creatively, to learn and grow intellectually, and to access help when needed.

Safe spaces are a symptom of student support failings

This article was also published at HuffPost. 

Debate around safe spaces, trigger warnings and university censorship erupted online during the latter half of 2015. One of the articles that sparked debate was a front page feature in the The Atlantic, ‘The Coddling of the American Mind’, in which Greg Lukianoff and Jonathan Haidt claim that a culture of trigger warnings and safe spaces may be making students’ mental health worse.

The mental health of students remains a major concern globally, so I spoke with leading trauma psychologist and Harvard Professor, Richard McNally, about Lukianoff and Haidt’s claim. Professor McNally appeared to be in agreement, saying, “Although unquestionably well-intentioned, trigger warnings and their implied counsel of avoidance are likely to be counter-therapeutic for students.”

The conclusion seems simple enough: students ought to be exposed to anxious situations, so any students promoting safe spaces and trigger warnings are being unhelpful towards struggling peers. But is it really that simple?

Research suggests that the therapeutic framework known as ‘exposure therapy’ is not without controversy, and, crucially, that it requires close management by a trained therapist. If this is the case then while blanket avoidance is unhelpful, blanket exposure isn’t necessarily therapeutic, either. There is a judgment call to be made about what’s appropriate for the individual, and it’s one that neither students nor academics are typically trained to make.

In the minds of Lukianoff and Haidt, exposure should be the default, and students have no authority to impose forms of ‘avoidance’ on their peers. Some of the world’s most distinguished academics and intellectuals appear to agree. But despite condemning the actions of students, few of the critics have talked about what ought to instead be done to help distressed students.

Lukianoff and Haidt devote over seven thousand words to arguing why students shouldn’t avoid troubling ideas, but they give just two words of advice to those with struggling in spite of (or because of) exposure: “get treatment”. No advice is offered as to how students might do this; nor any consideration of whether such services are readily available. As with most of the criticism of trigger warnings and safe spaces, the circumstances facing genuinely distressed students don’t appear to be a primary concern.

Civil liberties might be a more popular discussion point, but the failing of support services is an issue highly relevant to debates about campus censorship. “If certain course material produces intense distress”, said Professor McNally, “then students should strongly consider seeking psychological treatment.” When I pressed him on where he believes responsibility for this lies, he made it clear that it goes beyond the students, adding, “universities need to know how to refer students to therapists best trained to help them overcome the effects of trauma.”

It’s a given that students struggling with mental health issues should seek out professional support. But a brief glance at the state of support services shows that finding what they need is far from straightforward, and that universities continue to fall short of Professor McNally’s guidance. In the UK, mental health services have faced heavy criticism over cuts; university counselling services are overstretched; and the culture of pastoral care in higher education that previously saw university staff informally care for students has all but disappeared.

Lukianoff and Haidt are apparently either oblivious to these issues, or consider them irrelevant. But without adequate support services, the burden for helping struggling students increasingly falls on their peers. Some of these will be manageable struggles; others less so. It should be of little surprise, then, that students are growing more active and outspoken on the issue of student welfare.

Instead of criticising the methods of those students stepping up to try and help their peers, we can admire their compassion, and respect their determination to plug a failing support system. And if civil liberties campaigners don’t want this to deteriorate into censorship then they can join efforts to make sure that adequate support exists.

What happened to pastoral care?

This article was also published at HuffPost. 

We might be talking more about mental health at university, but there is a related concept, one more rooted within the tradition of higher education and yet crucial to any current discussion about mental health in education, that seems to have faded from view.

In an article for Times Higher Education last week, Anthony Seldon became the first university vice-chancellor to call out universities for not doing enough to protect students’ mental health. Those familiar with Dr. Seldon and his work on well-being at Wellington College and Action for Happiness will not have been surprised by what he had to say. But the article featured an expression that has been conspicuously absent from most of the conversations on mental health in higher education: ‘pastoral care’.

Over the past 10 years or so, usage of the expression has diminished. The Royal College of Psychiatrists’ 2011 95-page report on the ‘Mental health of students in higher education’ contains 290 references to ‘mental health’ and 56 for the word ‘well-being’, but just for 3 for ‘pastoral’ – with 2 of those referring to GP practices. By contrast, the previous report, published in 2003, was just 66 pages but contained 12 references to ‘pastoral’ – 2 more than ‘well-being’.

