Are We Talking About Therapy Too Much?
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Just go to therapy. It's the kind of thing that's become very common to say, regardless of the circumstances. For many, therapy or mental health treatment has become less like healthcare and more like exercise or eating healthy foods prescribed to everyone broadly, regardless of their individual circumstances.

In my opinion, destigmatizing mental illness and making people comfortable with asking for help is one of the great cultural innovations of the 21st century. But there have been increasing worries that this cultural shift and the policy and behavioral changes that have accompanied it, particularly in schools, are having some unintended consequences.

In a provocatively titled psychology article, our guest today, Dr. Lucy Foulkes, asked the academic community, quote,

She and her co-author theorize that mental health awareness efforts are leading to more accurate reporting of often ignored mental health issues, but also that awareness efforts are, quote, leading some individuals to interpret and report milder forms of distress as mental health problems.

This is Good on Paper. It's a policy show that questions what we really know about popular narratives. I'm your host, Jerusalem Dempsis, and today's show is about whether the effort to destigmatize mental health and encourage people to get therapy when they need it has not been tailored enough.

Not everybody needs to be in therapy. For some people, it may even be harmful. Lucy Foulkes is a really thoughtful guest, and I wanted to have her on the show because unlike many people in this space, she doesn't see this issue as black and white, but rather as a variety of trade-offs that we need to weigh against one another.

Questioning the growing orthodoxy that therapy is always good, or asking if frequent discussions of mental health may have some serious drawbacks, doesn't mean dismissing mental illness as a serious concern. But it does open us up to many difficult questions, ones I explore with Lucy in today's episode. Dr. Lucy Foulkes, welcome to the show. Hi, thanks for having me.

I want to start with a paper you published last year that I feel like set off a real firestorm. And it was called Our Mental Health Awareness Efforts Contributing to the Rise in Reported Mental Health Problems. So tell me about this paper. Why was it so controversial?

Well, I've been interested for a long time in the possibility that some really well-intended efforts to get people to talk more about mental health problems and to label them and to seek help for them might have had some unintended consequences. And that paper was the culmination at that point of my thinking about it, along with my colleague, Jack Andrews. And really, in that paper, we posed it as a question that needs to be investigated and tested and explored.

And the question was, is it the case that the more we encourage people to think and notice and talk about mental health, the more they end up reporting mental health problems? And we were interested or we posed two potential routes, one of which is if you raise awareness about mental health problems and destigmatize them and help people understand what they are, then you're probably going to have more people reporting problems who otherwise would have kept it hidden.

So maybe in previous generations, they weren't admitting these problems and now they are. So the actual kind of base rates aren't getting worse, but it looks like they are. And then the second route is the possibility that raising awareness about mental health might make people misinterpret milder, more transient levels of mental distress as symptomatic of mental disorder.

And whether that then in turn might make those problems become exacerbated or exaggerated in a kind of self-fulfilling manner. So tell us a little bit more about that. Why did you decide to look into this? Was there something you saw in the literature or something you saw when you were working in schools that made you concerned about this problem?

So I was working in schools as a researcher. So I was observing what teenagers were being taught in schools about mental health. And I was interested in that. You know, if you go to the bathroom when you visit a school, there are signs in the bathroom telling you to think about your mental health. For example, there's information on school websites. There's information, you know, they receive via assemblies and lessons. So quite early on, I was interested in the fact that

young people are learning about mental health now in a way that my generation never learned about in school. And I was also then working as an academic, as a lecturer at the University of York, and I was noticing that the undergraduate students were also, you know, receiving an awful lot of messages, encouraging them to notice and talk about their mental health. And there was one particular incident that I remember becoming a bit more sceptical was I, my colleague,

underneath her email signature she had in big letters, in crisis, question mark, you know, get help here. And I thought that probably is helpful for a student who is in crisis and doesn't otherwise know where to go. But I realised that every student that she emails will see that message and they'll see that message in the context of everywhere else being told that they are at risk of experiencing mental health problems and that there's certain language that they should use. And I think that was a bit of a

Turning point of starting to think, hang on, is this, are there some side effects to this that might be a problem, even if there are benefits for other students or other young people? So I'm interested in digging into a little bit of what we actually know right now, because I know this is a space that, you know, when you wrote this paper, it's you're setting out towards trying to get a lot more research done. But there is also a lot of research that's already done on mental health interventions. And something you said in a video you did struck me, which was that

All of this awareness isn't reducing rates of mental health problems. So what do we know? Do we have causal evidence that the increased awareness is leading to an increased rate of mental health problems?

