“A doctor needs to know what’s important to each individual”

This was an interesting article I found on: M. Q. Mental Health

See credits below.

As individuals, we all have different needs and wants – and it’s important these values are taken into account during important decisions.

Bill Fulford is a Fellow of St Catherine’s College and a Member of the Philosophy Faculty at the University of Oxford. His work focuses on making sure that the values of people living with mental illness can be incorporated into decisions about the treatment they receive. We caught up with Bill, ahead of his appearance at this year’s Mental Health Science Meeting.

Thanks for taking the time to chat to us, Bill. Can you tell us a bit about how you chose this field of research?

Great to meet you! I’m a bit of a hybrid, I suppose – my background is in medical science, including immunology and the study of bacteria. But I’ve always had lots of other interests, one of which is philosophy, which I studied alongside my medical degree. I saw psychiatry as a field where philosophy overlaps with medicine – where the question of what constitutes a disease rises to the surface and becomes part of the practice.

For example, if we take someone with appendicitis, there isn’t a debate as to whether they have a disease or not – there’s only the practical question of how you treat it. But for a person with depression, the issue of whether it is a disease they have, or whether it is a different aspect of them as a person – that philosophical question has a direct impact on how we might treat that person.

Going into psychiatry allowed me to bring my interests in medicine and philosophy together.

Your work centres around something called ‘Values-Based Practice’ – firstly, what do we mean by ‘values’?

When we talk about ‘values’, we’re talking about anything that matters or is important to us as individuals.

In most cases, it’s obvious that having a disease is something important to a person, in a negative way. Pain, for example, would be something that almost everyone would want to get rid of.

But in mental health it’s more challenging. For with the things we’re dealing with in psychiatry – emotion, motivation, desire, sexuality, and so on – what is ‘good’ or ‘bad’ varies widely between people.

For example, take something like hearing voices. For many people, that may be a bad experience – but others may consider hearing voices to be a positive experience. This is because a person’s values, the things that matter to them, are specific to that individual.

How does considering a person’s values impact on treating mental illness?

Values-Based Practice is a process of working with values which are complex and conflicting, as they often are in mental health.

Going back to the example of hearing voices – a person experiencing that may feel it is a positive experience, but it may have negative consequences for family and friends around them, and their doctors may also see the voice-hearing negatively.

So how do we best go about treating that person? Values-Based Practice can help make a balanced judgement on their individual case. It’s about making the best use of the science of medicine, while also taking into account the individuality of people and their needs, wishes, and wants.

Can you give us an example of Values-Based Practice in action?

Certainly – I know a woman who was being treated for a mental illness, and she had been given some medication by her psychiatrist which was controlling her symptoms effectively. However, she said that the medication was making her “a bit fuzzy”. She had a teaching job coming up and was worried that she wasn’t going to be able do it while she was feeling this way.

After having spoken with her psychiatrist about the fuzziness, she told me, “I was able to change my medication, with permission”. She felt empowered that she could have a dialogue with her psychiatrist and explain that, although the medication was working, it was more important to her to get rid of the side-effect of fuzziness. She was prepared to accept that changing medication may make her feel a bit worse overall if it meant she could do the teaching, because that was what mattered most to her at that time.

Doctors ought to know what will work best for a majority of patients. What Values-Based Practice adds on top of this is that the doctor should also look at what’s important for their patient as an individual. This will mean that, presented with a range of treatments available, the doctor and the person can come to a shared decision on what will be best way forward.

Why do we need Values-Based Practice now?

When I was starting in medicine, there was a pervasive attitude that ‘the doctor knows best’. Previously, there may have been only one treatment option for a condition, so it may have seemed that there was no need to consult people on what was best – there was simply no choice.

But today, as a result of 50 years of medical advances, there is often a range of options available which didn’t exist before. Whilst the doctor may know the risks and benefits for any particular option, they also need to consider what matters to the individual. That’s what Values-Based Practice can help with, and why it’s becoming increasingly important – not only in mental health, but in other areas of medicine too.

So what are the challenges of implementing Values-Based Practice?

Let’s use treatments for psychosis as one example. Anti-psychotic drugs can have side-effects such as weight gain, which is generally undesirable, as it can be detrimental to physical health and self-esteem. Values-Based Practice would suggest that it is important to discuss these side-effects, but it is possible that, as a result, people may decide not to take them.

The problem arises if the psychosis is acute – perhaps the individual is very distressed, may be having dangerous hallucinations or delusions, or possibly poses a danger to other people. From the doctor’s perspective, it’s important that their condition is controlled as quickly as possible.

So you can see the dilemma: should a doctor discuss the possibility of side-effects with a person who urgently needs medication, even if they may refuse it as a result? There is no overall ‘right’ or ‘wrong’ answer to this – but Values-Based Practice can help us to come to a balanced decision in the particular circumstances presented by a given situation.

Finally, what are your hopes for the future, and how we treat people experiencing mental illness?

I hope that we move towards increased shared-decision making, based on the model of ‘co‑production’, where there is an equality of voices between the patient and the doctor.

And I hope we can expand this model of co-production to other areas too -so that mental health service users have a voice in decisions about what research we do and how we do it, how we translate the science into practice, how we teach and train medical professionals, and how our healthcare services operate.

For some people facing mental illness, a medical approach is what they find helpful, but for others they would prefer a psychological or social approach. We need that range of provision and the ability to provide a mental health service that is responsive to individual people and their values.

Bill will be speaking at this year’s Mental Health Science Meeting – an event bringing together researchers across different disciplines to explore cutting-edge new ways to understand, treat and prevent mental illness. To find out more, click here.

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MQ Mental Health Science Meeting 2019 – Live blog

This was an interesting article I found on: M. Q. Mental Health

See credits below.

Hello and welcome to the live blog for the 2019 MQ Mental Health Science Meeting!

You can follow the meeting on Twitter and share your thoughts using the hashtag #MQScienceMeeting – follow us at @MQmentalhealth for regular updates.

You can also stay informed on the discussions right here on the live blog. This page will be updated frequently throughout the meeting, and you can jump to particular sessions or speakers using the links below:





Hello and welcome to the live blog for the 2019 MQ Mental Health Science Meeting!

Now in its 5th year, it’s one of the largest international scientific meetings dedicated solely to mental health science.

You’re joining researchers, healthcare professionals and members of the mental health community from around the world, to take on the biggest challenges in mental health.

Over the next two days, experts from a wide range of disciplines will be discussing their work and sharing their ideas on how we can best understand, treat and ultimately prevent mental illness.

The theme for the 2019 meeting is “Transforming mental health throughout the life course”. Many of the talks will be focussing on how our mental health – and how we might approach prevention and treatment of mental illness – changes throughout our lives.

09.30 – Welcome: Dr Sophie Dix, MQ: Transforming Mental Health

Dr Sophie Dix, Director of Research at MQ, welcomes everyone to the meeting.

Sophie sets the scene for why we're all here. We're at a tipping point of increased awareness of mental health. MQ and this meeting exist to ensure that mental health research is part of that conservation.

We need to tackle the big challenges. MQ's supporters, many of people whom have lived experience of mental illness are tired of 'trial-and-error' treatments. They're tired of delayed diagnosis. They're tired of treatments not working.

Sophie says we need to tackle the status quo. Only 2.7% of funding for mental health research comes from public donations – compared to 67% for cancer research. MQ exists to champion mental health research, to champion mental health research for the public.

Five years ago at this meeting, there were only 77 attendees – today we have 277 people registered. The Mental Health Science Meeting exists to break down silos and get people talking to one another – researchers, clinicians, and people affected by mental illness.

You can listen to an interview with Sophie below:

09.40 – Keynote 1: Sonia Johnson, “Should we prioritise social and self-management interventions in efforts to improve mental health outcomes through research?”

Our first talk of the meeting is a keynote speech from Prof Sonia Johnson from University College London. She’s calling for a change in how we conduct research and deliver mental health services.

Sonia begins by stating the progress made in tackling mental health problems – for example, in psychosis and bipolar disorder – has been disappointing. Rates of relapse have remained stubbornly static, and the 'mortality gap' (the rate of death amongst people with severe mental ilness compared to the general population) is widening, and the employment rate in people with psychosis has been going down. This is in stark contrast to cancer, for example, where on the whole, mortality rates have improved dramatically over the last few decades.

There are several factors which she believes have contribute towards this. One of these is the lack of investment, which means we're still waiting for the 'great leap forward' in treatments. Other factors include the stigma that is still attached to mental illness, and social factors which are hard for individuals to change – e.g. poverty, and other inequalities.

However, Sonia says that by listening to mental health services, we can make sure we're focussing on the 'right' type of research. The type of outcomes that people facing mental illness often say they value the most are social, not about relapse rates or symptoms. Community mental health teams are key to these kinds of outcomes, but there's little research into how they can provide the best care on a day-to-day basis.

Sonia sets out three priorities to help us do better in mental health research:

  1. It’s time to actually implement things that have been shown to work.
  2. For interventions that aren’t quite at the stage where we’re ready to implement them, we need to find ways to translate their findings into practise.
  3. We need to develop new interventions to address social problems like loneliness.

Sonia starts with an example of an intervention, 'individual placement and support' with good evidence which is 'ready to implement. Individual placement and support can help with ensure people get back into work.

The problem is the 'implementation gap' – interventions which have been shown to be effective, but which haven't yet been rolled out into everyday care for people with mental illness.

Sonia say we need to make friends with 'implementation scientists' – researchers whose job it is to understand how the barriers which prevent interventions from reaching people who need them can be overcome.

Sonia's second priority is to understand how we can scale-up the interventions we are developing now, so that they can be ready to implement. One example of this from Sonia's own research is 'supported self-management' – helping people to decide upon their own priorities for recovery and care, but with the support of others around them.

People who had recently experienced a mental health crisis were asked to fill out a ‘personal recovery workbook’, which included setting goals and plans for future crises. Participants were offered sessions with a ‘peer support worker’ – someone with their own personal experience of mental health crises – to help them in filling out the workbook. Sonia and her colleagues found that people who had a peer support worker were 34% less likely to be readmitted to acute care within one year.

Sonia says the challenge now is to try and weaving into the fabric of mental health care.

Sonia moves onto her third priority – we need to develop new social interventions, aimed at tackling social issues. These kinds of interventions are challening to develop for many reasons, but there is a strong case for focussing on this now. They can bring a fresh new approach to improve the situation for people with mental illness – both in treatment and in prevention.

An example of a social issue where we lack interventions with good evidence with which to tackle it, is loneliness – the subject of the next symposium.

Sonia shares an example of something she's been working on to tackle loneliness – the Community Navigator Study. The project is still in its early stages, but so far found, they've found that, with a group of people in four London boroughs, it's acceptable and feasible to implement.

Want to find out more about Sonia's research? Listen to an interview with her, by the Mental Elf.

10:30 – Symposium 1: "Loneliness and mental health: a two-way relationship?"

Next comes our first symposium of four at the meeting. The format of the symposium is simple – four speakers will talk on a particular theme, with time at the end devoted to further discussion, including questions from the audience.

Each symposium will have two people ‘chairing’ the session. One will be a research expert in the area, and – for the first time ever at the Mental Health Science Meeting – the other will be a person with lived experience, either directly or indirectly affected by the issue at hand.

The topic for our first symposium is loneliness – a very common experience which can shape our mental health.

Our chairs for this session are Prof Til Wykes from King’s College London, and Charly Cox, a poet and MQ ambassador living with bipolar disorder.

You can read more about Charly’s experience and her struggle to get a diagnosis in this blog.

10:35 – Pamela Qualter, “Children’s Experiences of Loneliness”

Prof Pam Qualter from the University of Manchester kicks off the symposium. Her research has looked at loneliness throughout life, but her main focus – and the subject of her talk today – is on children.

We were lucky enough to have a chance to interview Pam before the meeting, you can read more about her work in this Q&A.

Pam's first point is that social relationships matter – we need to know that we have people around us who 'have our back'. This comes out of our evolutionary history – human and other animals who formed groups for support are the most successful species.

Loneliness is not just about being alone – it is also about the threat of being alone, of feeling disconnected, of not belonging. Loneliness results from the mismatch of the kinds of relationships we want, and the kinds of relationships we have.

Throughout her career, Pam's research has focussed on study loneliness in childhood – in particular to understand whether children feel the same kind of loneliness as adults say they do. The short answer of all this research is yes – children can feel lonely, and the way they describe it is exactly the same as adults.

There's varying different relationships that people want, and which can be sources of loneliness, which change over time. The first is peer friendship – a close friend, which is particularly important to children. The second is peer group – being part of a group, not just with one person – which is particular important to teenagers. Finally, romantic relationships, which develop from adolescence onwards.

Everyone feels lonely, at various points during our lives, but there's certain times at which loneliness peaks. Loneliness is particularly common in adolescence and old age – because of the kinds of relationships we are developing, changing, and losing at these ages.

Pam wants to get across that loneliness is more of a symptom, not a disease. She says that loneliness is adaptive – it's horrible when we experience it, but it actually makes us want to make a change, to reconnect with others.

The problem with loneliness is when it is prolonged – people with chronic loneliness report multiple health problems, and as we'll see, mental illness.

Pam and her colleagues have shown that prolonged loneliness in childhood can lead to depressive symptoms in adolescence. And Pam's research shows that the relationship is two-way – depression can also increase feelings of loneliness.

Pam finishes with talking about how we might be able to intervene with childhood loneliness. Her research has found that CBT type therapies, to challenge people's beliefs about relationships (particularly distrust), are particularly effective.

One question from the audience is about social media and it's impact on loneliness. Pam shares that it depends on how teenagers use social media. If it's to interact with friends or other people, social media can be helpful – but if it's used as a distraction, it may have no impact on feeling lonely.

Listen to Pam talk about her research in a podcast recorded for The Mental Elf.

10:55 – Luc Goossens, “Loneliness in Adolescence”

The next speaker in the symposium is Prof Luc Goossens, from the University of Leuven in Belgium. Luc continues the theme of loneliness in young people, this time in adolescents.

Luc considers loneliness as a signal which we use to make a change – like hunger signals to us that we need to eat, loneliness can signal to us that we need to reconnect with others.