Part of the preference for ‘well-being’ over pastoral care can be attributed to the secularisation of university campuses. Wikipedia describes pastoral care as “emotional and spiritual support”. The idea of ‘spiritual support’ can seem old fashioned and unpopular, whereas well-being has been a popular subject of study amongst psychologists and economists.

Perhaps there is more to it than that. The Oxford Dictionary defines pastoral careas “relating to or denoting a teacher’s responsibility for the general well-being of pupils or students”. Central to this definition is the assumption that teachers (and educational institutions) have a responsibility for the well-being of students. Does the loss of the term ‘pastoral care’ reflect that we no longer tend to hold universities responsible for student welfare?

Widening access to higher education has brought sharp increases in the number of students. The effects of falling staff-student ratios on students have been compounded by pressure on academics to increase their research output. This isn’t how it’s meant to be. In the earliest days of western education, teachers might have had an entire week to devote to one or a handful of students. Today, students with a scattering of weekly classes can consider themselves fortunate if their lecturer even knows their name.

Some of the changes in higher education are inevitable. Most of us can’t afford to employ a private tutor. It’s unavoidable that giving more people the chance to attend university will mean sacrificing some of the small-group time between staff and students. But the disturbing thing is that we barely seem to have noticed this sacrifice.

Growing (and justified) criticism over inadequate funding for mental health services has overshadowed general wellbeing and support needs. And while university lobbying groups can argue that responsibility for treating those with mental illness largely rests with the NHS, the same cannot be said of general student well-being. There has always been an assumption that when a student arrives at university, their parents are handing over duty of care to the institution. In recent years, this assumption has become less and less justifiable.

There is a trend in academia towards distinguishing intellectual needs from emotional needs, and then trying to monopolise the former and dismiss the latter – something Dr. Seldon refers to as an “unhelpful divide”. This seems like an understatement. Intellectual development necessarily involves emotional upheaval. Good teaching helps steer us through that. As recent debates about trigger warnings and safe spaces show, if educational institutions ignore emotional needs then it’s not just our mental health that suffers, but also our intellectual growth.

If we acknowledge this as a problem, then it’s one that goes beyond the education sector, and dates back decades. The individualism championed under a Thatcher government tends to emphasise personal responsibility; the expansion of universities under a Blair government have made it harder for to provide individualised support, and the economics of higher education lead us to prioritise numbers before norms.

None of this means that pastoral care is doomed, and reinvigorating it doesn’t necessarily depend on reversing student numbers. Universities can prioritise (and monitor) personal tutoring, develop mentoring schemes and strengthen support services. But if we expect universities to take responsibility for the well-being of students then we need to tell them this. And, crucially, to recognise those that do it well.

A note on an article in The Lancet Psychiatry

The latest edition of The Lancet Psychiatry features an intriguing, if odd, article. Entitled ‘Rethinking the biopsychosocial formulation‘, its main premise is that, “to split the psychological and social from the biological is no longer scientifically tenable.” This is something I vigorously agree with and have discussed in criticism of the trendy political term, ‘parity of esteem’. As the authors imply, over-attachment to mind-body dualism is a major threat to improving healthcare. And yet, the conclusion that they appear to draw out of this premise is quite baffling.

As a precursor, I should say that my institution only allows me to access the first page of the article, but, assuming the authors don’t make a significant u-turn later on, the claim can speak for itself:

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The authors seem to be concluding that problems with ‘splitting’ approaches to mental illness into three perspectives require us to discard of two of these perspectives – no surprises for which of the two the authors and psychiatrists wish to discard. It’s unclear how they expect to be able to favour a biological perspective without first ‘splitting’ it from the other two, an action they claim to oppose, or how this can possibly encourage the “integrative-approach” they apparently support.

Putting aside the contradictions, in suggesting a shift towards a more biological viewpoint they seem to be dismissing decades of scientific research and cultural progress that has moved us towards an integrated interpretation of mental illness that acknowledges the influence of social factors, environmental circumstances, and cognition. If nothing else, this is insulting to other mental health practitioners.

