Silence, power, evidence and a debate with no clear answers

The debate on mental health revelations in The Psychologist continues.

[Editor's note: The headline above was for the print selection, and more letters have been added to this online version. These letters have included 'more clear answers'. However, if I change the headline, the original link - which has been widely shared on social media - will break. 

Please also remember that BPS members can log in to post comments below.]

 

We were interested to read Dr Roger Lindsay’s letter on mental health revelations in the February edition of The Psychologist. A thoughtful letter demands a reflective response, and we hope that some of the questions we pose here can contribute to a useful debate, and one which moves the discussion forwards.

With no intent to accuse Dr Lindsay being ‘unfeeling or lacking in empathy’, we would question why he would like people to stop publishing their lived experience in The Psychologist. It is encouraging to hear his acknowledgement that clinical psychologists may also experience mental health difficulties; however, we suspect that it may still be a novel idea to many others. In suggesting that professionals ought not to publish their personal accounts, are we re-enacting the silencing that we are already often guilty of as a profession?

As clinical psychologists, we agree that it is important not to assume that one is a good therapist purely because one has experience of adversity, though research in this area appears to be lacking. Although some studies do exist (e.g. Poal & Weisz, 1989), such work is generally notable for its absence. We are aware, however, of an ongoing study investigating empathy in mental health professionals with a history of mental health problems, which readers of The Psychologist may wish to participate in. Do we need more good-quality research into potential links between therapist adversity and therapist competence with the understanding that, as with many parts of the discipline, we may not like what we find?

Do personal disclosures actually help to reduce stigma? The overall picture from campaigns such as Time to Change is mixed (Smith, 2013) and shows that any initial decreases in stigma are not maintained over time. Whilst personal disclosures may be initially helpful to both the person disclosing and others who may read them, do they help us to tackle stigma in the long-term?

There are moves to be more inclusive across the profession of clinical psychology, with many examples of this evident at the recent Division of Clinical Psychology conference. We would question in more detail why this is, and what the agenda behind this may be – that there is a power differential in clinical psychology is evident, and in attempting to minimise this are we genuinely helping those less privileged than ourselves, or merely repeating narratives of oppression? And, if we are genuinely concerned about stigma and discriminatory attitudes within the profession, would it not be more useful to formulate an evidence-based and service-user led anti-stigma campaign?

Dr Lindsay questions whether The Psychologist is the place for such disclosures, and suggests a ‘personal confessions website’ as an alternative. Given that the British Psychological Society is a learned body, this does raise questions about the remit of The Psychologist, and whether a letters page necessarily needs to be an evidence-based, scientific forum. A ‘confessions website’ would, in our opinion, serve as an echo-chamber where little change would occur. Balancing the needs of clinical psychology as a profession with the needs of the 50,000+ people who receive The Psychologist magazine is, perhaps, an ongoing debate with no clear answers.

Dr Sarah Blackshaw
@academiablues
Dr Masuma Rahim
@MasumaRahim
Dr Che Rosebert
@CheRosebert

References
Poal, P. & Weisz, J.R. (1989). Therapists’ own childhood problems as predictors of their effectiveness in child psychotherapy. Journal of Child Clinical Psychology, 18(3), 202–205.

 

I am writing in response to the letter, ‘Mental health revelations: Enough is enough?’ (February 2017), in which the writer comments on the ongoing discussions in the pages of The Psychologist on the importance of healthcare psychologists being open about their psychological situation. This exchange has been gathering momentum over the past several months and the openness with which a number of psychologists have described their experiences, and how they draw on them in their work, has received near universal appreciation and acclaim.

Sadly, the writer appears entirely to have missed the point in a letter, which is not only ill-informed but which could also, tragically, be perceived to be extremely stigmatising.