As we heard from Pam Qualter’s talk before, adolescence is a period of our lives when we are particularly vulnerable to loneliness. There's plenty of other times where loneliness peaks, for many reasons, though Luc's message is clear – it's not just old people who feel lonely.

There are many negative consequences of loneliness, for our physical and mental health. Some of the research from Luc's research team has shown that loneliness goes hand in hand with social anxiety and depressive symptoms.

Luc moves onto the two types of loneliness in adolescence, connected to two different types of relationships. The first is with peers – the feelings that a person has fewer friends than others, or no friends at all. The second is with parents – feeling that your parents don't understand you.

There's also differing attitudes to loneliness – some people feel bad about being alone, but for others, feeling lonely can make them feel stronger and more motivated. Research has shown that during adolescence, teenagers tend to feel less negative about loneliness, and more positive about it.

However, this is not the same for all teenagers. Luc shows that there appears to be five different groups which each have their own 'trajectory' of loneliness, how their loneliness changes over time. The most common group is 'stable low' – who generally have low levels of loneliness throughout adolescence. Other groups have increasing or descreasing levels of loneliness, and a further group – 'stable high' – feeling very lonely throughout their teenage years.

Luc's take-home message is that the challenge for adolescents is to try and avoid prolonged periods of feeling lonely, and to find constructive ways to of dealing with time spent on their own.

11:20 – Tim Matthews, “Lonely young adults in modern Britain: Findings from an epidemiological cohort study”

Next up in this symposium on loneliness is Dr Tim Matthews from King’s College London. Timothy is discussing loneliness in young adults, and in particular, talking about a study of over 2,000 young people in England & Wales.

Tim thinks that 2018 was a milestone year for loneliness. The government created a 'Minister for Loneliness', and there was a big increase in the conversation in the media around loneliness. But the key focus in this conversation was on older people. As we have already heard, loneliness is not something that only affects the eldery, it is also something which affects younger people too.

But just because, when we look at the whole population, loneliness peaks in adolescence then decreases into adulthood – it doesn't mean that we shouldn't worry about teenage loneliness, or think that it's something that everyone will 'grow out of' eventually. Some young people never 'emerge' from loneliness experienced in adolescence – we need to better understand loneliness in young adults, to understand their experiences.

Tim goes on to talk about his study of a large group of young people. He and his colleagues found that loneliness was common amongst 18-year olds – a quarter of the respondents said they feel lonely some of the time, and 7% said their felt lonely often. Loneliness did not discriminate – there's didn't seem to be any particular socio-economic group of young people who experienced loneliness more than others.

Tim shows that loneliness in this group are more likely to also have mental health problems, such as depression and anxiety. Loneliness was also connected to poor sleep quality, and engage in less physical activity.

And loneliness is connected to their general attitudes too – lonely people were less likely to be satisfied with their life, and feel unable to cope with stress. Lonely individuals were more likely to be out of work, feel less confident about their abilities, and feel less optimistic about their prospects of getting a job.

Tim's message is that loneliness affects lots of areas of our lives. Doctors should be particularly focussed on people who say feel lonely, because it could be an indicator of other problems too. Early intervention is absolutely key to reducing loneliness, as soon as possible.

In terms of interventions – 'social prescribing' is all the rage at the moment, where people are brought together in groups, creating new opportunities for lonely people to meet others. But we do need to be mindful of how effective these are. People can still feel lonely, even in social groups. A 'one-size-fits-all' approach will not work, we need to support social prescribing with more targetted interventions and counselling.

11:45 – Jude Stansfield, “A Public Mental Health approach to loneliness”

Last to speak in this symposium on loneliness is Jude Stansfield, the National Advisor on mental health to Public Health England. Her talk is focussing on tackling loneliness from a public health perspective, to improve the country’s mental health.

Jude starts by reiterating that being connected to others matters for our health – both physical and mental. Given this connection, she considers a loneliness to be as important to our nation's health as smoking or obesity.

Jude says that loneliness is a complex issue, which shouldn’t be seen as just affecting one individual, or a medical problem, but as a social issue involving many factors.

Part of the work Jude is doing at Public Health England is to try and find ways to measure the levels of loneliness, at a local level. This has been a challenge so far, but its absolutely critical if we want to track the effectiveness of the interventions to combat loneliness we implement.

In terms of interventions for loneliness, there's no 'one-size-fits-all' approach that will work all the time, for everyone. To tackle loneliness, we need a broad approach, matching the complexity of the issue with complex solutions.

Jude is particularly keen on ‘community-centred’ approaches, for many reasons. These are different from 'community-based' approaches, which is typically shorthand for 'out of the hospital'.

Approaches centred around the community are participatory. They empower people to have a greater say in their lives and health. They can involved local volunteers and peers to help provide support. They involve more partnerships and ways of 'co-producing' interventions, where healthcare providers and local communities work together.

Community-centred approaches also often build upon existing local ‘assets’. These are the things which communities already have which improve and maintain their health – local knowledge, individual people, community groups, the physical environment, and the local health care resources available.

Jude finishes her talk by setting out what needs to happen next. We need to get better at involving the local community in developing interventions, and implementing them. We also need to find ways to implement these local solutions at a much larger scale.

In terms of priorities for research, we need to test the effectiveness (and cost-effectiveness) of community-centred approaches – in particular in relation to loneliness and social isolation.

12:10 – Discussion

We now move onto the discussion of this symposium on loneliness.

First question, if we can 'fix' loneliness, is there evidence that it will directly impact on mental illness? Pam thinks that's it's possible, but we don't have enough research to back that up. What is more certain is that addressing (e.g.) a person's depression on its own, without addressing their loneliness., their loneliness will not go away.

Another question is about why sleep is affected by loneliness. Timothy suggests that sleep is a time where we are particularly alone, and so heightened to their thoughts and their anxiety of potential loneliness. Lonely people don't necessary sleep more or less than the general population, but the quality of their sleep is worse.

One more comment is around the types of loneliness that people feel throughout their life. The reasons why older people feel lonely are to do with social relationships being lost. The loneliness this causes may be more readily tackled with social interventions of the type that Jude was talking about. But the reasons why younger people feel lonely are more individual and personal, so perhaps the focus on developing interventions should be on young people.

Pam talks about work she did in the BBC Loneliness Experiment, the largest survey on loneliness ever conducted. She found that people had a range of solutions to combat loneliness, and she knows that young people have found this particularly useful, using it like a 'toolkit' to try and tackle their own loneliness.

A question from Twitter about loneliness in other age groups:

Jude thinks that this would be interesting to study. Many big events and transition points happen in our lives between adolescence and old age – parenthood, marriage and divorce, work and redundancy, all of which may have an impact on our social connectedness.

Time for a break for lunch. We’ll be back at 1.30pm, to carry on with another set of interesting talks.

13:30 – Symposium 2: “Tracking the life-long effects of mental illness”

With everyone fed and watered, we move onto our second symposium of the meeting, called ‘Tracking the life-long effects of mental illness’. Just like physical health, our mental health changes over time – understanding how this happens is crucial to preventing and treating mental illness.

Our chairs for this session are Prof Andrew McIntosh from University of Edinburgh, and Arden Tomison, who has developed a digital platform to support psychiatrists deliver the best diagnosis and care they can.

Arden explains that he has had his own "run-ins with mental ill-health". His view is that research – and data in particular – is going to be key to transforming mental health.

13:35 – Bill Fulford, “Montgomery and mental health: shared decision-making based on evidence and values”

First up to the speaker's podium in this session is Prof Bill Fulford from the University of Oxford. His work focuses on making sure that the values of people living with mental illness can be incorporated into decisions about the treatment they receive – a framework known as ‘Values-Based Practice’. You can read more about his work in a Q&A.

Today, Bill is talking about an important UK legal case Montgomery vs Lanarkshire Health Board – known as ‘Montgomery’. The facts of the case are fairly straightforward, but the implications of the UK Supreme Court’s judgement on the case in 2015 have had a profound effect on medicine.

A pregnant woman named Nadine Montgomery, who was under the care of her doctor Dr McLellan, developed diabetes during her pregnancy. Sadly, her baby suffered severe birth trauma because of shoulder dystocia, a well-known but rare complication of vaginal birth in mothers with diabetes.

Dr McLellan had decided not to raise the possibility of a caesarean section, because she considered the risks of that to be greater than the possibility of shoulder dystocia. Mrs Montgomery sued for damages citing medical negligence, and two lower courts had dismissed the case. However, the UK Supreme Court overruled these judgements, allowing Mrs Montgomery to appeal her case.

Bill considers that people have gotten the wrong end of the stick with the Montgomery judgement. Some doctors have considered that they now need to give all patients all the information available, which is not what the judgement was about.

As far as Bill is concerned, the upshot of Montgomery is that, when making decisions about treatment, doctors should not just consider what they think are the most important risks and benefits of treatment. They also need to consider what the individual patient would reasonably consider to be important – in short, the doctor needs to consider a person’s individual values. It is about shared-decision making.

Bill says that all that the Montgomery case has done is, in fact, made shared-decision making the legal basis of consent to treatments, in all areas of health care.

Bill goes onto to explain how those decisions are made. It depends, in his view, on a combination of evidence-based practice and something called values-based practice. Values-based practice is how doctors can make sure they are taking into account person's values: their needs, preferences, and desires, or in other words, the things that matter to them.

Bill gives an example of how values-based practice works, based on a true story. Mrs Jones was due to have surgery on to replace her knee for arthiritis. She was particularly keen gardener, but the prosthetic knee was going to affect her ability to kneel down for her gardening. Together, she and her surgeon decided to not go through with surgery, and instead had other treatment. Mrs Jones' mobility was more important to her, which meant she was prepared to avoid surgery if it meant she could carry on with a hobby she enjoyed.

Bill then gives another example where values-based practice is more challenging, this time in treatment for psychosis. The drugs are effective, but one common side-effect of these anti-psychotic drugs is weight gain. Should a doctor discuss with a person experiencing psychosis – who definitely needs treatment – the side-effect of weight gain, even if it means that person ends up not going through with the treatment? Montgomery would say yes – that decision should be a shared decision, not just about what the doctor thinks is important.

14:00 – Rogier Kievit, “It’s about time: Understanding how mental health changes"

The next speaker is Dr Rogier Kievit from the University of Cambridge. His talk is focussing on how it is important to understand how our brains and mental health changes over time, rather than focussing on single ‘snapshots’.

The traditional view of an illness like depression is that all the symptoms occur at the same time – all of which arise from the underlying cause of depression.

However, Rogier subscribes to a more dynamic view of mental illness. Symptoms, instead of all arising at the same time, each of the symptoms affects each other. For example, sleep problems lead to fatigue, which causes low mood, which leads to irritability – and it is this pattern of symptoms which is the depression. Tracking people's symptoms over time can give a much clearer picture of mental illness. If we just rely on a 'snapshot', we get a skewed picture of how mental ilness develops.

Rogier share's some research he's been involved in, which links people's cognitive abilities – things like memory – with their mental health.

He looked at a group of people, and how their memory and mental health changes over time. The first thing to notice – and it's pretty obvious – is that no two people are the same, or in Rogier's words "people vary in how they change".

Rogier and colleagues also looked at whether there was a link between a person's memory, and how their mental health changed. They found that for people with good memory, their mental health didn't decline as much.

By looking at people's cognitive abilities and their mental health over time – rather than just snapshots – they are trying to pin-point what causes what.

Rogier argues that taking a long-term view – more like a ‘video’ than a ‘snapshot’ – can improve our understanding of mental health, leading us to better ways to prevent and treat mental illness. It can also help us to understand key questions like why problems with mental health often occur together.

14:25 – Jessica Agnew-Blais, “Understanding the course of ADHD across the lifespan: the importance of longitudinal cohorts”

Next in this symposium is Dr Jessica Agnew-Blais from King’s College London. Her talk today is on Attention-Deficit Hyperactivity Disorder (ADHD) and how studies have revealed it is not just a condition which affects children.

The symptoms of ADHD include inattention – for example, being easily distracted, or being forgetful in daily activities – and hyperactivity – for example, talking excessively. What's more, these symptoms are pervasive across all areas of life (e.g. at home and at school), and impair their day-to-day lives.

ADHD was originally thought of as a childhood disorder, which started in childhood and which kids eventually 'grow out of'. However, from the 1960s, researchers discovered that ADHD can persist into adulthood. Surveys have demonstrated that 2.5-5% of adults, or around 1 or 2 in every 40, have ADHD. The Guardian published an article in 2017 in which a few adults with ADHD tell their story of how they were diagnosed, and the effect it has on them.

And it's now being questioned whether it always starts childhood, or whether it can start in adulthood too.

Jessica shares some results from ‘longitudinal studies’, which track people over long periods of time. A recent study which Jessica led showed that about 22% of children who had ADHD went on to continue to have ADHD in adulthood – measured at age 18. They also identified a group of adults with ADHD who showed no symptoms of ADHD in childhood.

Jessica went on to study the long-term consequences of ADHD. She was interested in whether these depended on whether they developed ADHD in childhood or young adulthood, or whether it persisted throughout childhood and adulthood. She found that people had a higher risk of mental health problems if they had ADHD in adulthood, whether they had symptoms of ADHD in childhood or not.

So why do some people develop ADHD in childhood, and others in adulthood? And why does ADHD persist throughout their life in some people, but declines in others? A person's genes may hold a clue.

Jessica shares some innovative research using a study of twins, which can tease apart the influence of genes and environment on ADHD. Other researchers have identified tiny variations in our DNA which can affect our risk of ADHD. Jessica shows that the number of these variations that a person carries may influence how long their ADHD persists for.

The key to all of this work has been the longitudinal studies. These have helped to identify how ADHD and mental illness arise and develop over time.

14:50 – Philip Shaw, Understanding the different adult outcomes of childhood ADHD”

Our final talk in this symposium on tracking mental health over time is from Dr Philip Shaw from the National Human Genome Research Institute, USA. His talk is also focussing on ADHD and how it changes as children become adults.

It had previously been assumed that children with ADHD would eventually ‘grow out’ of the disorder by adulthood. As our previous speaker Jessica discussed, we now know that is not the always the case.