Thankfully another psychiatrist was quick to jump in and gently object to the point. After bringing the article to task for being “a little unfair” in its interpretation of the biopsychosocial model, Duncan Double, a ‘consultant psychiatrist and honorary senior lecturer’, discusses intellectual progress in psychiatry and the need for an integrated approach.

Dr. Double suggests that psychiatrists don’t need to be philosophers, but if they’re going to try and address the issue of dualism, they may do well to read up (here’s Stanford’s introduction). In contrast to their less labouring eastern counterparts, western philosophers have struggled with the mind-body problem since the time of Plato nearly 2500 years ago. Even in 400BC it was acknowledged that thoughts and feelings have a basis in the brain. But no sensible philosopher would go so far as to suggest that one should only view such things biologically – at least not until we can figure out consciousness and map out and biologically intervene in every thought and feeling. (That may take some time.)

Perhaps I’m being uncharitable towards the authors and the rest of the article is more nuanced; or perhaps they didn’t express themselves quite as intended? A quick search online and I see that the lead author of the article appears to have written a book on psychotherapy – which only adds to my puzzlement over the article. If those of us working towards joined-up approaches to mental health and healthcare can be a little sensitive about perceived threats to collaborative working, it’s only because we want to see the varying perspectives (biological, psychological and social) moving forward together. 

Are universities less healthy than they used to be?

This post was originally published to Huffington Post.

A journalist called me during a morning meeting recently to ask if I thought university was “unhealthy”. The question caught me off guard. It is not one those of us working in higher education tend to ask.

The existence of universities is such a given, and their place in society so highly valued, that to ask if they are ‘unhealthy’ can seem almost blasphemous. And anyhow, universities are just places of study, how can we generalise about whether they are healthy or not?

My initial response to the question was to point out that each institution is different, with differing support provisions and varied programs of study, so we can’t make sweeping claims. But the words coming out of my mouth left me uneasy. While I suggested that we can’t generalise the university experience, I realised that this is precisely what higher education lobbyists do.

Ministers and lobbyists speak of the value of a university education and of the higher salary one can expect. In doing so, they use what statisticians call an ecological fallacy– where the average in a group is used to wrongly infer the likelihood of something occurring for an individual. Lobbyists rarely make reference to individual differences – between institutions, between programs, between what’s right for particular people. Perhaps, then, we are reasonable in employing the same sort of sweeping judgments when considering the healthiness of a university education.

To answer a question like that on numerical data alone is problematic. We are relying on case-control studies, pitting those that went to university against those that did not. Such studies are inherently flawed measures of causality because healthy, wealthy parents are likely to send their healthy, well-supported children to university. Just as those attending university tend to have a head-start in terms of wealth over their non-graduating peers, so too do they in regards to health. Quite simply, there is no suitable control group.

Another issue with case-control studies is that they draw their conclusions over extended periods of time. For a stable and standardised intervention, like a pharmaceutical drug, that’s not an issue. But universities, economies and working environments are so changeable that a university education is anything but standardised. Graduating 10 or 20 years ago could be, and probably is, completely different to graduating in 2015.

If we wanted to use health related data from previous years to infer something about universities today, we might draw worrying conclusions based on rising suicide ratesand demand for counselling. But to avoid making claims based on historic data that doesn’t necessarily apply to institutions today, we can also break a university education down into its characteristics and constituents, and consider these against evidence-based determinants of health. When we do that, things don’t look much better.

One of the most studied social determinants of health is social support. In going to university, most students are moving away from their family homes and childhood communities, removing themselves from their most sustaining support units, which offered food and shelter, emotional support and the preventive healthcare that tends to be offered by one’s parents. In its place, they have access to informal support from university staff and peers, as well as formal student support services. These services consist of specific advice and guidance for students, as well as counselling services. While all universities have counselling services, waiting lists tend to be lengthy, and services have had their funds stretched since the recession – even in spite of rising tuition fees and rising demand.

In a recent publication, the Chief Executive of Universities UK, Nicola Dandridge, seemed to downplay the obligation of universities to provide adequate counselling and mental health services, saying, “institutions are academic, not therapeutic, communities”.