Not straightforwardly because it's a difficult thing to measure as a causal effect on a societal scale. But firstly, it's certainly not been the case that it's reduced the problem because almost year on year, more people, more young people in particular are reporting mental health problems. So the decade or so that we've had of really encouraging people to talk about their mental health has not yet worked.

But in terms of causal evidence, there are various bits and pieces that have come out since we wrote that paper and as groups trying to collect more evidence and we're trying to collect more ourselves. But there are some little clues so far, experimental studies.

showing that the way you encourage people to talk and think about their mental health does influence how they interpret and report it, which actually shouldn't be surprising at all. Like there's a big evidence base about expectancy effects and how what you tell people influences, you know, what they experience and what they report. So it's new. But yet there are several studies now supporting this idea. So there's this two,

Two kinds of interpretations that you've sort of laid out, right? Because one is that you've given people this language, this awareness, and thus you're able to find individuals who previously would not have, you know, known what they were experiencing. Like maybe they were like, they had depression, they were experiencing severe anxiety, and

As a result, like of the awareness campaigns, now a lot more people might be coming out and identifying themselves to doctors or to their teachers or to their parents. And the other is that there's this group of people who are not actually experiencing strong, what a clinician would describe as like severe depression or anxiety, but are pathologizing themselves instead.

How do we know, you know, how big either of those populations are? Are there like a lot of people? I mean, how do we know that there aren't just a lot of people with depression who previously weren't being counted and are now destigmatized and able to talk about it?

Well, that's part of the difficulty of all this, that it's very difficult to tease those two apart. And certainly there are some people that would argue that it's all the former phenomenon or it's, you know, that more people are reporting problems because in various ways life is more difficult now. So that's absolutely a possibility as well. So the question is, how do you

distinguish between the two groups that I describe and it's incredibly difficult especially considering that the way we measure mental health problems is to ask people to self-report symptoms so it's hard to tease those two apart.

And so when you say things are much harder now, like what do you mean? Oh, in terms of what on a population level? Well, there's an awful lot of interest in the idea that social media has caused the problem. You know, there's a camp of academics arguing for that. And then there's another camp of academics arguing back and saying, no, that that's not the problem or it's not the entirety of the problem. Then obviously there's the pandemic issue.

you know, COVID undeniably had an impact while it was going on and possibly in its aftermath. I'm never ever saying the case that this explains everything, but I think it's enough of a possibility that we need to take it seriously and not just look at an increase in reported rates and take it at face value. So what was the reaction when you released this paper? Did you get feedback from folks who were in schools?

Yes. Interestingly, I was expecting a lot of criticism, but I have got some criticism. But actually, I've received more support than I had anticipated. And

What surprised me and interested me is that people want to tell me it in private. So they say, you know, I'm saying this in confidence, I'm saying this off the record. And I quite often get people telling me I'm brave or that they wouldn't want to be the one saying this, which I think is interesting. And why is that? What's kind of the fear there? Well, it's a legitimate one, which is how on earth do we ask this question without undermining the

Firstly, the people who are most unwell, who are still not getting help, but also the people who might not have a mental disorder, but they have distress and difficulty that needs to be taken seriously. So the worry is that if you ask this question, you undermine the suffering of people who need to be heard. But I think actually the more we allow the conversation publicly to proliferate and go unchecked,

actually a risk of all of that is this kind of en masse skepticism that you're now seeing towards almost anyone who stands up and says I have a mental health problem there's a kind of collective shrug like oh well you and everyone else because yeah yeah yeah

So I want to get into some of the research here. So there's a big trial in the UK, the Myriad trial. Essentially what happens is the researchers randomize 85 schools to either get teaching as usual or to get something they call school-based mindfulness training. And school-based mindfulness training is a very common practice.

School-based mindfulness training has already been found by at least one systemic literature review of RCTs to have significant positive effects for things like mindfulness, executive functioning, attention, depression, anxiety, and stress. And they try to do this big trial and...