Philip describes two children he knew with ADHD. Both had the classic symptoms of ADHD, and were subsequently diagnosed with the disorder at age six. But the long-term after this point was very different. One had gone into 'remission', but the other, her ADHD had persisted well into childhood, and had severely impacted her adult life.

If we could understand more about how this happens – why ADHD goes into remission for some children, but doesn't for others – we may be able to develop new treatments which could ‘accelerate’ remission of ADHD in all children and adults.

What’s holding us back at the moment is that we’re not very good at predicting which children will ‘grow out’ of their ADHD and which will not, based upon the information we have right now. So instead, Philip studies genetics and brain imaging scans, to see if these can provide any insight into the long-term outlook for children with ADHD.

Philip has been using brain scan to study the brains of adults, some of whom had ADHD as a child, and some of whom still did as adults. He found that the brain 'reset' itself when ADHD goes into remission, such that it looks like those of people who have never had ADHD.

In another study of adults, he found that again, the 'wiring' of the brain in adults whose ADHD went into remission looked similar to that of adults who had never been affected. The brains of the adults who had persistent ADHD appeared to have many more connections between different parts of their brain.

However, in a final study, Philip shows that under certain circumstances, there are some differences in adults who had a history of ADHD, compared to those who had never had ADHD.

There's not a final answer yet as to how the brain changes over time as ADHD goes into remission or not. But finding this out could help to predict the long-term outlook for children with ADHD, and possibly could guide treatment for children and adults.

15:10 – Discussion

Now comes the time for a discussion on all the talks in symposium to do with tracking mental illness throughout life.

First question comes from Arden, our co-chair for this symposium. He asks a general question about how we could use data, particularly from private companies, to help advance research. Rogier suggests that apps could help with collecting data, as people tend to find they take a lot less effort than (for example) filling out a form. Jessica raises the point that apps may also help democratise science, reaching people who may otherwise be excluded. Philip also points out that interventions designed for children may also benefit from being apps – kids these days love their smartphones and tablets, and so an app-based treatment may actually be more acceptable to them.

Arden also asks Bill about the relationship between a person facing mental illness and a doctor – and how we can bring other people into the conversation about their values, for example a spouse or family member, or other healthcare professionals. Bill replies that conversations about the things that matter to us often arise 'out of nowhere', or when we're doing other things. There's challenges to taking the content of these conversations and bringing them into someone's care, for example confidentiality. But they can be overcome.

Another question is about ADHD, and its relationship with autism and anxiety – do any of the longitudinal studies reveal which comes first? The honest answer from Jessica and Philip is that we don't know – it is an area which would deserve more research.

We’ll take a break for tea and coffee – back in a jiffy.

16:00 – Rapid-fire talks

Our next session is new for 2019’s Mental Health Science Meeting – the Rapid-Fire Talks! Four speakers have five minutes to present their research to the audience. Start the clock, please…

16:05 – Shana Silverstein, “Observational fear learning: from mouse to man”

Our first rapid-fire talk is from Shana Silverstein, from National Institute of Mental Health & University College London. Her research focusses on ‘Observational Fear Learning’, how we develop a fear of something not by experiencing it ourselves but by observing others. Developing fears in this manner has implications for post-traumatic stress disorder and anxiety.

Shana has developed a method to study observational fear learning in mice. She has found that an area of the brain, called the 'dorso-medial prefrontal cortex' is crucial for the develop of observational fear learning.

Shana is now working on human studies. This work could shed light on the development of anxiety.

16:10 – Hjördis Lorenz, “Let the CAT out of the bag: A new measure to assess concrete and abstract thinking (CAT)”

Our next speaker is Hjördis Lorenz, from the University of Oxford.

Her research focus is on post-traumatic stress disorder (PTSD). Hjördis explains that student paramedics are more likely than the general population to develop PTSD and depression.

One factor involved in this is rumination – the tendency to focus on a stressful event or situation, rather than on the solutions. Linked to rumination is the idea of two types of thinking – ‘concrete’ thinking, which focuses on the facts, and ‘abstract’ thinking, which involves a mental process to come to some sort of theory about those facts.

It has already been shown that less abstract thinking and more concrete thinking can reduce rumination – and in turn reduce depressive symptoms. However, currently there’s no way to measure how much concrete or abstract thinking someone is doing.

Hjördis and colleagues developed a new method to measure concrete and abstract thinking (CAT), which she tested in a group of student paramedics.

In their study, Hjördis showed that the method was reliable, and showed a correlation (as expected) between higher levels of abstract thinking with rumination and worry, as well as PTSD, depression and anxiety.

Hjördis is now testing the CAT measure in a larger group of emergency workers in a study funded by MQ.

16:20 – Stephanie Lewis, “Current Prevalence, Trends, and Gaps in Diagnoses in Child and Adolescent Mental Health Services: A Clinical Record Study”

The next rapid-fire talk is from Dr Stephanie Lewis from King’s College London.

Stephanie wanted to understand the mental health services provided for children and teenagers, as well as how these services – and the needs of these young people – has changed over time.

She did this studying the data from mental health records in 17-year olds from four boroughs in South London. Stephanie and her colleagues were able to estimate how many of these 17-year‑olds were diagnosed with a mental illness between 2008-2017. Stephanie found that in 2017, 6.5% of the 17-year olds in the South London area she studied were diagnosed with a mental illness – up from 3.5% in 2008.

She was also able to estimate the actual prevalence of mental illness in this population, using a nationwide study of over 2,000 British youths. Stephanie estimated that as many as 90% of the cases of mental illness in young people went undiagnosed.

Stephanie says that her research shows there is a ‘diagnosis gap’. More work is needed to understand the barriers that prevent young people from making use of mental health services in their area.

16:30 – Joshua Buckman, “The Stratified Medicine Approaches for Treatment Selection (SMART) Mental Health Prediction Tournament”

Our fourth and final Rapid-Fire Talk is from Dr Joshua Buckman from University College London.

Joshua’s talk is about a vision of ‘stratified medicine’ – where people facing mental illness receive a treatment that is best suited to them and is most likely to succeed. He’s focussing on Improve Access to Psychological Therapies (IAPT) programme, where people receive a high or a low intensity treatment.

There is a lot of data from people available to researchers which may hold clues as to which IAPT regime is likely to be successful for them or not. However, the challenge is finding ways to make the best us of all this data, to create a ‘model’ which can predict the likely future for that person.

Joshua decided to take an innovative approach and throw the question out into a ‘tournement’ he called the Stratified Medicine Approaches for Treatment Selection – or SMART for short.

13 teams from across the world were provided with data all about 4,000 people in the UK with mental illness, as well as the outcomes of the treatment which they received from the IAPT programme. They used this data to develop a computer program which could be used as a tool to predict which therapies were most appropriate for different groups of people.

The SMART tournament itself tested all the teams’ tools on further sets of data, representing a total of 33,000 people. The winner of the tournament was whichever team came up with the computer program which predicted the outcomes of these people with the greatest accuracy.

The next step is to translate the discoveries made from this tournement into clinical practise, such that every person recieves the most appropriate treatment, tailored for them.

16:40 – Keynote 2: Michael Ungar, “Diagnosing resilience: A multisystemic model for positive development in stressed environments”

Our final talk of the day is a keynote speech from Dr Michael Ungar from Dalhousie University in Halifax, Canada. His talk focusses on resilience in young people, and how it depends as much on the environment and the people around them, as it does on the individual themselves.

Michael starts with a video that his team filmed, of a couple of minutes of the life of a young man in foster care in Canada, as he spends time with his extended family at a house. He seems very happy and confortable, despite the adversity he faced earlier in childhood. Michael then reveals that the house he is in is a gang house, with a lot of drugs and guns in other rooms. The young man has developed coping mechanisms to deal with his environment and his life history – this is resilience.

Resilience has many dimensions. The traditional definition is about all about the individual – an individual’s ability to overcome adversity and continue their normal development. But for Michael, it's about much more that this. It's also about the ability for a person to navigate towards resources which can help them – and the environment that provides these resources.

Michael gives an example, from a trip he made to Japan after a recent tsunami. One of the first buildings to go back up was a small temporary building, which acted like a school, where the children could go to do their homework. This resource – known as a 'cram school' – was what the kids wanted: it was part of their normal lives before, and it helped many of them to recover from the trauma they had experienced.

We need to think of resilience in the context of a person's environment, not just about the person and their qualities.

He makes the point by talking about the story of 'Cinderella', which seen as a story of resilience. Michael jokes that really it should be renamed 'The Fairy Godmother', who provides the support that Cinderella needs to avoid life of misery, and instead ends up with a fairy-tale ending. Joking aside, it is the reality that plenty of people have abusive childhood, and some of these stories have the 'fairy-tale' endings, because of the environment around them and support they can get.

Michael shares some work he and his colleagues to try and develop a measure of this view of resilience. He also talks about some research his team did in 2012 to try and understand how children developed resilience followed abusive childhoods. They found that their experience of mental health services has a profound effect on their resilience.

Michael talks about how the abuse that children had experienced might also influence how effective certain interventions might be – for example, enrolling in group activities to reduce depressive symptoms and delinquency.

He also shares research that shows that interventions which increase resilience in children from unstable homes engage in less risky behaviour. However, for kids from stable homes, the opposite is actually true – building resilience actually increases risky behaviour.

These studies underline the idea that there is no 'one-size-fits-all' approach for building resilience in children. We have to take into their environment and history too.

This context is particularly important if we want to understand how to build resilience in particular groups – such as children in care, or refugees from war zones. We need to better understand their environment, and the resources available to them, if we're going to give every child the opportunity to thrive in the future.

Part of this is to increase the diversity in the people who are doing the research, as someone in our audience points out:

You can hear more from Michael in this interview with The Mental Elf:

That concludes day one of this year’s Mental Health Science Meeting. The audience will be heading off to the poster presentations – we'll be reporting on the highlights from this session later.

Come back tomorrow for another day of cutting-edge science and important discussions on the future of mental health research. Until then, have a good evening!


Hello, and welcome back to the second day of the 2019 MQ Mental Health Science Meeting. Remember that you can follow updates here throughout the day, or by keeping an eye on the hashtag #MQScienceMeeting on Twitter.

09:00 – Symposium 3: “Mind and matter: intersections of physical and mental health”

The first session of day two is Symposium number three. The four speakers will be discussing the links between mental and physical health – how one can influence the other, and how we can break the link to improve wellbeing for everyone.

As we did in yesterday’s symposiums, we have two people chairing this session each with a unique perspective. We have Prof Matthew Hotopf, a researcher and psychiatrist from King’s College London, and Andrea Corbett, a wellness coach and mentor for young people.

Andrea opens the session by telling her story. She runs an organisation calleed FOCUS, but before this, she was 'Miss Corbett' – a school teacher. She was diagnosed with a mental illness, and was advised to go to the exercise – one thing lead to another and she ended up entering a bodybuilding competition – and won. She now mentors young people about the importance of looking after our physical health to help maintain our mental health.

You can read more about Andrea’s story and how bodybuilding helped her to turn her life around after being diagnosed with depression.

09:05 – Andrew Steptoe, “Mental health and the heart: how depression and anxiety influence, and are influenced by, heart disease”

Prof Andrew Steptoe from University College London is our first speaker in this symposium, talking about the link between heart disease and mental health.

Coronary heart disease is one of the most common health problems in the UK, and along with other heart conditions is responsible for a quarter of all deaths in the UK.

Andrew says that there is good evidence suggesting a link between heart disease and mental health issues, such as depression, anxiety, and post-traumatic stress disorder (PTSD). What’s particularly interesting is that this relationship appears to go in both directions.

Mental ill-health, such as depressive symptoms, is associated with an increased risk of heart disease – about 30% increased risk. This is even the case when you take into account other risk factors, such as age, body weight, and exercise. And in turn, high levels of distress are common in people who have heart disease – which may lead to depression and anxiety.

Andrew sets out what might be the cause of this link. Something like a heart attack is a major life event, which may represent a brush with death which might cause people to reassess their life. Heart disease also causes changes to the body which may in themselves be causing mental illness. People also may develop PTSD as a result of the heart attack.

We also know that people with heart problems who are depressed are at increased risk of developing further heart problems in the future. In the short term, people who distressed immediately after a heart attack are more likely to be readmitted to hospital within 30 days. And in the long term, people with depressive symptoms after a heart attack are more likely to die than those without.

One explanation Andrew shares for this link is that people’s behaviours are affected by mental illness – for example, reducing physical activity, unhealthy diet, and not adhering to medical advice. People who have depressive symptoms are less likely to take medication like aspirin for heart disease. Andrew also suggests there is possibly a biological link – heart disease causes inflammation in the body, which is a known risk factor for depression.

So how do we manage depression in people with heart disease? Most likely, people will need the standard treatments depression – drugs and CBT. However, we have to be aware of the side-effects of some of these treatments, such as selective serotonin reuptake inhibitors (SSRIs) which can cause bleeding.

Andrew raises the possibility that depression in people with heart disease is different to depression in the general population, but that requires more research to understand.

09:30 – Bridget Callaghan, “Brain, Mind, Body: How our early environments shape brain-gut communication across development”

Second to speak in this symposium is Dr Bridget Callaghan, from Columbia University in New York. Bridget is sharing some fascinating research linking our brains, our emotions and behaviours, with the gut microbiome – the collection of bacteria and other microbes which live in our bowel.

Bridget begins with setting out that many of the disorders we consider to be developing in adulthood – both physical and mental health – in fact have their origins in early childhood. Part of this picture is our gut and how the bacteria respond to other events happening in our body.

The gut microbiome – the collection of bacteria living in our guts – respond to stressful events, which suggests that the gut and the brain are tightly connected. Bridget says that this also applies to disease as well as health. For example, depression and anxiety increase the risk of developing irritable bowel syndrome (IBS) later on in life – and vice versa.

Bridget has worked with children who are in orphanages and carehomes, who – even under the best of circumstances – face severe adversity. Researchers have shown that children who experience adversity in early life have increased risk of gastro-intestinal problems. In addition, those who have high levels of gastro-intenstinal problems have an increased risk of develop anxiety in early childhood.