This is troublesome for a number of reasons. Firstly, it’s all very well to suggest that students ought to use community health services, as Dandridge seems to be implying, but most students are spending up to 9 months away from the communities they are familiar with. If students are expected to transition to community services in their university town, who else is going to support that transition and facilitate access to community services if not the university? To deny responsibility for that seems to show both a disregard for any adverse health events students may suffer, as well as discriminating against those students bringing existing health conditions. When we reflect on recent concerns raised by Stephen Hawking, universities hardly seem to be the progressive institutions that we like to think.

Secondly, while we might accept the claim that universities are places for growth and learning, rather than for correcting health issues, the attempt by Dandridge to disconnect academic and pastoral aspects of study suggests a worrying ignorance of what it means to be human.

As much as places of higher learning might wish to imagine humans only as ‘thinking beings’ without emotions or bodies, the reality is that pushing ourselves in our studies often also means pushing our mental and physical states to their limits. Extended periods of study often demand, or are at least conducive to, late nights, isolation, limited sunlight, limited exercise and poor diets, not to mention the stress of potentially having one’s entire career come down to a 2 hour examination.

Support goes beyond formal services. It includes the informal support offered by professors and staff. One of the promises of a university education is access to leading academics that can provide both intellectual and emotional guidance. But where once the student-staff ratio averaged approximately 1 to 12, it’s now around 1 to 22. And then there are the greater research burdens on lecturers that limit the time they can spend with students – and the quality of that time. While students being assigned a staff member as their ‘tutor’ on arrival would seem to be of value, the burden of obligations felt by staff elsewhere tends to make it a tokenistic arrangement consisting of minor administrative duties at best.

Then there is the informal support offered by peers. Peer networks are invaluable sources of information, emotional support, and belonging. But it’s not always a good thing, as the contagion of obesity has shown. Social networks lead to social norms, and if our networks are engaging in poor lifestyles, fuelled by alcohol and late-night kebabs, we’re probably more likely to do the same – particularly when struggling to make friends and settle into a new environment. And if we don’t manage to fit in, we have social isolation waiting for us, with all of its ill effects. The great range of study and living options, particularly outside of collegiate institutions, are such that we can find ourselves without any particular identifiable group aside from being a member of a 30,000 strong university. For those coming from a small town or school of a few hundred, it can be a bewildering experience.

Many student unions and societies are working to address the lack of support through health promotion, but these are not core structural functions of a university education. They are not standardised for students; they serve a complementary role as fringe additions to the formalities, set up in recognition of university limitations. And the increasing attention shift by student unions away from political issues towards welfare issues shows the true extent of these limitations. For the government, that’s probably quite convenient – students addressing health crises through peer-support means fewer students fighting abuses of power; although, as some students are beginning to recognise, the two are closely related.

No one would be brazen enough to say that universities are ever going to be ideal environments for one’s health. Few would be brazen enough to expect that. But if our hospitals are places to reduce poor health, is it too much of a stretch to suggest that our universities ought to be places that protect good health?

All mental health advocacy is political

This post was originally published at Huffington Post.

Equating mental health issues with physical illness is fashionable amongst health commentators. From analogies associating mental health issues with a broken leg or cancer, to calls for parity of esteem, the inference is that mental illness and physical illness ought to be considered in the same way. But while the message may have served a purpose in recent years, it’s also a simplistic and increasingly misleading interpretation of mental health, and we owe it to our society and to the millions struggling with mental health issues to do better.

In the aftermath of the general elections last month, New Statesman journalist Laurie Penny wrote an impassioned article that linked the election result with depression. Social media backlash quickly followed, accusing the author of being insensitive and naive about the seriousness of mental illness.

A political commentator lacking insight into mental health might have been inclined to admit error, even if only to avoid confrontation. But Penny is no stranger to the subject of mental health. Quite the opposite. One of her first roles in journalism was writing for One in Four, a magazine whose raison d’etre was to provide a voice for those with mental health issues.

What Penny knows, and what we perhaps all need to remind ourselves of, is that mental health and sociopolitical factors are deeply intertwined. Not least of which is the economy, with studies showing dramatic rises in suicide during periods of recession and high unemployment.

There is also a strong relationship between inequality and mental illness. And an underlying risk factor for poor mental health is a perceived lack of control over our lives – something that almost every political decision could be said to have an influence on. Interpreting mental health with a strictly medical model precludes all of this.