After they separate out these schools and randomize them, they find no evidence that school-based mindfulness training is better than teaching as usual. And they even find some, you know, small differences, but they do find that some who had experienced the intervention had higher self-reported inattention and hyperactivity and higher panic disorder and OCD and lower levels of mindfulness skills. Yeah.

This isn't just like school-based mindfulness training, though, right? Like I, you know, I found studies about dialectical behavioral therapy in Australian teens who showed, which showed that the kids who got the treatment got worse. And another study of kids with CBT or cognitive behavioral therapy. And there's almost no effect between getting CBT versus usual therapy.

school coursework. And so, I mean, these are types of interventions like mindfulness training, CBT, DBT. These are things that have these are evidence based practices. So why is it that then when you see these tools that have been developed by researchers that have been shown to work in other contexts, why aren't they working here? What's going on?

Firstly, those three studies that you describe are large-scale, good-quality trials, so we should pay attention to their findings, and they have made an important impact on the field. But it is still the case that some other studies have found that

generally small positive average effects or null effects. So it's definitely not the case that all school interventions are finding these negative effects. But because of their quality and size, people have paid attention to these three effects.

I think what's important about all of them is that they're universal interventions. So that means that they were taught to all young people in a class regardless of need. So with the very reasonable idea that why not try and help everyone? Why not try and give everyone the tools and knowledge that they might need, either because they're struggling now or because at some point in the future they might benefit from this information program.

But the trouble is what that does is you're taking principles that were originally designed to be taught one-to-one and then you're teaching them to a group of 25 or 30 teenagers or young people all in one class. So if you learn these techniques in one-to-one therapy, you can adapt them to your specific issues.

You can troubleshoot with your therapist when you're having difficulty. You can ask for explanations and clarifications when you don't understand. You know, that mindfulness is a difficult skill to learn. So you, I think part of the issue for why these interventions don't work well or sometimes have negative effects is

is because you have diluted the practices too much and then in addition to that you are by definition teaching it to a whole class with a variety of needs but that means within that class you will have a lot of young people who are actually fine you know we it's become a bit unfashionable to talk about this but there are lots of teenagers who don't have mental health problems and

So potentially you're asking them to learn skills that aren't relevant to them. And a lot of young people, if you ask them, you know, they say they find these lessons boring and not relevant to their lives. Or at the other end of things, you have people who are having such significant difficulties that this kind of intervention doesn't really touch the sides. You know, they need something to change in their life or they need a lot of one-to-one support. So potentially it's difficult for them to be

made aware of a problem that can't then be fixed with the solutions that they're given or they try and they fail and then how will that make them feel so i think that the field is starting to move very gradually early days but possibly become more skeptical of this idea of universal interventions whether there's actually useful stuff we can teach everyone en masse that will you know meaningfully make a good difference to enough of them

And so, I mean, part of what I started wondering about these large universal interventions in schools or just largely in society, how we're changing, how we're talking about this, is that it's kind of just an implementation issue maybe. Is it the case that if people were...

better at implementing, whether it's CBT or mindfulness training, if you actually had the investments to make, you know, teachers, you know, experts on this, as well as doing their jobs, educating students. I mean, I guess I'm trying to get at here, like, would you think that there is a problem in a world where you had that level of investment? Or are you just saying, like, we're never going to get there, so we should stop doing this? Because I feel like that's two very different conversations. Yeah.

Yeah, the implementation thing is really interesting because there can be therapy designed in a certain way or an intervention designed in a certain way and it's not necessarily how it ends up being delivered. And certainly there's variation from school to school within a trial about how well things are delivered for all sorts of practical reasons. It's also relevant with Myriad because they taught students

existing school teachers to deliver the mindfulness intervention. And that's really important because really what Myriad was showing was not necessarily that mindfulness doesn't work, but that you can't teach existing school teachers in a short period of time to deliver mindfulness en masse that works.

So that's important. But the resources question is still there. So we do not have the resources to train people to become mindfulness teachers, which can take a long period of time and that level of expertise and then deliver it one to one.

If you could, I'm sure we might have different results. But I think that still rests on the assumption that what everyone needs to solve their mental health problems is one-to-one therapeutic intervention. And I think that's potentially, you know, ignoring all the other external factors that cause mental health issues.

So one thing I was thinking, too, is that whether this is a function of age, right? Because a lot of the studied interventions are happening in like the middle school level. These are like the preteen to early teen level. And I'm not sure, but I don't think we're seeing this kind of like problem as much in older adults.