Bridget's team looked closer at the microbiome of children, by analysing the different types of bacteria present in their poo. Children who had experience early life adversity had a less 'diverse' microbiome – fewer different types of bacteria. In addition, children who had experience stable homes had larger amounts of a bacteria family called lachnospiriaceae. In turn, this bacteria affected the way that children responded to threats, in an experiment involving showing them pictures of 'threatening' faces whilst in a MRI scanner.

Bridget and her team have also studied the link between the gut microbiome and mental health in rats. Her research suggests that it may be possibleto reduce the effect of early life adversity in rats by manipulating the gut microbiome using probiotic drinks – but this has not yet been proven in humans.

Bridget thinks that there is a huge amount of promise in manipulating the microbiome. This applies not just to gut disease, not even just for mental health, but for other conditions too, such as Parkinson's disease and multiple sclerosis.

However, there is a lot we don't know, and it'll require a huge amount of research to really unpick the link between the gut microbiome and our mental health.

09:55 – Clare Llewellyn, “Obesity: a matter of the mind, body and behaviour”

Next up in this symposium is Dr Clare Llewellyn from University College London, who is talking about the link between obesity and mental health.

About 1 in 4 adults in the UK are affected by obesity, and about 1 in 10 children starting in primary school are obese – becoming 1 in 5 by the time they leave primary school. Once a person develops obesity, it is then very difficult to return to a healthy weight – so Clare considers obesity as a chronic disorder.

Mental health problems often go hand in hand with obesity, particularly depression, partly because obesity itself can cause mental health problems, and vice versa. There are a wealth of different factors which link obesity and mental illness. These include social factors like poverty, biological factors like sleep and medication, psychological factors like self-esteem, and behavioural factors, like diet and physical activity.

Clare thinks that one of the most important factors is obesity stigma – negative attitudes towards others because of their weight – which is very common in the UK. People with obesity are commonly stereotyped as being weak-willed, lazy, greedy, and stupid. As a result, nearly 9 out of 10 people with obesity report they have been stigmatised, criticised or abused because of their weight.

What’s more, people with obesity report that some of this stigma has come from healthcare professionals. Clare says that this can result in people with obesity becoming disengaged with the healthcare system, and avoid lifestyle or psychological support, which in turn can make their physical and mental health worse.

At the core of obesity stigma is the belief that obesity is a ‘choice’ that an individual makes, and is entirely responsible for. There is a pervasive idea that it can be easily ‘fixed’ if the person ate less and exercised more. However, Clare says that these beliefs are over-simplistic.

Obesity is caused by many factors, including our genetics, our environment and culture, and complex social factors too, such as wealth and education. For some people, these factors ‘conspire’ together to make healthy choices and behaviours difficult to achieve. Clare takes us through a few of the most important factors which influence people's behaviours.

Our 'food environment' is a particular important factor. Clare shares research from America which shows that obesity in all groups of people increased from the late 1970s, right after deregulation on the amount of sugar that foods could contain.

Wealth is important too – children who come from poor backgrounds have higher rates of obesity than those from wealthier backgrounds. 'Healthy' food choices are relatively more expensive for poorer families than more affluent families. And fast food shops are more common in poorer areas than wealthier areas.

Clare says that our genetics may also play a part in obesity, though the relationship is quite complicated. Clare thinks that certain genes may influence our appetite – both how attracted we are to food, and how much food we can eat before we feel full. As one point of evidence for this – our appetites are pretty consistent throughout life, include after birth, where some breast-fed babies are 'hungrier' than others.

Clare concludes by saying that to tackle obesity, and the mental health problems it causes, we must tackle obesity stigma. We need to educate everyone – including healthcare professionals – about the real causes of obesity. We also need to raise awareness of the link between mental health and obesity, such that researchers in both areas should be talking to each other more to understand how their work overlaps.

One comment from the audience following Clare's talk says that some of the medicines used to treat certain mental illnesses can themselves cause weight gain – which adds another layer to this complex relationship.

10:25 – Simon Gilbody, “Smoke free mental health services: from rhetoric to reality”

Our final speaker in this symposium on the cross-over between physical and mental health is Prof Simon Gilbody from the University of York. Simon is focussing on how we can help people facing mental illness to quit smoking.

After a brief lesson in post-modern architecture, Simon begins by setting out the importance of helping people to stop smoking – in terms of things we can do to reduce our risk of early death or poor health, quitting smoking should the number one priority.

However, the smoking rate amongst people facing severe mental illness is two to three times higher than the general population. One of the things which had previously contributed to this was a 'culture of smoking' within mental health services, where people began smoking as they used these services.

Simon says smoking contributes to long-term health conditions faced by many people with poor mental health, who have a reduced life expectancy by 20 to 25 years, on average. It also contributes to poverty, as cigarette smoking is an expensive habit. What's more, the stigma that has developed around smoking also contributes to mental illness (in the same way that obesity stigma does, as we heard from Clare's talk earlier).

Simon turns to some "mythbusting" around why smoking is more common amongst people with severe mental illness. Firstly – the myth that people smoke to reduce stress – not true. Secondly – the myth that smoking can counteract the side-effects of medication – but people who quit smoking end up taking less medication.

A third myth is that there is never a good time to quit, because quitting smoking will lead to relapse of mental health problems. The final myth is that people don't want to quit – that is also not true.

How can we help people with mental illness to quit smoking? Simon says that the same things which work for the general population, also work for smokers – behavioural and nicotine replacement therapies. But the main problem for people facing mental illness is access to these services.

Simon moves on a trial he ran called SCIMITAR, which aims to develop a smoking cessation programme, tailor-made for people with severe mental illness. In the small pilot study for SCIMITAR, they managed to double the 'quit-rate' for the people in the study.

The results from the SCIMITAR+ trial – the largest trial ever conducted into stop smoking services for people with severe mental illness – will be released very soon. But Simon reveals that the results from the pilot study appear to hold up when they look at larger numbers of people with severe mental illness.

Simon finishes by promoting a programme called ‘Closing the Gap’, a research network looking to reduce the inequality in physical health for people facing severe mental illness.

10:50 – Discussion

It's now time for discussion on all the talks on the link between mental health and physical health.

First question is about stigma – but specifically about the discrimination that people with mental illness face. Does that also contribute to physical health? Andrea says that she faced discrimination as a black woman, she was immediately prescribed medication without any discussion about the possibility of cognitive behavioural therapies. Andrew says that doctors whose specialty is in physical health (such as heart health) aren't as familiar with mental health problems, and how they may be treated and prevented. Simon and Clare confirm that for access to services to support people to quit smoking or lose weight, sadly there is some subtle discrimination against people with mental illness.

Another question was about the efforts that people make to improve their physical health – many people carry with them a 'fear of failure', that their efforts may not work or they won't sustain them. Does that contribute to mental illness? Andrew says that the message we should be getting across to people, in the example of physical activity, is that any level of physical activity is better than none. Andrea says that with the young people she works with, it's not about just sending them to the gym – some of them play golf or do other activities to achieve their goals.

We have a question about the genetic effects of these links. Clare says that there are about 1,000 different genetic variations which are linked to obesity, and scientists are trying to work out the biological effects of these variations. The problem is that the vast majority of these variations only make a tiny difference on their own. But Clare says it's not really the direction we should be heading – focussing on the environment will benefit a lot more people that just focussing on the the genetics behind obesity.

You can hear more from Bridget, Clare, and Simon in this interview with The Mental Elf:

Time for a quick break for tea and coffee. Back at 11.30 for more important talks and discussions.

11:30 – Keynote 3: Joshua Gordon, “NIMH priorities and progress"

Our next talk, and our third and final Keynote speech, is from Dr Joshua Gordon. As Director of the USA’s National Institute of Mental Health (NIMH), Joshua has a unique overview of the opportunities – and the challenges – for mental health research, which he is sharing with us today.

Joshua sets out the complexity of problems faced by mental health research. To illustrate, he shows the audience a picture of a 'rosehip neuron', a type of cell in the brain. It has dozens of little branches, and at the end of these branches it connects to hundreds of other nerve cells, and there are thousands of proteins involved in these interactions. The billions of cells in our brain, with trillions of connections between these cells, is what causes our behaviour, and mental illness. Joshua says that NIMH set itself a mammoth task to understand all of this complexity.

Joshua moves onto one priority area for NIMH's work – neural circuits, which are basically how our brains are wired. Neural circuits are groups of cells in our brain which are connected together to carry out a particular task. These circuits can sometimes go wrong however, which can contribute to several conditions, including Parkinson’s disease and some mental health conditions.

Joshua says that studying these neural circuits has traditionally been difficult, because the tools available to do so are fairly blunt – they may switch on or off large areas of the brain at once. But with new techniques and imaging, we're much more able to understand how these neural circuits affect our behaviour.

As an example, Joshua shares some research in mice. Using a virus to force nerve cells in mice to produce particular molecules, scientists can test how particular areas of the brain are involved in anxiety. This research shows that blocking the specific connection between two brain regions makes the mice much less anxious – they are more likely to explore open spaces, which is not a normal behaviour for mice.

The challenge of this research is now to translate these findings into humans, to learn more about human behaviour and mental illness. Even if we are able to show something happens in mice, it doesn't necessarily mean the same happens in human brains. For technical and ethical reasons, scientists are not able to do the same experiments in humans as we might do in mice, so new approaches are needed.

Another priority for NIMH is an approach called 'computational psychiatry'. Researchers are looking at mental health at multiple different levels. Some are looking at the small scale – the genes, molecules, and cells involves – whilst others are looking at the ‘high-level’ experiences – the behaviours and the social impacts of mental illness. This is a real strength for mental health research, but it also presents challenges – for any one condition, or for any one person, how do we bring together the research at all these levels, to make sense of what’s going on, and how to treat them?

Computer science can help to address these challenges. Scientists can use computers to bring together data at all these different ‘levels’ of a disease, so that they can figure out how the ‘high level’ experiences arise from the interactions at the smaller end of the scale.

Joshua gives an example of research into reward-predicting and mood. It involves a smartphone app, with a basic gambling game, where the action was interspersed with asking about the player's mood. The researchers were able to show that happiness was linked to reward-prediction behaviour. But what's more, they were able to link the areas of the brain involved in mood and reward prediction. This can help to understand how the link between depression and reward-seeking behaviour, something that is known to be affected in depression.

Joshua also shares some other research which shows that MRI scans of people's brains may be able to identify whether people with depression will respond to a particular treatment or not.

Joshua moves onto the third priority area for NIMH, suicide prevention. Suicide is one the biggest causes of death in people in the US – particularly in young people. He shares research which shows that screening for suicidal thoughts in hospital emergency rooms – by asking about people's suicidal thoughts – can significantly reduce the number of subsequent suicide attempts. He also shares some provocative research which suggests that the drug ketamine can dramatically and quickly reduce suicidal thoughts. Finally, Joshua talks about a study hoping to predict the risk that people will attempt suicide.

Joshua's final message is that research can provide hope for the future, but applying this science to help people facing mental illness as soon as possible, that is the real challenge.

You can hear more from Joshua in this interview with The Mental Elf.

12:20 – Panel Discussion: “Can research ‘move the needle’ on mental illness?”

The next session is a panel discussion on how research can ‘move the needle’ on mental illness.

The attention paid to mental health across the world has never been higher. Members of the Royal family, celebrities, business leaders and Governments are speaking out and committing to action. But the scale of the challenge is huge. And a lack of progress in our understanding and treatment of mental illness means we haven’t yet seen the advances necessary.

Research has the potential to transform the status quo – as it has done for cancer or HIV/AIDS. But mental health is a long way off seeing similar steps forward. Levels of funding for and awareness of research into mental health are huge barriers.

But does the issue run deeper than this? After leaving his role as Director at the National Institute of Mental Health, USA, Tom Insel said in an interview:

"I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realise that, while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs – I think $20 billion – I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness."

So how do we ‘move the needle’? How do we translate the outcomes of research into tangible benefits for people facing mental illness? Do we need to change our research priorities? Or maybe the way that research is done?

All of the questions above will be addressed by a panel of speakers. The session will begin with a two-minute statement from each of the panel members. Then, the discussion will open up to questions from members of the audience, and the chair of the session, Kate Kelland, Health & Science Correspondent for the news agency Reuters.

We begin with an opening statement from Prof Louise Arseneault, from King’s College London. As far as Louise is concerned, the key is to try and get the discoveries made into the public, to make changes to healthcare, but we don't know enough about how best to do that. The model of 'co-production' – where scientists and doctors work with people affected by mental illness to develop new interventions – will also be important, but again, it is difficult to know exactly how to do that.

Next to speak is Dr Sarah Carr from University of Birmingham. Sarah thinks that mental health research should cut across all different areas of researchers. We should do better to break out of our bubbles, and work with others from outside of the mental health research, including people from the arts and humanities. We also need to diversify how we fund research, such as working with the voluntary sector. Finally, we should involve people affected by mental illness more. That doesn't just mean have someone on the research funding panel – we could involved people facing mental illness in deciding the priorities for research, and even in doing the research itself.

Following Sarah is Dr Joshua Gordon from the USA’s National Institute of Mental Health, who gave the keynote speech in the previous session. In response to his predecessor's comment that we haven't made a difference in mental health care – Joshua think's he's "dead wrong". Research is making a difference, but the problem as Joshua sees it is that it's not making a difference fast enough. We need to set goals – short, medium, and long-term – which will speed up how translates research into benefit for people with mental illness.

Next is Prof Tim Kendall, the National Clinical Director for Mental Health for NHS England. Tim thinks we're unlikely to see the major breakthroughs in the future – the 'silver bullets' that can treat huge numbers of people. Funding for mental health services is absolutely key, particularly in North and West of England, where they are lacking. Tim thinks we also need to change our focus, to do more research into prevention and understanding mental illness. And again, we need to do better at translating our research into benefit for people facing mental illness – there are pockets of great work doing just this, but they need to be rolled out further.

Our final panellist is Andrew Welchman from the Wellcome Trust, a charity which has made funding of mental health research a priority. Andrew states that he is optimistic – organisations like Wellcome and MQ are investing more and more into mental health research. But we need to continue to "make the case" for funding mental health research to get everyone "singing from the same hymn sheet". Building this broad research community is a major part of MQ's work and one of the purposes of the Mental Health Science Meeting.