None of this is to say that mental illness doesn’t also have a biological basis. Of course it does. Medical interventions can help. And a medical interpretation of mental illness can reduce blame associated with those who are suffering. But a denial of social and environmental factors can also leave us feeling helpless and insensitive to what’s going on around us.

Studies have also indicated that a narrow, brain-based interpretation of mental illness may increase pessimism about recovery, reduce confidence in psychotherapies, and actually increase aspects of stigma.

The solution, needless to say, is with an integration of biological and sociopolitical factors. That may be difficult and uncomfortable to do in our dualist, western society with its love of clear definitions and boundaries, but only when it happens will we be on the right path. Not just for the benefit of those with mental illness but also for those with mental health. (Yes, I mean everyone.)

Mental health advocates have a tendency to lose sight of this. While some campaigners delighted in political parties putting mental health service funding in their 2015 election manifestos – others were skeptical in light of the government’s rhetoric-defying NHS cuts.

Irrespective, rises in mental illness and suicide should not only prompt an increase in medical service provision – which is a given – but also an examination and reversal of social and political contributors. Like the canary dying in the coal-mine, it should be seen as a sign that something is not right.

The onus to point this out shouldn’t only fall on the mental health community. It should fall on the political ‘left’. If the left is lacking direction, as some have claimed, it would do well to reflect on its attitude towards mental health, and its neglect of the social sciences. The Conservative government has mined the area, with its‘behavioural insights’ and ‘wellbeing index’. Why has the left not done the same, and used the the abundance of social sciences literature that inherently supports its position?

Were it to do so, it wouldn’t refer to the rise in mental health issues only in terms of health services, but in terms of a need for broad social and political reform. Reform that starts by recognising that the association between recession and suicide is a symptom of a society failing to do enough to protect its people from the downsides of misfortune, whether economic or otherwise.

There is no biological reason for why economic depression should lead to clinical depression. It’s entirely social and political. We’re all affected, and we need more public figures to be talking about it.

Why Parity of Esteem is Not Enough

This blog post was originally published at:

Mental health campaigners have been given cause for optimism recently thanks to increasing political discussion about underfunded mental health services. Whilst we can be thankful that such conversations are being entertained, there is cause to be wary of the rhetoric if we consider real implications to those at risk of mental health problems.

In 2011, the UK government published a mental health strategy which referred to the goal of giving “equal weight to both mental and physical health”. Others, including the Royal College of Psychiatrists, have talked about achieving “parity of esteem” between mental and physical health. These expressions may have captured public attention, but as an article published last week in the British Medical Journal pointed out, the phrasing is simple to the point of simplistic.

Any armchair philosopher can question the logic of the rhetoricians’ suggestion that the ‘mental’ is somehow distinct from the ‘physical’. To do so can be seen as uncharitable; pedantry that misses the point. Those using the expression would say that their aim is only to draw attention to the underfunding of mental health services; and with mental health services having been dangerously slashed, such efforts should be applauded and given full public support.

Having said that, while we engage in topical conversations about mental health, we must not allow ourselves to ignore symptoms of an underlying problem. Health services need to appreciate the deep interrelatedness of mental and physical health; at present they don’t, and the rhetoric doesn’t help.

The largest health burden facing the world this decade involves non-communicable diseases such as heart-disease, cancer, and diabetes. A better collective term is ‘stress-related disorders’, since they are all either caused by, or associated with, chronic stress (or lifestyle patterns related to chronic stress, such as smoking, unhealthy diets and alcohol consumption). Meanwhile, researchers are continuing to shed light on the gut-brain axis that shows how fundamental the links are between intestinal conditions and psychological health – and that’s before we get into comorbidity of mental and physical illness.

Modern medical science is increasingly revealing mental and physical health to not be separate yet interrelated domains, but rather two ways of viewing a single system. A health service that appreciated this wouldn’t encourage the idea that mental health services sit apart from other health services; it would do everything it could to strengthen pathways between the two, alongside a longer-term aim of embedding a consideration for mental health deep into every corner of the health service and every module of medical training.