And so is this issue just that it's too early to be introducing this sort of language or that the societal wide shift needs to be different just for young people and how we talk to very young preteens and teens or...

Is it something that's actually a problem for all age groups? My prediction would be that older adults haven't had the same transformation in language, but I actually don't know. And I think it's a good question. I mean, I'd say when you hit certain demographics, like middle-aged men, that the problem is still that they don't talk about it enough. So, you know, there's still massive stigma talking about mental health. So I

I don't know. The concern and the conversation is certainly about what's happening in young people. And the thing that's worrying to me is because, first of all, the reason why these universal interventions are done is because they're much more cost effective than the one-on-one interventions that you're talking about. But secondly, I mean, you...

You can choose not to implement school-based mindfulness training, right? But when we're talking about this larger societal shift in how we talk about mental health, like there's no policy lever that undoes that, right? So is part of your concern here not just these like large-scale changes in schools towards investing in universal mental health treatments, but also kind of like this larger societal discussion of how mental health is talked about in public?

Yeah, and I've been asked before, do you not think it's too late now? Is the cat not out of the bag? And, you know, it's...

If we were to make a societal shift, it would be a big one, you know, because it's not just what's happening in schools. It's even the psychiatric language. The language of therapy is in pop songs. It's in sitcoms, reality TV shows. It's everywhere online. So culture has become saturated in the language of psychiatry and mental health.

I don't think that means we don't ask questions. And if you look back across time, society has changed gradually in how it frames society.

distress and talks about mental health. So I don't think it's fixed. I actually gave a school, talking to school a couple of months ago and a teenager who's maybe 17 asked me, what did I think was the kind of long-term prediction for what would happen? She said, do you think it's just, we're going to talk more and more and more about it? Or do you think there might be a peak and then things will start to change?

fall again. And I thought it was such a good question. I wonder if, you know, we will reach such a saturation point and the skepticism will become sufficiently high that this language doesn't have the same currency as it once did, and maybe we'll start using it less. When you say the currency that mental health language has, can you talk a little bit more about that? Like, what are the ways in which this is seen as beneficial?

So I think it's in lots of settings, the language that you need to use to be taken seriously. And I...

partly because so many people are using this language, everyone else needs to use it to kind of be taken seriously. It's not enough to just say that you're sad or you're worried. You know, when everyone else is saying that they're depressed, you have to match that level and possibly go above it in order to be heard. Certainly in a

in a society that has limited resources for helping you, you know, the threshold for getting mental health treatment in the NHS is extremely high in some cases. So people are incentivized to use this language because it's the language that they hope will get them heard. But I think

It's difficult because the more everyone else uses it, the more it becomes inflated to kind of keep your head above the water, I guess. So I want to dig into what the actual harm is here, right? Because, you know, you're focused a lot on young people, adolescents, and especially in the school context.

And so if there's a kid in a class and he starts exhibiting some sorts of like lethargy or he seems really sad and his teacher is worried about him and he or she decides to report to the guidance counselor, to the parents, hey, I think your kid might be depressed. And let's say he gets depressed.

And he goes to a clinician and they talk about his problems and, you know, he either gets, you know, medication or he gets, you know, just someone to talk to. And then, you know, he goes to therapy. Like why, even if he doesn't have clinical depression, right? Like what is the harm that you're seeing in that, in that, you know, series of events? Yeah.

Yeah, it's a good question because it, and I think the issue is that the series of events that you describe doesn't necessarily happen and that each of those steps something might go wrong. So certainly in the UK it's very difficult to access good quality one-to-one therapy. So one possibility is that you identify a supposed problem in a young person and then there's nothing you can do

offer them to help. So you're encouraged to go to the GP. That's what the campaigns tell you to do. And then you get there and you say, well, actually, you know, it's an 18 month waiting list. So that's a potential problem that if that person isn't

you know, clinically unwell, or even if they are, there's a potential harm involved in telling someone that they have a problem and they need help and then telling them that the help isn't there. But then there's also the assumption in that sequence that having therapy will be helpful. You know, therapy doesn't work for everyone and it makes a small but not, you know, not irrelevant proportion of people worse. So it's not necessarily the case that

you know, I've been asked before, can we, should we just give all teenagers therapy? Would that solve the problem? Well, no, because therapy doesn't work for everyone. And also, you know, it may be a problem that therapy can't help. There's

It's quite individualized, these messages that we get that, you know, to go and get help and get therapy sort of implies that the problem is situated within the individual. And that could potentially mean you're not getting them help in other aspects of their life that would actually be helpful in terms of

bullying or maybe they're living in poverty, you know, I think to frame it as a mental health problem and send them down that pathway might be unhelpful because it means ignoring other sources of solutions, I guess. So, yeah, the ideal is if someone has a mental health problem, you identify, you get them the right help quickly and the help works, but it doesn't necessarily work like that. So I feel like there's...