The disclosure of psychological history in the letters to which the writer refers is nothing whatsoever to do with catharsis. Rather, its purpose is to demonstrate that whilst psychological distress may be both disturbing and painful, it can, as with most other conditions, be treated, lived with and overcome, and that most of those so affected can go on to have productive and full careers. As such, it is a much-needed challenge to the widespread prejudice in society, and to the belief held by many, including sadly some of those personally affected, that psychological distress only affects the ‘vulnerable’ and is something to be ashamed of. This message needs to be promulgated loudly, robustly and widely until such time as psychological distress is viewed in exactly the same way as any other type of distress, where there is no stigma attached to revealing a psychological history, and where a person’s psychological history does not de facto affect that person’s training, recruitment, selection, preferment and advancement, either in the profession of psychology or elsewhere.

The experience of psychological distress, and the accompanying experience of ‘occupying the other chair’ as client or patient, are also extremely valuable ones, and ones that should never be trivialised or minimised. They can be a rich source of knowledge and empathy in the delicate human undertaking that is psychological practice; indeed, the latter is compulsory in some branches of applied psychology.

It is clearly apparent that the writer is at least partially conversant with mythological literature. Hence it should come as no surprise to him whatsoever that the reversal of cultural stigma and its effects on society (financial, moral, social and, of course, psychological) is, has been, and will continue to be, for the immediate future at least, a Herculean task. Hence it is that so many of us are engaged, in many complementary ways, in seeking to reverse it and its effects.

And it is for this reason that it is more important than ever to state that, despite the apparent irritation of the writer, the voices of which he complains will not be silenced, either within the pages of The Psychologist or anywhere else, until stigma is banished.

Professor Jamie Hacker Hughes CPsychol, FBPsS
London SE17

Smith, M. (2013). Anti-stigma campaigns: Time to change. British Journal of Psychiatry, 202(s55), s49–s50.

 

The Minorities in Clinical Psychology Pre Qualification Group welcomes the recent set of letters from psychologists talking about their lived experience of mental health issues. The clearing house figures states that 1 per cent of people applying to training disclose a mental health difficulty, yet recent research suggests that these figures are significantly higher.

With several of our members having completed the doctoral form and having faced the issue of whether or not to disclose and, if so, then choosing how much to share. We have found that the one thing that we all have in common is the sheer mix of information and advice we have received from those higher up the profession. This ranges from the supportive (e.g. it will be seen as an asset or a positive) to the cautious (e.g. maybe don’t go into detail or you are ‘brave’) to those actively opposed (e.g. do not rock the boat or maybe leave it till you are on training/when you are qualified). This mix of messages has left us feeling confused and wondering quite how big a risk we are taking by being open.

We are hopeful that this situation will change and feel that the more people at the top are open, the more that this will filter down and hopefully one day we will be in a situation where there is no choice to make and disclosing will become routine. We will not then have members worried about contributing to discussions and subsequently articles on these topics for fear of what this may mean for their career.

Camilla Hogg
Mental Health Organiser,
Minorities in Clinical Psychology
Pre Qualification Group

 

The long misanthropic attack by Roger Lindsay on psychologists who talk publicly about their experience of mental health problems contains a flawed logic about the role of empirical knowledge in human science. His conclusion is that the pages of The Psychologist should be limited to ‘information based upon solid evidence and likely to be of interest and value to a greater proportion of the readership’. However, the majority of the readership of any publication will be personally touched in some way biographically, and often profoundly, by mental health problems; either their own, their friends or their relatives.

Moreover, personal experience is central to these problems because of the high risk of invalidation. This is a social-existential matter: one has a broken leg but one is mentally ill and to lose one’s reason is a highly risky business in a society dominated ideologically by forms of (contestable) rationality (Pilgrim & Tomasini, 2012). Because a diagnosis of a mental health problem is both an experiential attribution by medicine and a source of stigma and social rejection in the lay arena, then professionals speaking out about their own difficulties are providing a useful role. They are exposing that experience to fuller public understanding and reducing the probability of the ‘othering’ of psychiatric patients. Some psychiatrists have offered such accounts productively (e.g. Gask, 2015) and there is no case at all that psychologists should demur.