Now Kate invites questions from the audience.

The first question asks why people with mental illness are not invited to take part in clinical trials, in the same way that people with cancer are? Andrew says that the uptake of clinical trials for psychiatry is way too low, and the people entering these trials are not representative of the whole population. Tim makes the point that the funding disparity between cancer and mental health research is stark – £1,000 is spent on cancer research per cancer patient per year, but for mental health research, that figure is more like 10p. Louise makes the point that in the same way that cancer research is focussing on helping people live with cancer, mental health research should also focus on helping people live with their condition.

Joshua and Kate raise the question of whether the language we use might affect how we see mental illness – saying that people have mental health 'issues' or 'problems', as opposed to 'illness', might belittle mental health and make it seem like it isn't a priority for research funding.

Tim says that the conversation around mental health is changing in the UK. As an example, he says that nowhere else in the world would you see on tabloid newspapers being sympathetic to mental health conditions. Andrew agrees that we have seen a massive shift in attitudes towards mental health – in the media and in government priorities.

Kate asks the panel if there is any particular priority areas where we should be investing our money.

Louise says that the focus should be on prevention – treatment is important, but for the long-term, the mental health of children and young adults will be absolutely key. Joshua talks more about screening which he discussed in his talk, in relation to screening for suicidal thoughts. However, Joshua says that screening programmes can be challenging to develop depending on the type of mental illness we're trying to tackle. Tim thinks that schools are promising settings for mental health awareness, screening, and interventions. Sarah thinks that prevention is key, but we need to consider people struggling with their mental health throughout their life – for them, prevention of mental health crises should be the focus.

Another question from the audience is about setting ourselves goals. The UN has 'global development goals' for tackling poverty – could we set ourselves similar ambitious targets to help us all move in the right direction? Kate invites the panel to contribute ideas for some goals.

Joshua says one goal would be to get a test – any test – which can predict which treatment which be beneficial for a particular person with a mental illness. But setting goals, and then making research decisions to acheive those goals, are two very different things.

One more question from the audience is about the 'implementation gap' – the time it takes for research findings to actually be implemented in the health service and make a difference to people's lives. How can researchers make changes to their research to make it more likely to be implemented? Louise talks about research networks which are already trying to do this implementation work. Sarah thinks that scientists ought to be thinking at the beginning of a research study, rather than at the end of the study, how their work will be implemented.

A final question is about how people with lived experience of mental illness can contribute to research. How can we ensure this involvement is not 'tokenistic', and how can we remove the barriers which prevent people from getting involved? Sarah thinks that research should be 'co-produced' – design and carried out by people with mental illness in collaboration with scientists. People with mental illness have a massive amount to contribute, in their knowledge and their experience. We should reduce the bureaucracy that universities throw up to get more people involved.

That brings the panel discussion to a close, and I’m sure there will be plenty more discussion over lunch. We’ll be back at 2.15pm for the final sessions of the meeting.

14:15 – Rapid-Fire Talks

Certain to wake up anyone feeling a little sluggish after lunch – it’s the Rapid-Fire Talks! We’re following the same format as yesterday – four speakers have just five minutes to share their research highlights. On your marks…

14:15 – Alexandra Schmidt, “Physical activity and depression: Do the beneficial effects extend to individuals with adverse childhood experiences (ACEs)?”

Our first speaker in today’s Rapid‑Fire Talks is Alexandra Schmidt from the University of Sussex.

We already know that physical activity can help people deal with depression. What we don’t know enough about is whether it can also help people at risk of depression – specifically, people with adverse childhood experiences.

Alexandra explains that adverse childhood experiences include situations like domestic violence, experiencing neglect or abuse, a family member being in prison, or growing up in a household with alcohol or drug addiction.

Alexandra used data from the National Survey of Health and Development – a group of more than 5,000 people followed throughout their lives.The results of her study confirmed that more physical activity is associated with less depressive symptoms.

Interestingly, she found that people who had a particular type of adverse childhood experience benefited more from physical activity in adolescence, and reduced their risk of developing depression later in life. This suggests physical activity can protect against depression, and could form the basis of an intervention for young people who experienced adversity in childhood.

14:25 – Urška Košir, “Relationship between physical symptoms and psychological well-being in adults with soft tissue sarcoma”

Our next Rapid-Fire Talk is from Urška Košir from University of Oxford. Her research focuses on the mental wellbeing of people with soft tissue sarcomas, a rare type of cancer.

These tumours often require invasive medical procedures to preserve life and limb, but which often result in disfigurement or amputation. Pain and fatigue are very common in people with these sarcomas, and up to 50% of patients with these cancers report long-term disability. All of these experiences are factors which are known to increase a person’s risk of mental illness. Therefore, Urska wanted to explore the experiences of people living with soft tissue sarcomas, and the impact these tumours had on their mental wellbeing.

Conducting interviews with a group of 28 people with sarcomas, she found that many of the patients had experience significant disfigurement, which led them to feel self-conscious. But they were mostly concerned with the functionality of their limbs before their appearance. People who had concerns about their body image were more likely to have a lower mood.

Urska believes that her study provides evidence that health care professionals treating sarcomas should consider the impact that surgical procedures can have on a person’s mental wellbeing. She believes that interventions which help these patients develop and improve their ability to cope with possible disfigurement may have a positive impact on their mental health.

14:35 – Radhika Kandaswamy, “DNA methylome marks of exposure to psychosocial stress during adolescence: Analysis of a novel longitudinal MZ discordant twin study”

Our third talk in this Rapid-Fire session comes from Dr Radhika Kandaswarmy from King’s College London.

Radhika starts by sharing some fascinating evidence that stressful events in our lives can leave a ‘fingerprint’ on our DNA. This fingerprint – chemical changes to the DNA known as ‘epigenetic’ changes – is different in people who have been exposed to adverse experiences, compared to those who haven’t. Chemical changes may affect how active particular genes are, so this evidence points to a potential a biological mechanism for how stressful experiences have an impact on our mental health.

However, Radhika says that the evidence so far hasn’t been reliable enough to be useful – it has come studies which were too small, or from very specific groups, which make it difficult to generalise the findings for a wider group of people.

Radhika shares work that she has carried out using a group of 118 twin pairs who take part in a study called ‘E-Risk’. She carefully chose pair twins where one twin was exposed to adverse experiences and one was not. As this groups of twins share identify DNA, Radhika was able to look at the impact of adverse experiences in adolescence and be more confident that the effects were purely down to the experiences rather than any other factors. The twins in this study had been asked to give cheek swabs and blood samples throughout their childhood between the ages of 5 and 18.

Her results show that there is indeed a specific fingerprint left on the DNA by adverse experiences, which also change during childhood. This work contributes to our understanding of the consequences that stressful events can have on our genetic code, and ultimately our mental health, during adolescence.

14:40 – Sophie Li, “Are women’s catastrophic beliefs ovary-actions? Progesterone levels predict reductions in phobic avoidance following cognitive restructuring in women with spider phobia”

The final speaker in our Rapid‑Fire Talks session is Dr Sophie Li from the University of New South Wales in Australia.

Sophie is focussing today on the fear of spiders in women. Phobias like this result in ‘catastrophic beliefs’ – the irrational belief that some sort of worst-case scenario will certainly happen if that person is exposed to the thing they fear – in this case, spiders.

Exposure therapy – where people are exposed to the thing they fear in a controlled setting – can form part of treatment which can help to reduce anxiety, and ultimately their phobia. However, Sophie explains that the results for this in women are not consistent. There is evidence to suggest that the reason for this variability are hormone produced by the ovaries – namely, oestrogen and progesterone.

In her study, Sophie measured the levels of progesterone and estradiol (a type of oestrogen) in blood samples given by people undergoing exposure therapy for spider phobias. She then looked at the levels of these hormones in relation to the outcome of the therapy – whether the women avoided spiders less often, or reported that their fear of spiders had reduced.

She found that increased level of progesterone (but not estradiol) were associated with less avoiding of spiders in these women – they were able to move closer to a box with a lab spider called "Little Miss Muffet". However, neither hormone was associated with a reduction in fear of spiders that these women reported.

Levels of progesterone change during a woman’s menstrual cycle. Sophie says that her research suggests that exposure therapy for women with anxiety may be more successful if the therapy was timed to coincide with a peak in progesterone in the blood during her monthly cycle. It also raises the possibility that increasing the levels of progesterone using drugs may increase the effective of exposure therapy in women – though more research is needed to prove this.

14:50 – Symposium 4: “Tackling suicide and self-harm”

Our final session of the Mental Health Science Meeting is looking at suicide and self-harm – one of the most emotive topics in mental health, but also one of the most important. The researchers are discussing how we predict who is most likely to attempt suicide, and how we can prevent this from happening.

Chairing this session is Gregor Henderson, Director for Wellbeing and Mental Health for Public Health England, and Paul McGregor, a mental health campaigner, advocate and author.

Paul begins the session by sharing his experience. He says his story is really about his dad. Paul says that his dad had everything on paper – a good job, good physical health. But when Paul was 18, his dad completely changed, to someone very distant. Paul's dad was prescribed antidepressant drugs, and later attempted suicide. His dad's depression got worse, and he struggled as he received treatment in a mental health unit. Sadly, his dad took his own life – six months after he was first diagnosed with depression. What made Paul feel even worse after this event, was that he was never able to answer the question 'why' – why his dad took his own life. Accepting this helped Paul move on, but also made him a strong advocate for research into suicide.

You can read more about Paul’s experience and his hopes for the future.

15:00 – Rory O’Connor, “Psychological Processes and Suicidal Behaviour”

Prof Rory O’Connor from the University of Glasgow is our first speaker in this symposium. Rory focusses on understanding the psychology behind suicidal thoughts and actions, and hopes to identify ways to prevent suicide.

Rory came in to chat to us with Paul McGregor (the co-chair for this session), you can listen to their conversation on our podcast.

Researchers have been trying for a long time to define exactly how suicide develops. Rory today is going to try and get across one aspect of this – the thought processes that an individual person goes through when they are considering suicide.

We know that 90% of people who die by suicide have a recognisable mental illness. However, on the flip side, the vast majority of people with mental illnesses do not attempt suicide – that figure is maybe 4-5%. Rory say's particularly interested in that 4-5% of people with mental illness, who go on to attempt suicide.

One key component of many recent explanations is the link between suicidal thoughts and suicidal actions (i.e. suicide attempts). The theory behind this is that having suicidal thoughts, and these thoughts progressing into actions, are two separate stages, and have different explanations behind them.

In 2011, Rory published a scientific paper which presented his method of explaining the progression from suicidal thoughts to behaviours – known as the ‘integrated motivational-volitional model of suicidal behaviour’ or the IMV model for short. He has since updated this IMV model with the help of Olivia Kirtley from University of Leuven in Belgium.

Briefly, the IMV model has three phrases:

  1. A pre-motivational phase – where various factors, including a person’s upbringing and specific ‘trigger’ events, make someone more likely to develop suicidal thoughts.
  2. A motivational phase – where suicidal thoughts emerge, as a result of feeling defeated and trapped.
  3. A volition phase – where suicidal thoughts make the transition into behaviours and actions, including suicide attempts.

Rory presents some research where he asked people who had attempted suicide about a range of factors, and then followed them for another four years to see if they attempt suicide again. One of the most important factors which could be used to predict whether someone would attempt suicide again was feelings of 'being trapped'.

Rory then focusses on the transition from having thoughts about suicide, to acting and attempting suicide. Rory's IVM model puts forward the theory that there's eight 'volitional' factors which influence that transition, and his research has shown that in a group of Scottish young people, these factors do indeed predict who is most likely to make suicide attempts.

Rory moves onto talking about some interesting research into the biology of suicide, in particular the hormone cortisol, known as the 'stress hormone'. Reseach that Rory conducted with his twin brother (who is a stress researcher) shows that people who have attempted suicide in the past have a 'blunted' response to stress, with lower levels of cortisol when exposured to stressful events.

Rory finishes his talk by discussing an aspect of our thought processes which is understudied in relation to suicide – the 'automatic system', which is responsible for our unconscious, impulsive behaviour. In a study, Rory and his colleagues were able to show that people who unconsciously focus more on death than life are more likely to attempt suicide in the future.

Rory ends his talk by reaffirming that suicide research will need an approach that mixes science from lots of different areas – he says we all have a role to play in suicide prevention.

15:25 – Becky Mars, “Transitions from suicidal thoughts to attempts”

Following Rory in this symposium is Dr Becky Mars from University of Bristol. Becky is discussing how young people who have suicidal thoughts make the transition to making suicide attempts.

Becky reiterates that for everyone who has suicidal thoughts, only a small number of them will go on to act on these thoughts. Research has told us which people are more likely to have suicidal thoughts, but we don't have any good measures to predict who will go onto to make a suicide attempt. Knowing this would help doctors to target interventions at people most like to act on their suicidal thoughts, and hopefully prevent them from dying.

Becky goes on to discuss different 'models' of suicide – different theories which try to explain how people develop suicidal thoughts, and then how they make the transition to attempting suicide. These models (which include the IVM model our previous speaker Rory developed), have varying amounts of evidence to back them up.

For her research, Becky has been using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), also known as the ‘Children of the 90s’ study, which charts the health of 14,500 families in the Bristol area. Each participant in the study has provided a huge amount of data which researchers like Becky can use to identify risk factors for all kinds of health conditions, such as suicidal thoughts and attempts.

Becky has identified several factors which can influence the chances that someone who has had suicidal thoughts, or has self-harmed, will go on to make a suicide attempt. Those factors include substance misuse, having friends or family who have self-harmed, and certain personality traits.

Becky then talks about another aspect of her work with the 'Children of the 90s' study, which is only made possible because the participants are tracked over time. She tried to uncover whether, for people who had suicidal thoughts at age 16, if there's anything which predicts if they would then go on to attempt suicide later in life. The results from that work will be released soon.

15:45 – Ellen Townsend, “The Card Sort Task for Self-Harm: An innovative method for investigating the complexity and temporal dynamics of self-harm”

Next to speak in this symposium on self-harm and suicide is Prof Ellen Townsend from the University of Nottingham. She is talking about a technique she developed with her colleagues which could help to identify the factors which lead a person to self-harm.