There are a lot of this, which is also just like the network impacts on broader population. So like a kid, maybe maybe the best case happens. Right. And he's able to go to a therapist and like finds out that, you know, he's he's not experiencing some clinical depression, but he's able to get some help.

but he goes back to school when he tells his classmates about it and they're influenced by that. Or, you know, it's clearly a situation where a lot of, you know, this is a concept that you talk about, this idea of co-rumination. Young people are talking to each other about their mental health issues. And, you know, even if this kid gets therapy, like he doesn't, he's not an expert himself. And so he's advising now a bunch of other people that they also have a problem. So it's a

big part of the issue that you're also worried about that you are targeting a lot of the people who are currently sick, but you're getting a bunch of people who are less sick kind of now really pathologizing themselves and then like demanding resources that may otherwise be better used, targeted at the really ill populations. Yeah. So there's a lot that's interesting there, firstly, about social influence. And I think that's really, really interesting. I certainly get

I was told anecdotally about it a lot. So I had a parent after a talk say to me that her teenage daughter felt left out because she was the only one in her peer group who didn't report having anxiety or depression.

You can get all kinds of interesting merchandise on Etsy, which is that I saw there are badges that can say, you know, I have anxiety and little heart. Or you can get the latest I saw was a hoodie that says hot girls take antidepressants. So I think there's, which is funny, but also a sign of a big problem, I think, in terms of

In some cases, absolutely not for everyone, but in some cases that we might have so far overshot moving away from stigma that we've moved into some of these things being possibly socially desirable. And then what impact does that have among peer groups? And there is some, like last week came out in a paper about how disorders might spread within peer groups. So I think it's a really, really relevant issue.

you know, adolescence is a period of heightened susceptibility to peer influence. And I don't think we should ignore that context when we think about telling them to talk and think about their mental health. Okay, we're going to take a quick break. More with Lucy when we get back. This episode is brought to you by Shopify. Whether you're selling a little or a lot.

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When we're talking about the problems with mental health education efforts in schools, how much of this is a concern about resource allocation? Definitely, it's a problem and it's a difficult argument to make. But if certainly in the UK, this huge drive to tell people to need...

mental health problems and label them and go and seek professional help for them has not been matched with help at the other end. So you're now funneling more people into a system that doesn't have resources to help them. And then what happens is people try and find alternatives, particularly in schools, in terms of teaching children en masse about mental health.

because that's cheaper and fairer than one-to-one therapy. But I think that has its own difficulties. I don't think that's necessarily the solution. So in a world where there aren't enough mental health resources being provided, whether it's because there's actual scarcity or it's because of government policy or whatever reason, is it better, in your view, not to know whether or not you're depressed?

As in, is it better off to have never known? Like you have the same symptoms, the same kind of issues going on and like, you know, whether or not, and there's not going to be therapy, there's not going to be antidepressants available to you. Is it just better not to know you're depressed? So I think it depends on whether there's

other useful change that can happen as a result of knowing that information. So it's very possible that learning that you have depression is still helpful if it means you can understand yourself better, communicate that to other people in a way that leads to better social support. And it might be helpful if it means you can implement social

certain forms of self-help which is useful. So the idea of self-understanding, communicating it with other people, being able to implement change, all those things might mean it's useful to change

Learn that you have depression, told you should go and get professional help, turn up, and it's not there. It might still be useful information, but I think it's a reasonable question to wonder whether that sequence of events ends up being harmful for some people.

But it sounds like you're saying that when people find this information, like, you know, that's not what's happening. Like, even if they can't get treatment, there's not like they're able to or at least there's a large number of people that you're worried about are not actually able to use this to self-actualize. They're using this to kind of identify in a way that's actually harming their self-image and making it harder for them to exist in the world.