Finally, empirical knowledge about functional psychiatric diagnoses ipso facto is predicated wholly on what people do and what they say. There is no objective disease state to study; that is why the more humble term ‘mental illness’ (not ‘disease’) is used, even within a medical model, to signal the centrality of subjectivity of both the patient and the professional. Where those subjectivities intersect surely is of both psychological and social importance to us all.

Dr David Pilgrim
Honorary Professor of Health and Social Policy
University of Liverpool

References
Gask, L. (2015). The other side of silence: A psychiatrist’s memoir of depression. London: Vie.
Pilgrim, D. & Tomasini, F. (2012). On being unreasonable in modern society: Are mental health problems special? Disability and Society, 27(5), 631–646.

 

I’m sometimes frightened about writing letters such as Dr Lindsay’s, in case I write something so glaringly obvious that everyone regards me as being silly. Also, of course, nothing is black or white. This letter might turn out to be one of those black and white letters that’s glaringly obvious.

There is an underlying difference between medical and psychological practice – medical tries to deal with certainty (technical) whilst psychology deals with uncertainty (adaptive). It’s easy to understand what an ingrowing toenail is and what needs to be done about it; it’s an adventure to find out why you feel uncomfortable and panicky in different situations and what can be done about it.

Medical practitioners have power over their patients, largely because of the threat that ill health poses to individual survival. Whatever their behaviour the technical processes will lead to some kind of result. Psychological practitioners don’t have similar power. The threat of psychological challenges is perceived not to be as strong. Therefore the behaviour of psychologists plays a huge part in influencing how far their client will progress in revealing and in restoration, as there isn’t the same threatening imperative to reveal in order to survive.

Patients and clients both suffer fear. Patients with a physical condition are fearful of the threat their condition poses to their lives. Clients with a psychological challenge are fearful of the consequences of revelation on their reception by society – communities, neighbours, friends, family, institutions.

Medical practitioners use the strategy of imposition with their patients. It’s a choice but the choice is often take it or leave it. Psychological practitioners use the strategy of conviction – they need to convince their clients about their authenticity to intervene with their client. Their clients are not recipients of an imposed solution; they are participants in their own discovery and restoration. Clients have to, somehow, abandon their fear and open their mind.

There are two sub-strategies to the strategy of conviction – the rational/empirical strategy based on reasoned argument, and the normative/re-educative strategy based on example. These can be used separately or in combination.

For clients to abandon fear and have an open mind they need to trust their psychologist. Trust is the absence of second guessing the motivation of others, to a point when you accept at face value what the other person says and does, without question. Medical practitioners tend to be trusted by patients, largely because they deal with a subject that is far removed from our normal understanding and want the threat to our survival lifted. They are accepted experts, hence their power and ability to use the strategy of imposition. Not so with psychology. Everyone believes they are a psychologist. Clients only believe you have expertise when you reveal something they regard as insightful. If you don’t achieve this, clients will view you like they view their doctor, as a technician.

A key attribute and behaviour in this process is attentiveness. Psychologists want to provoke the strong reciprocity properties that attentiveness possesses, so that the interaction can optimise its chances of a successful outcome. One of the triggers of attentiveness is asking or sharing something unique between the parties. In other words – to provide an example of an experience that is unique to both.

Jamie Hacker Hughes and Peter Kinderman are highly respected leaders and clinicians in their field. The fact they have revealed, rather than concealed, events in their lives that are examples of experiences relevant to their clients only serves to help the process of a successful outcome. They have revealed in a public space because they are leaders, hoping to inspire followers to do the same.
Of course, there is the bigger picture. The element of fear that those with psychological challenges face is currently justified by the general reaction to revelation.

Dr Lindsay’s reaction is an illustration. The antidote is more revelation, not less.

Derek Mowbray PhD, CPsychol, FBPsS
Director, MAS

 

As clinical psychologists who have a diagnosis of autism, we are grateful for Dr Roger Lindsay’s sceptical letter in February’s edition. As he suspects, we have found it personally beneficial to disclose our own diagnoses, and are encouraged by colleagues’ recent disclosures of their mental health challenges. We also see such disclosures as having more a general purpose, which would not be adequately served by hiding them on a dedicated website, tempting as that may be. After all, the hole into which King Midas’s barber whispered the secret of the king’s asses ears failed as a confidential confessional, because the secret echoed through the land until everyone knew it. In a modern retelling of the myth Dr Lindsay cited (Maddern, 2004) the shameful secret lost its stigma once it was no longer secret.