Firstly, Ellen makes the case that we should be careful with our language around self-harm and suicide. Nobody 'commits' suicide, they 'die by suicide'. And we shouldn't refer to 'self-harmers', we should recognise them as people. One of Ellen's team, Emma Nielsen, has written an excellent blog on this topic of language.

Ellen focusses on young people who self-harm, partly because there is a massive increase in the rates of self-harm in adolescence, but also because it strongly linked to suicide – the leading cause of death in young people.

In the UK, 200,000 people self-harm every year – which is four times as many as people as who ran the London Marathon in 2017. But Ellen says this is just the 'tip of the iceberg' of people who self-harm, without making contact with mental health services.

The technique Ellen has developed is called the Card Sort Task for Self‑Harm, or CaTS for short. It allows people who have self-harmed to share the complexity of their experience, and also show the 'sequence of events'. For Ellen, the order of events really matters.

People who have self-harmed are presented with a set of 117 cards, each with a different statement on them. The cards were divided in five categories: Thoughts (e.g. ‘I could not trust anyone’), Feelings (e.g. ‘I felt trapped’), Events (‘I had an argument with my friend’), Behaviours (‘I was not able to sleep’), and Services & Support (‘I talked to a teacher which helped’).

The people are then asked to think of either their first or their most recent incidence of self-harm. They are asked assign cards in a time sequence, ranging from 6 months before they self-harmed, up to the event itself, and then afterwards.

Ellen says that the CaTS task allows people to tell their own story of their experience of self-harm. Importantly, it was also developed with people who have lived experience of self-harm. Ellen is very passionate about 'co-production', where people with lived experience of mental illness work together with researchers to develop new interventions.

For the researchers, it could help to identify common events and feelings leading up to self-harming, which could present key opportunities at which to intervene. One common sequence which Ellen found was that the idea of 'impulsiveness' occured frequently before self-harm – acting on impulse without planning.

When people were asked to reflect on their most recent experience of self-harm, there was a tendancy for people to report that they felt they wanted to die. In addition, people no longer reported that they felt 'relieved' after self-harm, which was a common feeling after the first ever attempt of self-harm. Ellen says that this suggests that how people feel about self-harm deteriorates over time as they repeatedly self-harm, which is concerning, as it could lead people to attempt suicide in the future.

Ellen has subsequently created an online version of CaTS, known as e-CaTS. This will mean that more young people will be able to share their experience of self-harm, and so researchers like Ellen will be able to better understand the process of self-harm.

The young people who have been involved in developing and testing the CaTS tool have also found it useful. Ellen says that many of them have reported a 'light-bulb moment', and now better understand their own thought processes.

16:15 – Reinhard Lindner, “Multimorbidity and the wish for assisted suicide”

Our final speaker for this symposium is Prof Reinhard Linder from the University of Kassel in Germany. His talk is focussing on ‘physician assisted suicide’ and is working to identify the factors which influence the decisions of those who request it.

‘Physician-assisted suicide’ – requesting help from a medical professional to end one’s own life – is often linked to a struggle with multiple diseases – and has an interesting link to this morning's symposium on the link between physical and mental health.

Reinhard explains that the desire for help to end one’s life isn’t really connected to the severity of a particular disease, or the combined severity of many diseases – but is actually about the psychological burden of these diseases, and losing the ability to cope. Studies have reported that about 5% of elderly people with multiple health complaints have requested assisted suicide.

Reinhard thinks it's important to distinguish between different thoughts around death. Many older people with multiple health problems have a 'tiredness of life' – a desire to die but without any action. Others report 'death wishes', which take on many forms. Some 'accept' death, in the sense of being satisfied with their life, whilst others wish the natural process of death to start earlier, but without wanting it to be accelerated.

However, in the case of assisted suicide, people often feel like they wish to speed up death, as a result of feeling like they are a burden to others. Research has shown that these people are likely to have had suicidal thoughts earlier in life as well.

Reinhard says that the question of assisted suicide and euthanasia is important and timely. We're now more able to treat people with severe physical illnesses, such that their live is extended, but sadly for many of these people the quality of their life may not change. In many countries and regions across the world, assisted suicide and euthanasia is legal. Here in the UK, there are ongoing, passionate debates about assisted suicide.

Reinhard sets out what we know about the factors which make people more likely to request physician-assisted suicide. One group of these factors are psychological. For example, Reinhard explains that a feeling of ‘losing control’, as well as the fear of death, and 'fear of the unknown', are factors which make people more likely to request assisted suicide. Other factors, such as holding strong religious beliefs, make people less likely to request assisted suicide.

There are also ‘social’ factors which affect the likelihood of requesting assisted suicide. Factors such as ageism, availability of access to support networks, quality of social networks, and economic burden, all have a role to play in someone’s wishes to request assisted suicide.

Reinhard says that to prevent suicide in groups of people like this, we need to focus on psychosocial interventions. Specific training for healthcare professionals and relatives of people with multiple health problems may also be useful to help address these issues.

16:40 – Discussion

We now move to a discussion around the previous talks on suicide and self-harm.

One question is about whether bereavement is a risk-factor for requests for assisted suicide – particularly in older people who lose spouses. Reinhard says that it certainly is possible, and that we should offer more support to people who lose loved ones later in life.

Ellen answers a question about where we should be focussing on research funding in relation to self-harm and suicide. She believes that it depends on the exact challenge we're trying to address, but she is a fan of community-based approaches.

Paul asks a question about the 'ripple effect' of suicide – that exposure to suicide in family or friends is a risk factor. How strong is that risk factor? Rory says that, like suicidal thoughts, not everyone who loses someone to suicide will themselves try to take their own life, but the effect is particularly strong up to five years after that person's suicide.

Paul finishes the discussion with a final question. How can we educate children to keep them safe? Ellen says we should take what young people say seriously. We do young people a diservice if we don't listen to them.

We now close the meeting with some awards. For poster presentations, they are: Ruth Roberts from University College London, and Radhika Kandaswamy, from King's College London. There is a travel prize for Sophie Li from of New South Wales in Australia. And an 'audience vote' prize for Faith Matcham from King's College London. Congratulations to them all!

And with that, the MQ Mental Health Science Meeting for 2019 draws to a close. It’s been a fantastic meeting with some great science and intense discussion.

Thanks to everyone who has contributed to the conversation on Twitter via the #MQScienceMeeting hashtag, and thanks to everyone who’s been reading the live blog.

Next week, we’ll be sharing a round-up of the most important learnings from the meeting. Until then, thank you, and see you next year!

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Overcoming Impostor Syndrome in the Age of Social Media

This is an interesting article I found on: www.goodtherapy.org

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Social media enable everyone to build, create, and curate their own brand. Others interact with this personal brand, refining and changing it. This dynamic process can create a social media image that feels divorced from the person behind the profile.

Most social media profiles present a person’s life through rose-colored glasses, depicting only the best and most likable aspects of a person. A single “candid” image might have required hours of preparation and hundreds of photographic outtakes. The unfavorable or imperfect images all go unseen.

For some individuals, social media use can contribute to impostor syndrome. These individuals may have trouble acknowledging their accomplishments. They may feel as if their true selves don’t live up to their reputations and feel severe self-doubt as a result. An estimated 70% of people will feel impostor syndrome during their lifetime.

Recognizing Impostor Syndrome

In the 1970s, researchers first identified the phenomenon among high-achieving women who felt like frauds. Since then, researchers have identified impostor phenomenon among many groups, including white men. Yet marginalized groups—women, genderqueer individuals, racial/ethnic minorities, people with disabilities, etc.—may be more vulnerable to impostor syndrome.

Historically marginalized communities see fewer examples of successful people who look like them. Oppression, discrimination, and microaggressions may help activate feelings of self-doubt. A 2017 study linked impostor syndrome among racial and ethnic minority students to increased depression and anxiety.

People with impostor syndrome may worry that they have fooled everyone into overestimating their talent, intelligence, popularity, etc. They often believe their success is merely illusory, a product of luck instead of merit. Other common characteristics of impostor syndrome include:

  • Being unable to claim credit for one’s own achievements. For example, a woman receiving an award at work might downplay her contributions and highlight the accomplishments of her team.
  • Fearing judgment for perceived failures or shortcomings. They may fear being “found out.”
  • Not feeling a sense of belonging. This is especially prevalent among minorities in competitive workplaces, political organizations, and other groups whose membership provides social status.

Impostor syndrome can sometimes be a self-fulfilling prophecy. When people are unable to claim credit for their achievements, others may be less likely to notice those achievements. This can slow career progress, reducing rewards and encouragement which could convince a person that they deserve their success.

How Social Media Can Amplify Impostor Syndrome

Social media platforms allow a person to display the things they most want others to see. Some social media users are better at this than others, creating a compelling personal brand that creates the illusion of a perfect and highly successful life. The ready availability of social media profiles makes it easy to compare oneself to dozens of other people in just a few minutes. A person can even search for people with similar backgrounds, in similar jobs, or of the same age.

The viewer can’t compare to this flawless image. This can lead to insecurity and impostor syndrome, especially when a person compares themselves to people at work, school, or those in the same profession.

Social media users may be able to push back against impostor syndrome by viewing social media as a curated, deliberate branding effort—not an honest and complete presentation of a person’s life.It’s easy for even mundane aspects of daily life to become a source of comparison online. Self-care, for example, is vital for well-being. It can also be a way to signal how much leisure time, support, and money a person has. A struggling college student who sees photos of their peer at an expensive spa may feel hopeless about their own prospects for self-care.

Parenting, pet ownership, gift-giving, time management, and even cleaning can likewise trigger social media comparisons. So while a person who felt like an impostor at work might previously have comforted themselves with reassurances about their other skills, social media make it possible to feel inadequate across numerous domains.

Over time, this constant comparison can lead to impostor syndrome and other mental health issues. A person viewing an apparently flawless life may wonder, “Why can’t I do that?” The reality is that the person who appears to be living a flawless life probably doesn’t lead the life they present on social media.

A 2017 study found people who spent 121 minutes or more per day on social media were more likely to report feelings of isolation and identify with statements such as “I feel like people barely know me.” Other studies also support a link between heavy social media use and worsening mental health. For instance, a 2015 study of adolescents found that those who used social media for more than two hours per day were more likely to report poor mental health.

Social Media Literacy

Social media can undermine our sense of what is normal. For example, after days of scrolling through perfectly organized homes, people with flawless skin and hair, or employees who never make mistakes at work, a social media consumer may begin to view these experiences as the norm. This can be deeply unsettling, especially for those who are already vulnerable to impostor syndrome. A person may also view their own social media image as fraudulent while taking another person’s image at face value.

Social media users may be able to push back against impostor syndrome by viewing social media as a curated, deliberate branding effort—not an honest and complete presentation of a person’s life. Social media accounts act like personal advertisements, highlighting the good and framing a person’s life in only the most positive terms.

How to Deal with Impostor Syndrome

A handful of strategies may help counteract impostor syndrome. These include:

  • Consuming representative and diverse media. When minorities see people who look like them in successful roles, they may be less likely to feel like frauds.
  • Employ cognitive strategies. Remind yourself that many successful people feel like impostors. People often present a much more confident, “together” image than they internally feel.
  • Limit social media usage if it consistently hurts your self-esteem.
  • Find a mentor who has similar experiences to your own.
  • Build a diverse support system.
  • Remind yourself of recent accomplishments. Keeping a file of compliments or awards may help. Remember that achievements may also be more subtle, such as training a subordinate to succeed in their role or improving morale at the office.

Therapy can help with impostor syndrome and the painful emotions it triggers. A therapist can also help an individual prevent impostor syndrome from hindering their success. In therapy, a person may learn cognitive-behavioral strategies for correcting self-defeating thoughts. They might explore how their history—familial, cultural, and social—influences their self-concept. Or they might practice strategies for becoming more assertive and taking credit for their achievements.

A licensed counselor can help you manage impostor syndrome and prevent social media from destroying self-esteem. You can find a counselor here.


  1. Bothello, J., & Roulet, T. J. (2018, April 28). The imposter syndrome, or the mis-representation of self in academic life. Journal of Management Studies, 56(4), 854-861. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/joms.12344
  2. Brooks, R. (2017, April 24). Study: Impostor syndrome causes mental distress in minority students. USA Today. Retrieved from https://www.usatoday.com/story/college/2017/04/24/study-impostor-syndrome-causes-mental-distress-in-minority-students/37430839
  3. Cokley, K., Smith, L., Bernard, D., Hurst, A., Jackson, S., Stone, S., . . . Roberts, D. (2017). Impostor feelings as a moderator and mediator of the relationship between perceived discrimination and mental health among racial/ethnic minority college students. Journal of Counseling Psychology, 64(2), 141-154. Retrieved from https://psycnet.apa.org/record/2017-09930-002
  4. Imposter syndrome? 8 tactics to combat the anxiety. (2018). Retrieved from https://www.americanbar.org/news/abanews/publications/youraba/2018/october-2018/tell-yourself-_yet–and-other-tips-for-overcoming-impostor-syndr
  5. Sakulku, J. (2011). The impostor phenomenon. International Journal of Behavioral Science, 6(1), 75-97. Retrieved from https://www.tci-thaijo.org/index.php/IJBS/article/view/521
  6. Weir, K. (2013). Feel like a fraud? gradPSYCH Magazine, 11(1), 24. Retrieved from https://www.apa.org/gradpsych/2013/11/fraud

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Body Dysmorphic Disorder’s Impact on Kids Today

This is an interesting article I found on: www.psychcentral.com

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The teenage years are hard on kids’ sense of identity and self-esteem, especially as their bodies and minds are changing and growing at a rapid rate. As a parent, it may feel like you are jumping through mental and emotional hoops, doing your best to build up your child while still maintaining discipline. However, adolescents who struggle with body dysmorphic disorder (BDD) may need more help than most parents may realize.

Body Dysmorphic Disorder Strikes at a Vulnerable Age

Body dysmorphic disorder is a mental disorder that leads individuals to constantly think about their perceived appearance flaws. These flaws may be small and therefore unobservable by others, but for someone with BDD, those perceived defects in their appearance can be all-consuming.