So that's the question that I'm trying to understand and that I want to understand over the next few years. What happens when you self-label with some of these disorders and these terms? How does that change the way you understand yourself and how does that change what you do? So there's some evidence that identifying yourself as having depression or

Over and above the levels of symptoms that you actually have is associated with more problematic coping, so less useful coping strategies. So that means even when they're controlled for the actual level of depressive symptoms, there's something about considering yourself to have depression, which might be unhelpful.

But having said that, it's a correlational study, so we don't really know the direction of the effect. So there's more work that needs to be done. That was led by a PhD student called Isaac Ahuvia, and he's doing lots more interesting work in this area. So I suspect for some people, and we need to identify who they are,

Taking on these labels ends up being actively unhelpful. So just like if I have sad feelings and saying, oh, these are depressive feelings, that that has a different impact on my own experience of the world than saying I'm a depressed person, like taking that on as a label?

Yeah, or I have the clinical disorder depression. You know, that can set off a whole sequence of thoughts about the extent to which you think you can control those symptoms and your fear about what those symptoms mean about you or your future. If you're sad and have difficulty, it's a very different framing of the problem if you say it's because of a mental disorder. Yeah.

So I feel like a lot of this conversation is also difficult because these are not like discrete categories. As you've said, it's not a situation where you can take a blood test and someone can tell you you have, you know, depression or you have anxiety. These are different.

conditions that are difficult even for clinicians to diagnose accurately and require often a battery of tests to be reasonably certain about someone's condition. And so you've referenced the work of a Canadian philosopher, Ian Hacking, and he talks kind of about these problems of classification and how classification happens and

how social, medical and biological sciences, they create new classifications and they often interact with the populations themselves. Can you tell us about his work and how it's influenced your thinking? Yeah, so I think perhaps even more important or in parallel, equally important to the fact that these things exist on continua is the fact that psychiatric disorders aren't biological entities that exist constantly.

in the real world, you know, that exist in nature. They are constructs that have been created around symptoms as a kind of useful framework of understanding some incredibly difficult, disruptive, dysfunctional thoughts, behaviors and feelings. But there are some people who argue, you know, that you should

never useful to frame these kind of symptoms and human distress as disorders. So there's a lot of arguing about what psychiatric disorders even are and where we put the boundaries around them. But what kind of linked to that, what Hacking was saying is that

In that act of labelling something as a disorder, when professionals, you know, scientists, doctors, academics put a boundary around a set of symptoms, a level of symptoms and call it a disorder, you kind of bring that disorder into being in a way that it didn't exist before. And the looping effect that he's talking about is that

What happens when you diagnose or label someone as having a problem or a difficulty, like, for example, binge eating disorder, which is a relatively newly diagnostic category. They then go up and read about it. They learn about it. They...

view themselves as someone who has that disorder and then they turn up again at the doctor's office or the research study holding in mind that diagnosis, that self-concept, that change behavior and then the professional observes them and themselves starts to learn more about the disorder. So what Hacking was trying to say is that there's this sort of iterative effect between

the labeler and the labeled, that means that category of person kind of comes into being. And none of this is to say, for example, that binge eating isn't real or that it's not a hugely destructive problem. But he was talking about how powerful it is when humans get labeled with something in terms of how they view themselves and how other people view them.

And I think what I was really interested in his work, too, is also this part of the interaction between someone who becomes labeled and how that affects...

their demands on scientists and people who are doing the labeling, right? So, I mean, this interacts with what you're talking about a lot too. So it's not just that there is now the classification called binge eating disorder. It's that when they hear that framing and they learn all that stuff, maybe they're on WebMD or whatever, they themselves are then

going and sort of demanding that that classification get expanded perhaps to include other things. So thinking about these other psychiatric disorders that we're talking about, like anxiety or depression, you know, you go on TikTok or something like that and you hear, oh, like you have high functioning anxiety if sometimes you're staring at a wall too long. But if you then have like a population that's saying, OK, you have this thing called anxiety and now we want

this other thing called high functioning anxiety. And then you go to your therapist, you go to your scientists, you go to your researchers and you say like, this is a classification. And then they feed that back to the population as well.