Calling for mental health to be on an equal level with physical health doesn’t necessarily run counter to the aim of bringing mental and physical health services closer together. It can increase funding for mental health treatments. It can increase awareness of mental health at GP level. But it can also conjure up a combative image of mental and physical health as being in competition with one another, straining the already thin bonds between the two service areas. With a health system already under pressure, discord is the last thing needed.

That there should be wariness about bringing mental and physical health services closer together is understandable. The mind is a variable that’s hard to control for in medical studies. We just about manage to recognise its influence on the body with accounts of the placebo affect, but barely so. Going much further than this is scary; it draws us towards unchartered academic waters and requires us to traverse the borders between academic disciplines. Perhaps it also moves us towards a more preventative approach to health that might be seen as a threat to traditional institutional structures and finances.

In the field, it’s already being done. Encouragement can be taken from pragmatic examples like the use of cognitive-behavioural therapy in bowel disorders and social-prescribing in mental health (such as recommending forms of exercise for moderate depression). But these are still very much on the fringes. We need more of this kind of crossover at a strategic level; this whole-systems thinking that the World Health Organisation has been talking about, for 28 years already. We also need to look at alternative ways of categorising services.

The idea of dividing the mental and physical has deep roots, going back to Ancient Greece with Platonic ideas of conflicting poles and dichotomies. Perhaps the categorical thinking that gave rise to the ‘mind-body problem’ helped fuel Western progress and moved us ahead of the softer wholism of the East for half a millennia, but, right now, it threatens to stunt our health system.

So while the prospect of more funding for mental health services is a good thing, it’s no real victory if mental and physical services are not brought into unison. A health system that was in tune with medical science would have mental wellbeing at its core. But it would also see the body and mind as a single system. And, as with all systems, if you neglect one aspect then you affect the whole.

In digital healthcare, who moderates the moderators?

The collapse of The BeatBullying Group raises serious questions about duty-of-care in digital support services, and to what extent such services need to be regulated. 

As an independent consultant to the charity’s mental health service, Mindfull, I was aware of the lengths that were taken to ensure rigorous safeguarding procedures worthy of the trust of users and third party stakeholders. My experience of working with the charity, and with the staff there, was entirely positive. It’s for this reason that the events of the last few weeks – with the sudden closure of services and secrecy – have been such a surprise, to myself and to many others.

The charity’s safeguarding protocol involved a sophisticated hierarchy of moderators, administrators and mental health professionals – all watched by NetMod, a piece of algorithmic technology that picks up on keywords and text patterns. The aim was to provide a comprehensive safety net for users so that they could depend on the service. Apparently, in spite of such measures, there was no safety net for the service itself.

Since the service was taken offline, communication from The BeatBullying Group’s Trustees has been slim-to-none. Staff and consultants were aware of delays in paying salaries some months ago, but were unaware that the service was under threat. Emails since the closure have been deliberately vague, speaking of “intense negotiations with a number of third parties”, but revealing no details. For those professionals with concern for the service, all that’s really known is that the Trustees decided that it would be better to pull the plug on services rather than openly discusses the challenges of keeping it online.

I have no reason to doubt that the charity’s trustees did what they thought right for users, or that they consulted legal professionals and mental health experts before switching off services. But had they sought the views of those of us working for the services, I have no doubt that the idea of switching services off without notice would have received no serious consideration.

At the heart of any digital support service is trust. Those turning to an anonymous service like BeatBullying are often doing so because they find it difficult to find places of trust elsewhere; it may have been ripped away from them by troubled family lives or abusive parents. BeatBullying promised to be a place of trust and dependability, and the thousands of young people using the service saw it as such. That trust and dependability has disappeared. Not just because of the loss of the service, but because of the manner in which it was switched off. To do so without prior notice or consultation has the whiff of a foster parent that has tucked their children into bed and then vanished during the night.

Were it a face-to-face support service or rehabilitation centre with regular day users, it would surely be immediately investigated if it closed its doors to users without notice – particularly as a registered charity with public funding. There would be an explicit duty-of-care to service users. At present, online support services appear to be held to a different standard, or none at all. For the public and mental health professionals to have faith in such services, this must be addressed.

As for the future of The BeatBullying Group, and its services, staff and volunteers continue to wait patiently for news whilst worrying about those young people who were depending on the service. For those feeling let down by the charity, the only consolation a conclusion may bring rests with the hope that important lessons may be learned.

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