And the problem is that disabilities still hold stigma. Like others, we at times have asserted that our autism make us better clinicians. In doing so, we have not intended to claim that we are better at our jobs than colleagues without a developmental disorder. Rather, the main purpose of disclosure is to challenge the prevailing assumption that a diagnosis makes us worse at our jobs or even disqualifies us from them. It is good to know that Dr Lindsay for one has never made such an assumption. We have met it at various stages in our careers. We also know numerous colleagues with developmental disorders who, because of their disabilities, have had to overcome more than the usual barriers to further qualification and training in caring professions, or who still repeatedly face such barriers, or who fear the barriers they would face were they to disclose. We regret that some potentially good practitioners are being lost to psychology and related professions.

Every psychologist has different strengths and weaknesses in their skills. Equally, all psychologists have different beliefs, personalities, perspectives and experiences (including of being a mental health service user, a member of another stigmatised group, or neither of these) that can bring advantages as well as disadvantages to their work. As these patterns might be more unusual in some cases, such as ours, like other members of minority groups, we are finding embracing and reflecting on diversity more helpful than ignoring it. Public self-disclosure can help reduce stigma for others (Cross & Walsh, 2012). We also hypothesise that disclosure of diagnoses by BPS Presidents, and other psychologists who have experience, qualifications and a career in the field, will help encourage others with disabilities to pursue careers in psychology as an open and accepting profession. Rigorous research to test such hypotheses would be welcome, but autobiographical accounts or case studies can help begin to challenge prevailing assumptions in formulating research questions, as well as breaking down stigma.

David Hawker
Clinical Psychologist, Nottingham
Joshua Muggleton
Trainee Clinical Psychologist, Edinburgh

References
Cross, W. & Walsh, K. (2012). Star shots: Stigma, self disclosure and celebrity in bipolar disorder. In J. Barnhill (Ed.) Bipolar disorder: A Portrait of a complex mood disorder (pp. 221–236). Rijeka: In Tech.
Maddern, E. (2003). The king with horses ears. London: Frances Lincoln.

 

With regard to Dr Roger Lindsay’s letter in the recent Psychologist; I certainly agree that more care needs to be taken to moderate material being placed in the public sphere by people who may later come to regret their hasty actions due to that material being ill-thought-out; and so potentially subjecting them to the ill-feeling of their colleagues and the wider public. Certainly, Dr Lindsay’s letter is a blow for right-thinking people everywhere.

This is not to say that I feel disclosure of mental health problems by psychologists is a bad thing, quite the opposite. Those brave individuals who have been able to be open about their struggles and humanity are owed a debt of thanks – and will doubtless be on the right side of history as we shed the Victorian moralism of the uber-therapist who is somehow never tried by the slings and arrows faced by us lesser mortals. Hopefully in due course, we will have such things easily and openly spoken about, but for now we rely, as ever, on the brave few as our vanguard – those willing to face risk on a personal level for the benefit of others. Of course, there may be some additional secondary gain for those people involved; but to assert, as Lindsay does, that that is the primary motivation (“I find it difficult to believe that anyone benefits except the narrator…”) is specious at best and perhaps sophistic.

Motivations dealt with, I was also rather bemused by Lindsay’s phrase “I will, however, only believe that such experiences feed into therapeutic practice in a positive way when I see hard evidence to that effect” without Lindsay presenting any supportive of their own. The correct response to unfounded assertions of this type is naturally always the reverse - “I will only believe that such experiences do not feed into therapeutic practice in a positive way when I see hard evidence to that effect”. That aside, let us consider the evidence that Lindsay has failed seek:

Usually when ‘Hard evidence’ is requested and complied with, the retort is then that said evidence is not ‘Hard enough’. Unless one has a dozen Cochrane-reviewed meta-analyses of long-term double-blind studies with vast Ns, tiny alphas, and magnificent effect sizes the evidence is dismissed. Even if you do provide such mythical literature, the retort is invariably “But some of those studies are from last year!” etc., But let’s see what we can find from just a quick poke of the internet…

A few minutes later and we have: Angermeyer, Matschinger & Corrigan (2004); Cross & Walsh, (2012); Evans-Lacko, Brohan, Mojtabai & Thornicroft (2012); Machlin, King, Spittal, & Pirkis (2014); Mojtabai (2010); Pettigrew, Donovan, Pescud, Boldy & Newton, (2010); and SANE Australia (2009). I’ll not bore you with a full literature review here as the point is made - a point easily researched, one might think.

Further, there is a whole section in Cooper’s seminal Essential Research findings in Counselling and Psychotherapy (Cooper, 2008) which is an excellent place to start when one has questions of this sort. For example, Cooper reports Barrett and Berman (2001) who showed that clients in an increased therapist self-disclosure group had less symptom distress; And several studies have shown that therapists who self-disclose are rated as more likeable, warm and relatable (Dowd and Boroto, 1982; Nilsson, Strassberg & Bannon, 1979; VandeCreek and Angstadt, 1985). Further, Hill, et al (1988) found therapist self-disclosure as the most helpful intervention; and Bedi et al, (2005) found 30% of clients rated therapist disclosure as critical within therapy. Of course, the studies reported in Cooper (2008) were in the therapy room where disclosure must be balanced against many other important factors which must also be considered; but they give a feel for the place of disclosure within professional applied psychology practice.

Perhaps for these reasons, we can see that there is consensus regarding the use of the self in professional applied psychology; and if one has had experience of mental distress this will, naturally, be a part of that self. Indeed, one would hope that people commenting on such matters would have knowledge of the British Psychological Society’s own position statements on this matter such as the Professional Practice Guidelines of the Division of Counselling Psychology (DCoP, 2005) and indeed The Health and Care Professions Council (HCPC) itself – the regulatory body of applied psychologists (HCPC, 2015).

There, that was ten minutes or so for some actual evidence to support my assertions. Not that it was necessary; it seems to me that as psychologists we should support one another to be everything we can. Especially if it seems likely to benefit others (both within and without our profession) to really see that we are all one group of humanity - rather than an “us” of psychologists (with no mental distress or with hidden distress) and a “Them” of patients.

Dr Christina Richards

MSc DCPsych CPsychol MBACP (Accred.) AFBPsS

HCPC Registered Counselling Psychologist

Senior Specialist Psychology Associate

Clinical Research Fellow

References

Angermeyer, M. C., Matschinger, H., & Corrigan, P. W. (2004). Familiarity with mental illness and social distance from people with schizophrenia and major depression: testing a model using data from a representative population survey. Schizophrenia research69(2), 175-182.

Barrett, M. S., & Berman, J. S. (2001). Is psychotherapy more effective when therapists disclose information about themselves?. Journal of consulting and clinical psychology69(4), 597.

Bedi, R. P., Davis, M. D., & Williams, M. (2005). Critical Incidents in the Formation of the Therapeutic Alliance from the Client's Perspective. Psychotherapy: Theory, research, practice, training42(3), 311.

Cooper, M. (2008). Essential research findings in counselling and psychotherapy: The facts are friendly. London: Sage.

Cross, W., & Walsh, K. (2012). Star Shots: Stigma, self-disclosure and celebrity in Bipolar Disorder. In J. Barnhill (Eds.), Bipolar Disorder- A portrait of a complex mood disorder (pp. 221-236). Rijeka: In Tech.

Division of Counselling Psychology (DCoP) (2005). Professional practice guidelines. Leicester: British Psychological Society.

Division of Clinical Psychology (DCP) (2005). Professional practice guidelines. Leicester: British Psychological Society.

Dowd, E. T., & Boroto, D. R. (1982). Differential effects of counselor self-disclosure, self-involving statements, and interpretation. Journal of Counseling Psychology29(1), 8.