Yeah, exactly. And so, I mean, that was Hacking's idea. I've had clinicians say to me that they have young people coming into their clinic using diagnostic language that actually doesn't exist as far as the clinician is aware. So it's not grounded in, you know, academic psychiatry or clinical psychology. It's been born on the internet. So I think TikTok in particular is a kind of phenomenal

phenomenon on its own about the way it's encouraging people to view and understand their personalities and their difficulties. You know, high functioning anxiety is not a clinical term. I mean, interestingly, to get an official diagnosis of an anxiety disorder, you need to have high numbers of a lot of symptoms for quite a long period of time.

But you also need it to have a significant impact on your daily functioning, on your ability to navigate the world and live your life the way you would want to. So high functioning anxiety is removing that kind of key diagnostic component. That doesn't mean high functioning anxiety is zero.

is nice or easy to have. But it's interesting that they have so explicitly kind of removed that criteria that clinicians would recognize about impact on functioning. And another part of this is just that it seems like there's not really a way to get this totally right.

Because whichever system you create, right, you're either bound to be overly inclusive or overly exclusive. You either tell educators and parents, err on the side of caution, talk to your kid about depression, get them to the GP if you can or to the doctor, and then, you know, whatever.

And if you see someone in class behaving in a way that's really concerning, like, you know, get them to the guidance counselor so they can talk about whether or not they're depressed or have anxiety or whatever it is. And, you know, in that kind of world, like you're going to get some false positives and the alternative is going to be false negatives, right? It's going to be like, OK, like, yes, we know that there are people out there, kids out there who are really suffering and struggling, but we don't want to inflict

kind of a bunch of costs and harm on them, their families and society by over-diagnosing too much. And so unless you're pretty sure that this kid is experiencing some kind of harm, we want to err on the side of

Talk to them and check in with them, but don't like pathologize them or don't bring them into the tell them they should go to their doctor or medicalize their experiences too much. And so you're going to end up getting some missed. You're going to miss some of the kids who do need that help. And so it's not really I mean, obviously, you want to get as close as possible to accuracy, but there's no way, of course, of designing a perfect system that doesn't err in one direction or the other. And so.

Given that it's kind of like good for some people, bad for others, like how do you even distinguish which pool of people is bigger or which harm is worse and which harm is acceptable? How do we think through those questions? I think at the moment we're leaning much, much, much more towards the idea of let's not miss anyone and let's treat everyone as a risk. And I think...

Some of the criticism I have had is that by asking the questions that I'm asking, who cares if there's some people with milder problems who are mislabelling themselves, if actually it means we can get to the ones who really need help. There's not a straightforward answer, except that I think we should care about both problems equally.

It's one of those things where, of course, you're a researcher, you're a scientist, and you're wanting to get a lot more of that information. But on a practical level right now, I mean, you're saying that you think we've gone a little bit too far in talking about and pathologizing young people's emotions and erring too far on the side of maybe they have depression. I mean, if you're a teacher hearing this, right, and you're wanting to make sure you're not harming your kids...

And, you know, you look out in your classroom. I mean, how do you want that teacher to change how they're interacting with their students? Or how do you want school systems to change in how they're interacting with their population?

I guess it's what I'm always reluctant to answer because I don't know yet. So I don't have clear instructions about what's better than what we're doing at the moment. And I'm extremely cautious about causing some of the problems that we've talked about in terms of dismissing people. I think on an individual level, you know, if there's someone in front of you who's distressed, whatever they call it, you have to, of course, take it seriously. The most important thing is to

validate it and listen to it. And actually, I'm running a study at the moment with a master's student called Katie Cunningham-Rowe, and she's interviewing clinicians about what they think about this change in language, particularly the increase of self-diagnosis. And something that quite a few of them have said is that

Often a young person will come in with a self-diagnosis, but across several sessions they will gradually start to let go of it or lose their grip on it. And that they say that actually once you...

Pay attention to them and take seriously their distress and listen to them and what's happening in their lives. You often find that the diagnostic language matters less. But, you know, there are plenty of people who do have, you know, mental health problems and mental disorders. So it's, I think you have to err on the side of caution.

One thing that is clearly pushing people to err on the side of caution, though, is also kind of the legal frameworks, right? There's also this backstop of people are worried about lawsuits or legal liability. I mean, how is that playing a role in this?

I think it's playing a big role in universities, but also in schools. Obviously, the biggest fear of any educational organisation is that a student will take their own lives.