According to research, this disorder often strikes sometime during either childhood or the later adolescent years, with 16 being the average age of those diagnosed. Since teens are often going through many difficult changes during this time period, their BDD may go unnoticed by parents or simply seen as an extension of teenage angst. However, a child’s body dysmorphia and overall obsessive unhappiness with their appearance may not be their only mental health issue.

Comorbid Disorders Often Impact Teens with BDD

The same research that pointed out that adolescence is usually when body dysmorphic disorder begins also stressed that children struggling with this issue often had other comorbid mental health problems. As BDD is considered part of the obsessive-compulsive family of disorders, it is not surprising that anxiety is one of the common mental health issues present with BDD.

Depression is another major factor in those struggling with BDD, along with suicidal thoughts and attempts. Eating disorders were also found to be comorbid conditions in adolescents with body dysmorphic disorder.

In fact, a case report concerning a teen with severe body dysmorphic disorder also had several severe comorbid mental health disorders, regularly suffering from depression, delusions, and suicidal ideation. The professionals who wrote up her case suggested that BDD is underdiagnosed by professionals who focus on treating the co-morbid issues without directly addressing the body dysmorphia.

Signs Your Child May Have Body Dysmorphic Disorder

Now that you understand the impact body dysmorphic disorder can have on your kids, it is also important that you are able to recognize the signs of BDD. Commonly, those with BDD have an unhappy obsession with one or more of their body parts, such as:

  • Facial feature, i.e., acne, nose size, complexion, etc.
  • Skin and veins
  • Hair appearance
  • Genitalia
  • Breasts
  • Overall musculature

These signs can manifest in a number of symptoms. Some of the symptoms of BDD you may see in your son or daughter are:

  • Constantly preoccupied with a flaw in their features, which you may or may not see. Even if you do see a minor flaw, your teen perceives it as far worse.
  • Believe that their perceived flaw makes them hideous or visibly deformed.
  • Withdrawal from social situations and functions to keep people from seeing the flaws.
  • Spending an inordinate amount of time styling hair, makeup, or clothes to help disguise perceived flaws.
  • Believing that people are constantly noticing their flaws and are making fun of them.
  • Perpetually seeks yours and others reassurance about their appearance.

Ways Parents Can Help Kids Struggling with Body Dysmorphic Disorder

While body dysmorphic disorder can have a serious impact on your teen, you have the ability to help them overcome their disordered thinking. Some of the best things you can do are:

Be available to talk

Your support and insight can make a world of difference to your child. Even though teens may sometimes act like they never want to talk to you, knowing that you are there and willing to listen when your child needs it can help them feel heard and less isolated with their obsessions and anxiety.

Access professional help

In many cases of BDD, children need the help of professionals to assist in overcoming their obsessive thoughts. Should your child have depression or other comorbid conditions with their disordered thinking, a residential treatment center could be a nurturing environment staffed with the professionals your child needs.

Provide accurate health information

Weight and body composition unhappiness is a significant feature for those who struggle with BDD. This unhappiness may lead them to make poor health choices such as severely restricting their food intake.

Instead of allowing this behavior, you can provide them with accurate health information, whether it is the nutritional value of food or the best workouts to help them become more fit. The natural reward hormones released by exercise can also be beneficial in altering your child’s mindset.

Model healthy behaviors

Parental behaviors can play a profound part in a child’s self-perceptions, so it is essential that parents model healthy behaviors.

It can be tempting to make off-hand, critical remarks about your body, but while you may not mean them to a severe extent, it is easy for a young child or teen hear you and follow your example to a more extreme conclusion.

When it comes to body dysmorphic disorder, the sooner your son or daughter receives treatment, the higher the probability that BDD will have a less severe impact on them. So, if your teen has been complaining about their appearance, be sure to listen to see if there is an obviously obsessive and false component to what they are saying and be ready to get them the help they need.


Jacobson, Tyler. (2019). 6 Mental & Emotional Flaming Hoops You Jump Through for Your Kids. Retrieved https://psychcentral.com/blog/6-mental-emotional-flaming-hoops-you-jump-through-for-your-kids/

Bjornsson, A. S., Didie, E. R., Grant, J. E., Menard, W., Stalker, E., & Phillips, K. A. (2013). Age at onset and clinical correlates in body dysmorphic disorder. Comprehensive psychiatry, 54(7), 893–903. doi:10.1016/j.comppsych.2013.03.019

Thungana, Y., Moxley, K., & Lachman, A. (2018). Body dysmorphic disorder: A diagnostic challenge in adolescence. South African Journal of Psychiatry, 24, 4 pages. doi: https://doi.org/10.4102/sajpsychiatry.v24i0.1114

Jacobson, Tyler. (2019). How Parents Can Model Healthy Behavior for Their Kids & Teens. Retrieved https://psychcentral.com/blog/how-parents-can-model-healthy-behavior-for-their-kids-teens/

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Overcoming Trauma Is Possible – with Help

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When you see news accounts of people experiencing traumatic events, shootings, violent or sexual assaults, kidnappings, accidents, fires, drowning and more, it may seem both commonplace and far removed at the same time. The fact that the news tends to sensationalize such terrible events might numb you to the magnitude of the trauma these victims endured.

But when it happens to you, you’re stunned, frozen with fear, totally unprepared. The aftermath leaves you deeply scarred, physically, psychologically and emotionally shattered.

I know exactly how this feels. I was a victim of such trauma. Yet, I did overcome this life-altering experience with psychotherapy.

The Attack

It was a beautiful, sunny day in June when I drove into the parking space behind my best friend’s apartment building. She lived on the other side of the building, and so couldn’t see me approach. Thus, she had no idea what was about to happen. Neither did I.

Since we were going to do our hair and nails at her place before going out to a restaurant for dinner afterward, I gathered my purse and situated the bag containing shampoo, conditioner, blow dryer, curling iron, hair spray, makeup and change of clothes in the front seat. There was no one on the sidewalk and no cars nearby. As I opened the door to get out, my purse was hanging on my shoulder, my car keys in my other hand.

Suddenly, I felt something sharp pressed into the left side of my neck, and someone grabbed me roughly to pin my right arm back.

“Don’t move,” a man’s voice commanded.

I didn’t. I couldn’t. Everything seemed so surreal. Time seemed to stretch on forever as I stood petrified.

I felt my purse yanked off my shoulder and felt the sharp tip leave my neck. I sensed motion and after a few seconds realized my attacker was gone. I turned my head and saw two young males running down the sidewalk that led to another apartment building and forked to a small park.

For some reason, I started yelling at them to stop. Then, inexplicably, I took off after them. One turned, saw me, and they split. I ran after the one I thought had my purse, although I couldn’t be sure. He had a huge head start on me and I soon lost him.

The sidewalk ended on a residential street. There was a man watering his tiny patch of grass and I ran up to him and asked if he’d seen a young guy barreling by. He said he hadn’t and asked me what happened. Out of breath, just then beginning to realize how foolish my actions had been in trying to chase my attackers, I told him. He urged me to call the police.

I felt like my legs turned to Jell-O, but I slowly made my way back to my friend’s place and tearfully related what happened. She drove me to the police station and I made a report. The officers held out slim hope that the attackers would be apprehended, but said they’d be in touch if they did.

We went back to my friend’s place and had some iced lemonade. Forget the evening plans. Forget me going home to my apartment that weekend. My house keys, identification, wallet, address book with my home address in it, my checkbook with the same, my medication, all were now in the hands of my attacker.

I did call my upstairs neighbor to give him a heads-up. He promised to watch my place.

Three days later, on my return home, my neighbor met me at my door. It had been broken into and the doorjamb was destroyed. My neighbor said he heard loud banging the night before and went out on his balcony to look down. He yelled and saw two guys making off with something, although he couldn’t see what it was. He called the police.

I spent the next few nights at my mom’s house, while the landlord installed a new door and lock at my apartment. I also got a call from someone who said they’d found my purse, and wanted to know if I wanted it. I was afraid this was a scam, so I arranged for the finder to meet me at the police station with my purse. I did, and the purse was fine, although the money, my ID, checkbook and keys were gone. I offered a $20 reward, which the man gratefully accepted. I had to borrow the money from my friend to give to him.

The Nightmares and Flashbacks Begin

For months after the attack, I never slept through the night. I tossed and turned, knowing that when I did fall asleep, I’d have vivid nightmares that replayed the traumatic event over and over. In the daytime, any sudden movement put me on edge. The sound of a man’s commanding voice anywhere – on the TV, radio, in the market, at work – put me right back to the attack. I felt the knife tip, heard his insistent voice, saw the wild-eyed look in his eyes. The latter is something I remembered in the split-second when he turned to look at me on that sidewalk.

As I attended night school at university, I was also afraid to go from my car to classes. My schoolwork suffered. I had to finally drop out of school for the semester.

At work, my attention wandered. I couldn’t stay focused on the task at hand. Often, my supervisor would find me gazing off into space. I barely knew he was there, for what I was seeing was the attack happening all over again.

He suggested I go for counseling and said my company benefits would pay for it. I asked a few friends for recommendations for a psychotherapist, selected one, made an appointment, and began therapy.

The Long Road Back to Mental Health

It wasn’t easy reliving the violent episode with my therapist. Although he knew that was the reason that I started therapy, there were other items in my past that needed attention as well. We first had to establish trust. I’ll admit the thought of psychotherapy was very unnerving, but I was in a precarious state and needed help.

My therapist was a kind, gentle man. He spoke softly, whether to ease my fears or that was his regular demeanor. All I know is that I instinctively trusted him and believed he wanted the best for me.

In helping me learn how to deal with my trauma, we went over self-protective measures I put in place immediately following the attack. He also encouraged me to stay in close contact with my upstairs neighbor, my family, co-workers and friends so they knew my schedule and could tell if something was off. This gave me an added sense of security.

Working to rebuild my self-confidence and self-esteem took quite some time, and he used different approaches for that. I know I cried a lot during sessions, and a lot more at home. Still, I felt I was getting stronger every day.

I knew that I’d never again put myself in harm’s way. Before exiting a vehicle or building or wherever I went, I taught myself to be keenly aware of my surroundings. I needed to be able to quickly identify escape routes, to impress on my memory specific details of people, places and things around me – in case I needed those facts later.

While in those days, I don’t recall the words post-traumatic stress disorder or panic attack, I know now that I probably suffered from both. I was prescribed anti-anxiety medication that I took for a period of months before my therapist felt I could be weaned off them.

Did therapy help me overcome trauma? Absolutely. Was it a rapid healing process? No, it took a couple of years to undo the damage that one traumatic act of violence inflicted. Yes, I did heal. Frankly, the episode gave me an overwhelming appreciation for life and gratitude that I was able to survive what could have been another fatality statistic.

Overcoming Trauma Is Possible – with Help

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Histrionic vs. Narcissistic Personality: What’s the Difference?

This is an interesting article I found on: www.goodtherapy.org

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Narcissistic personality (NPD) and histrionic personality (HPD) are both cluster B personality disorders. These personality disorders are characterized by the following:

  • Patterns of thinking and behavior that seem erratic or unpredictable
  • Actions or thoughts that others consider dramatic
  • Patterns of thinking and behavior that seem too emotional for a specific situation
  • Behaviors are persistent and inflexible and lead to impairment and distress

Some mental health experts consider HPD and NPD the most similar of the four cluster B personality disorders. Similarities between these conditions may include attention-seeking behavior, flirtatiousness that’s often inappropriate, behavior that seems shallow or uncaring, and a need for approval and admiration from others.

Some researchers have even suggested HPD is a manifestation of NPD rather than a unique condition, but the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists HPD as a separate diagnosis. However, it’s possible to have both conditions, or any combination of personality disorders, and this may sometimes complicate diagnosis.

Some people believe those with personality disorders will never change their behavior. It’s true these behavior traits often respond less readily to therapy than symptoms of other mental health conditions, but treatment is still possible.

What’s the Difference Between Histrionic Personality Disorder and Narcissistic Personality Disorder?

These two conditions may present similarly, but they differ in several ways.


Estimates suggest HPD only occurs in about 1.8% of people, while NPD is more common. Diagnostic criteria can vary, and the actual prevalence isn’t known for certain, but recent estimates suggest about 5% of the general population could meet diagnostic criteria for NPD. Among people diagnosed with NPD, between 50 and 75% are men. Research suggests HPD is more commonly diagnosed in women.

Ability to Show Empathy

A main characteristic of NPD is a failure to show empathy for the feelings of others. Lack of empathy, however, is not a primary characteristic of histrionic personality. The behavior of people with HPD may seem shallow or self-centered at times.

One study from 2018 suggests people with any cluster B personality disorder may have a hard time identifying emotions—those of others as well as their own. Being unable to clearly recognize emotions can make it challenging to know when to offer compassion or support, which could seem like a lack of empathy.

Different Types of Attention-Seeking Behavior

Grandiosity, or feelings of superiority or exaggerated self-importance, is a primary feature of narcissism. This trait is not a significant feature of other personality disorders. People who have NPD think highly of themselves and their abilities and may, out of this superiority, tend to keep themselves apart from others in a group. People living with HPD, on the other hand, tend to want to belong and fit in.

This desire for belonging and approval marks another distinction between narcissistic and histrionic personality disorders. Both involve a deep-seated need for attention, and people living with either condition may manipulate others in order to get this attention. People with NPD don’t only need attention, however. They need admiration, praise, and recognition.

People with HPD may care less about the type of attention they receive and allow themselves to be seen in a vulnerable or even negative way, so long as attention is centered on them. They’re more likely to have a low sense of self-worth and seek approval from others to build up their self-esteem.

With HPD, efforts to get attention may seem excessively emotional or dramatic. People living with this condition may become upset easily and shift rapidly between moods. This extreme emotionality, a hallmark of histrionic personality, is less common with narcissism. People with narcissism usually show less emotion and tend to be more reserved and self-possessed.

Why Do These Differences Matter?

Narcissism and histrionic personality affect personal relationships and general well-being in different ways. Both issues are characterized by unstable or impaired personal relationships. People with HPD may struggle to be emotionally intimate with others, while people with NPD are more likely to cause significant emotional harm.