Evans-Lacko, S., Brohan, E., Mojtabai, R., & Thornicroft G. (2012). Association between public views of mental illness and self-stigma among individuals with mental illness in 14 European countries. Psychological Medicine, 42(8), 1741-52.

Health and Care Professions Council (2015). Standards of Proficiency: Practitioner Psychologists. Retrieved 2nd February 2017 from: http://www.hpc-uk.org/assets/documents/10002963sop_practitioner_psycholo...

Hill, C. E., Helms, J. E., Tichenor, V., Spiegel, S. B., O'grady, K. E., & Perry, E. S. (1988). Effects of therapist response modes in brief psychotherapy. Journal of Counseling Psychology35(3), 222.

Machlin, A., King, K., Spittal, M., & Pirkis, J. (2014). The role of the media in encouraging men to seek help for depression or anxiety. Centre for Mental health, Melbourne School of Population and Global Health.

Mojtabai R. (2010). Mental illness stigma and willingness to seek mental health care in the European Union. Social Psychiatry and Psychiatric Epidemiology, 45(7), 705-12.

Nilsson, D. E., Strassberg, D. S., & Bannon, J. (1979). Perceptions of counselor self-disclosure: An analogue study. Journal of Counseling Psychology26(5), 399.

Oxford Centre for Evidence-Based Medicine (2011). Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence. Retrieved 2nd February 2017 from: http://www.cebm.net/wp-content/uploads/2014/06/CEBM-Levels-of-Evidence-2...

Pettigrew, S., Donovan, R., Pescud, M., Boldy, D., & Newton, R. (2010). Mature adults' attitudes to mental health service utilisation. Australian Psychologist 45(2), 141-50.

SANE Australia (2009). SANE Research Bulletin 10: Stigma, the media and mental illness. SANE Australia, Melbourne.

VandeCreek, L., & Angstadt, L. (1985). Client preferences and anticipations about counselor self-disclosure. Journal of counseling psychology32(2), 206.

Dr Roger Lindsay responds: It was a relief to see a let-up in the seemingly endless flow of me-too disclosures of mental health difficulties amongst clinical psychologists, and the advent of a little critical reflection on the purpose and function of such disclosures. Particularly illuminating was the set of references supplied by Dr Christina Richards which led her to conclude: “that there is consensus regarding the use of the self in professional applied psychology”. A little short of demonstrating that mental health difficulties improve professional practice, but instructive nonetheless. Incidentally, the reason that I hadn’t researched the topic, for which Dr Richards obliquely chides me, is that I don’t have much interest in it, and the reason I had come to suspect that perhaps relevant evidence doesn't exist was the fact that The Psychologist has chosen to publish numerous disclosure narratives amounting at best to low quality raw data, rather than commissioning an article reviewing such evidence as that cited by Dr Richards.   

A number of the replies to my letter offer the struggle against stigma as a rationale for the plethora of disclosure stories. I am puzzled both by the apparent assumption that co-professionals in the world of Psychology are the most urgent target for this message, and by the manifest ineffectiveness of the strategy – it is heartwarming to hear that disclosing practitioners believe that their professional effectiveness has benefited or has not been harmed by their mental health tribulations, but such beliefs no matter how often repeated, do not and indeed cannot, add up to a demonstration of their own truth.  

Professor Hughes warns me thatdespite the apparent irritation of the writer” (which I can assure him is real as well as apparent) “the voices of which he complains will not be silenced, either within the pages of The Psychologist or anywhere else, until stigma is banished”. If Professor Hughes is misguided enough to believe that the endless repetition of more-of-the-same disclosure stories will materially contribute to this banishment, we could be in for a very long ride. I can assure him that after the first two or three such stories, I had already concluded that nothing new was to be learned and taken to skipping as rapidly as possible over such further examples as he has sought to impose upon me. I do not incidentally wish to silence any voices, merely to persuade them either to convey a more informative message or to continue their articulations outside my earshot. It is a great mistake to believe that freedom to speak imposes upon other people an obligation to listen.

Dr Roger Lindsay

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