And that questions will be asked about, you know, whether the institution sufficiently protected and supported them. You know, and there have been specific cases asking those questions in the UK in the last few years. Like which ones? So there was a university student suicide and she had social anxiety disorder and her

they didn't make reasonable adjustments for her. And her parents successfully argued that it was a disability and that they should have done. And so that has had repercussions for other universities and schools here.

One thing I wanted to go back to is you mentioned that a teen had asked you this question in the auditorium about whether we're just going to kind of talk about this less as a result. And I find this a lot with different, whether it's social media or different kind of big technological or cultural shifts in society, that there's a transitional period where there are a lot of transaction costs and uncertainty about who's being helped and who's being harmed. And it can

either be a reasonable panic or like it can be a moral panic that's kind of out of step with what's actually going on there. When you were asked by that teen about whether or not this is just sort of a period in which we're talking about it a lot and it'll just kind of naturally subside as people get better and better at distinguishing between maybe regular emotions that young people are having because it's a hard time and things that are really diagnostically concerning. I mean, what was your answer to that young person? I mean, what did you tell her?

My answer to a lot of questions, which is that I don't know and then it's really interesting. But yeah, I was impressed with her and her peers. Actually, they were really engaged in the topic and agreed with it, said that they were seeing it a lot among their peers and online. So I just thought it was a really insightful question, but I didn't have the answer yet.

I mean, do you see this applicated in other places? I mean, I know with hacking, Dworkin and other places, there's a sort of like sense that, you know, right when something is coming into being, whether it's understandings about multiple personality disorder or it's binge eating disorder, as you mentioned, there's sort of this transition period, right, where like people are still trying to figure out this term and.

who it should apply to, whether that's from medical perspective or from the population's perspective. I mean, do you think that this is sort of just this liminal transitionary period we're living through or it's something that, you know, you are concerned could become the status quo that we just in perpetuity are just constantly retreating more mild symptoms as being, you know, really concerning and thus seeing these kind of larger, broader effects that you're worried about?

Presumably there's an upper limit when so many people identify themselves as having a mental health problem that that loses the meaning that it once had. You know, part of the reason why these labels have power is because they signal that you're experiencing something unusual in its level of difficulty and disruption. So, you know, if I had to make a prediction, I would say there will be

It can't carry on indefinitely in the direction it's going in because it will reach a point if we carry on in this direction where everyone is diagnosable with something. And then I think if we reach that point, then the labels lose the power that they once had. So always our last question. What is something that you thought was good on paper, but it didn't really pan out the way you expected?

I mean, this is quite a literal example, but I always wanted to write fiction and I wrote a novel and I, you know, which took years and I had a literary agent and

And it didn't work out. They didn't want to pitch the book to publishers. So I thought I might try writing nonfiction instead and then I could kind of circle back to it. And it made sense to write about mental health because that's what I was interested in in my work at the time. But I've kind of fallen in love with psychology writing. I don't know if I will go back to fiction. So it was a slightly weird route into psychology.

the books that I've written, but I think I had in my head, in my heart, that I would write novels and it was an awful lot of work for not the outcome I wanted. What was the book about? It was in the...

domestic noir there was that kind of trend for kind of things happening behind closed doors they didn't know about and kind of domestic drama so it's kind of down that road actually in hindsight it would be a good example of like things you really wanted but in hindsight you're glad didn't work out I'm very glad that book's not out in the world yeah

Well, I feel like the process of having written it can be can be cathartic anyway. But I'm glad you're writing about this. And thank you so much for coming on the show. We're really happy to have you. Thank you for having me. Thanks.

Good on Paper is produced by Janae West. It was edited by Dave Shaw, fact-checked by Anna Alvarado, and engineered by Erica Huang. Our theme music is composed by Rob Smirciak, Claudine Bade is the executive producer of Atlantic Audio, and Andrea Valdez is our managing editor. And hey, if you like what you're hearing, please leave us a rating and review on Apple Podcasts. I'm Jerusalem Dempsis, and we'll see you next week.

There's a common perception that democracy ends with a battle, soldiers in the streets, a coup d'etat, the fall of a government. But we know that democracy can be lost one little step at a time. We've reported on it and lived through it. And when we look at America today, right now, we see a place where the slide to autocracy has already begun. It's not some distant future, it's the present.

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