The words and actions of people with NPD are often hurtful since they generally have little regard for the feelings of others. In relationships, people with narcissism may require complete focus on their own needs and feelings. A partner who attempts to share feelings or get their own needs met will usually face emotional rejection or complete withdrawal. The person with narcissism may accuse the partner of being selfish or not caring for them enough.

Narcissism can make it difficult to do well in the workplace, as a fear of shame or failure can lead people with NPD to leave jobs when they face criticism. They also tend to react with outrage or disdain when facing embarrassment or criticism. Persistent feelings of shame can lead to withdrawal or depression. Other issues linked to narcissism include substance abuse and anorexia.

People with HPD may struggle in relationships for different reasons. A desire for gratification and excitement can lead to boredom in long-term relationships, and they may seek new partners frequently. Histrionic personality is also marked by a tendency to consider relationships more intimate than they actually are. Having to face the true nature of a relationship may lead to distress.

In relationships, people with HPD often depend very strongly on partners and may act in manipulative ways in order to get attention or comfort. However, people with HPD can and do show empathy and compassion for the needs and feelings of others. They may experience depression and feelings of emptiness when they lack attention or affection and make suicidal gestures or threats to increase the attention or care they receive.

Because people living with HPD often struggle with boredom, they may struggle to keep the same job and change positions or careers frequently. They may be more successful in jobs that are less routine and involve varying duties.

Somatic symptoms and conversion disorder both commonly occur with HPD. People living with the condition may seem to be in poor health or report a variety of health symptoms to get attention, but they may also truly experience the health symptoms.

Existing research on the two conditions suggests people with HPD are more likely to eventually get help, either for symptoms of depression or anxiety or when their behavior causes difficulties like friendship or relationship issues. Behaviors associated with histrionic personality are more likely to improve than those associated with narcissism.

Treatment for HPD and NPD

Personality disorders are diagnosed when behavior patterns are unyielding and persistent over a long period of time. Some people believe those with personality disorders will never change their behavior. It’s true these behavior traits often respond less readily to therapy than symptoms of other mental health conditions, but treatment is still possible.

For treatment to succeed, a person must be able to recognize harmful patterns of behavior and want to make changes. People with HPD and NPD often don’t feel they need treatment and may not seek therapy on their own. It may be particularly challenging for people with narcissism to understand how their actions harm others, so they may see nothing wrong with their behavior.

Research on treatment for narcissism is very limited since people with narcissism rarely seek treatment. When they do, therapy can help them realize how their behavior impacts others. Skills training can teach how to relate to people in positive ways and how to accept and cope with personal flaws, failures, and criticism from others. The root of NPD is often a deep sense of self-loathing and low self-esteem, so when therapy can address these concerns, some behaviors associated with narcissism may improve.

Schema therapy is one specific approach that has shown promise in treating narcissism. This approach helps people identify and address maladaptive schemas, or patterns, that affect their behavior. Through therapy, people may be able to heal these schemas and learn to get needs met in healthier ways that don’t cause harm.

Several approaches can have benefit in treating histrionic personality. Therapy often focuses on helping people develop self-esteem and learn to meet emotional needs in healthier ways.

Cognitive behavioral therapy may help people learn to challenge thoughts that lead them to desire attention and replace attention-seeking behaviors with other actions. Psychodynamic therapy can help people understand the reasons behind the interpersonal challenges they experience, which can help contribute to positive change. Family counseling may also help, since involving loved ones in counseling can help people realize the impact their behavior has on others. Skills training and group therapy helps people learn to relate to others who deal with similar challenges.

In some cases, couples counseling can help people with personality disorders address relationship issues. But keep in mind that narcissism in particular often involves patterns of deceit, manipulation, and emotional abuse, and many therapists don’t recommend relationship counseling for abusive relationships. It’s important to first address and change long-standing patterns of manipulation and other harmful behavior. Good progress in individual therapy could indicate relationship counseling may help in the future.

Therapy typically also addresses co-occuring issues, including depression, anxiety, or substance abuse. Some people might also have more than one personality disorder. If this is the case, a combination of therapy approaches may be most helpful. If it’s not possible to address all presenting concerns at the same time, therapy generally aims to treat the most serious or harmful issue first and then continues to help the person work through other challenges.

Getting Help

Traits of any personality disorder can lead to serious emotional distress and impact your life, relationships, and the people close to you. If you or a loved one have signs of any personality disorder, reach out to a qualified counselor today. Therapy is the best way to address symptoms and learn new methods of coping and behaving.

The stigma surrounding personality disorders can be discouraging. You may have heard that some therapists won’t work with people who are living with a personality disorder, particularly narcissistic personality disorder.

But contrary to what many people believe, personality disorders are treatable, and there are skilled therapists who can offer support. If you want to make changes in your life, begin your search for a trained, compassionate therapist at GoodTherapy.


  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Association.
  2. Behary, W. T., & Dieckmann, E. (2013). Schema therapy for pathological narcissism: The art of adaptive reparenting. In J. S. Ogrodniczuk (Ed.), Understanding and treating pathological narcissism (pp. 285-300). Washington, DC, US: American Psychological Association.
  3. Caligor, E., Levy, K. N., & Yeomans, F. E. (2015, April 30). Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry, 172(5). Retrieved from https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2014.14060723?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&
  4. Dieckmann, E., & Behary, W. (2015). Schema therapy: An approach for treating narcissistic personality disorder. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26327479
  5. Ekselius, L. (2018). Personality disorder: A disease in disguise. Upsala Journal of Medical Sciences, 123(4). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6327594
  6. Histrionic personality disorder. (2018, January 23). Cleveland Clinic. Retrieved from https://my.clevelandclinic.org/health/diseases/9743-histrionic-personality-disorder
  7. Mayo Clinic Staff. (2016, September 23). Personality disorders. Retrieved from https://www.mayoclinic.org/diseases-conditions/personality-disorders/symptoms-causes/syc-20354463
  8. Mayo Clinic Staff. (2017, November 18). Narcissistic personality disorder. Retrieved from https://www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/symptoms-causes/syc-20366662
  9. Ritzl, A., Csukly, G., Balázs, K., & Égerházi, A. (2018, September 13). Facial emotion recognition deficits and alexithymia in borderline, narcissistic, and histrionic personality disorders. Psychiatry Research, 270. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/30248486
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Narcissistic Families: Growing Up in the War Zone

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When you are raised in a narcissistic family it can feel like there is no help.

Parents who are narcissistic are often self-focussed. They will relate to their children as “self-adjuncts” serving to support them and their image of themselves.

Do something that reflects well on them and you are suddenly the Golden Child. Make a mistake, ask for help or express your vulnerability, and you are on your own or worse, ridiculed.

Children in this situation learn quickly that their needs are unwelcome. Because they are raised to ignore, undermine or suppress their natural sense of who they are, they become alienated from their authentic selves. It can take a lot of work in therapy to unravel this masking process and reveal the true self.

Often this fragile and undermined true self will be associated with intense shame.

Parents who are narcissistic will normally shame a child for asking for her needs to be met, because they are considered inconvenient. Having an imperfect, needy child can bring the narcissist back in contact with their own denied vulnerability, the unfolding shame causing them to become hostile and shaming towards their child. This temporarily rids them of their shame and puts it into the child, who becomes a convenient long-term container for the parent’s unconscious projections.

This shaming process is intensely destructive for young children — the younger they are, the more damaging it will be. Narcissistic parents often don’t provide the soothing and reassurance needed by the child to cope with the overwhelming emotional states accompanying these shame experiences. A child in this situation will develop their own coping mechanisms, usually leading to the splitting off of traumatic memories around the abuse and sometimes, dissociation.

Shame is the fundamental weak spot for narcissists.

Their vulnerability around shame will make them project it onto others, including their children.

Because they are hardwired for attachment, all children will gravitate towards an attachment figure, working to maintain a relationship with parents and looking for support, soothing, nourishment and validation. But the narcissistic parent is often unable or unwilling to provide the emotional validation needed by the growing child. They will be too caught up in their own needs to be attuned to their child or to provide the sensitive responses which help children learn to understand their own emotions.

In some cases these narcissistic parents will be overwhelmed by their own history of trauma.

Being confronted by the emotional needs of a child can bring up painful, sometimes dissociated memories of their own infancy and childhood. These experiences will be more than enough to prevent them from being able to empathize with their children.

A child in this environment soon learns that their emotions are overwhelming for the parent and will unconsciously lose contact with their genuine responses and feelings, understanding that these are likely to be met with hostility.

Narcissistic families often operate in an atmosphere of enmeshment and secrecy, where there is a lack of healthy boundaries and open dialogue. Communication will be unclear, perhaps tangential. Those who ask for what they want will soon learn that this is not welcome. Emotions will not be verbalized, but will be acted out (or “behaved”) sometimes with violence or verbal abuse. At times, addictive behaviors will be used to mask the pain of underlying feelings, making the parent even less available to their children.

A narcissistic home can at times resemble a war zone, with hidden traps and exploding emotions.

The non-narcissistic parent will be desperate to avoid triggering their partner, hoping that things will be OK, but never really knowing what they will come home to.

Often the non-narcissistic parent will deny their own emotions and dependency needs, tiptoeing around the narcissist in a misguided attempt to manage the destructive anger that can tip over into violence and abuse.

For young children, the unpredictability and unspoken tension of a home like this can be particularly harmful. Most children who experience these environments will develop trauma responses, including the complex trauma response.

As adults, these children will often be unaware of the trauma they experienced. They will be vulnerable to depression and anxiety — and loneliness. Some will find a way to manage their unacknowledged pain through addictions. Others will be left wondering why they find it hard to relate to others — or to trust.

It is only through psychotherapy that these neglected children will come to understand themselves and eventually come to terms with the pain of their past.

Narcissistic Families: Growing Up in the War Zone

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Do Ideology and Stigma Impact How We See Sex Addiction?

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According to a 2008 study, between 3-6% of Americans engage in compulsive sexual behavior (CSB), better known as sex addiction. Other studies cite similar statistics, and some addiction facilities cite even higher figures. Many people feel plagued by unwanted sexual feelings or by a desire to engage in sex or view pornography that feels compulsive.

Yet the American Association of Sexuality Educators, Counselors, and Therapists (AASECT) asserts there is insufficient empirical support for the existence of sex addiction. In 2017, the Center for Positive Sexuality (CPS), The Alternative Sexualities Health Research Alliance (TASHRA), and the National Coalition for Sexual Freedom (NCSF) echoed this sentiment in a statement published in The Journal of Positive Sexuality. The Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition (DSM-5) does not list sex addiction as a diagnosis.

So what explains the discrepancy? Mental health advocates disagree on this, too. Sex addiction remains a controversial concept. One thing is certain, however: sexual behavior can cause difficulties in a person’s life even when their behavior does not rise to the level of an addiction.

Even if sex is not addictive in the traditional sense, people may still struggle with sexual behavior.

Is Sex Addiction Real?

Research on sex addiction is mixed. Some studies claim to have uncovered a fairly high rate of addictive sexual behavior. These researchers say sex addiction functions like other addictions, triggering a release of dopamine that causes a person to continually chase a sexual “high.” Like other behavioral addictions—shopping, gambling, video gaming—these studies say sex addiction can act like a drug and cause a person to make damaging and unsafe decisions.

Most bodies that research human sexuality, including AASECT, argue that the concept of sexual addiction is rooted in ideology, not science. They cite research finding no specific level of sexual activity that is inherently addictive or harmful.

A 2013 study looked at the brains of 52 people who said they struggled with sex addiction. Researchers used brain imaging to look at participants’ brains while they viewed sexually suggestive images. Contrary to what theories of sex addiction would predict, their brains did not behave in a way consistent with addiction. People addicted to drugs and alcohol show distinct brain patterns when viewing addictive substances. “Sex addicts” did not display these patterns.

It’s possible that sex addiction functions through different neural pathways or that the study was poorly constructed. It’s also possible that sex truly is not addictive.

Even if sex is not addictive in the traditional sense, people may still struggle with sexual behavior. There are many reasons to seek treatment for sexual issues. For example, a person might find that their sexual behavior is inconsistent with their values or that childhood guilt and shame undermine their ability to seek sexual fulfillment. Others may want to pursue non-normative relationships, such as open or polyamorous relationships, and wonder if doing so signals a problem.

It is important for people to be able to label their own behavior in a way that feels comfortable. If the sex addiction model fits, there’s no harm in identifying with it. For others, the notion of sex addiction—or the ideology that sometimes accompanies it—may feel stigmatizing.

Ideology and ‘Sex Addiction’

Sex is an inherently social activity that is heavily colored by social norms. In some cultures, polygamous relationships are common, while in others, having sex with multiple partners during the same time frame is stigmatized. Religious, cultural, and other ideologies are inextricably linked to people’s feelings about sex, sexuality, and sex addiction.

Many religious traditions have strongly advocated for the existence of sex addiction. In many cases, these religions also argue that pornography use, especially frequent pornography use, can cause addiction. Conversely, advocates who argue for greater sexual freedom and acceptance are less likely to accept the notion that sex can be addictive or that certain sexual practices are more likely to lead to addiction.

When evaluating addiction treatment programs or looking at your own behavior, it’s important to weigh the role ideology plays. A religious sex addiction program may draw more on its spiritual tradition than on empirical research. Likewise, a person’s internalized cultural values may cause them to feel guilty or ashamed of their sexual behavior even when there is nothing inherently wrong with it.

Signs Sexual Behavior Has Become a Problem

Because sex addiction is not a widely recognized disorder, different sources list different symptoms of the addiction. Sometimes ideology plays a role in the list of symptoms. For example, a religious sect that believes sex outside of marriage is sinful may list repeated sexual encounters outside of marriage as a sign of sexual addiction.

There is no empirically supported amount of sex or interest in sex that is inherently harmful or addictive. Having a high sex drive, multiple sex partners, or significant interest in sex does not mean a person has an addiction. Non-normative sexual interests, such as an interest in bondage or group sex, are common and do not mean a person has a sex addiction.

Instead, consider looking at how sex affects your life. People who find that sex damages relationships or self-esteem may benefit from therapy.

Some warning signs that sex may be a problem warranting treatment include:

  • Continuing to have or pursue sex even when you do not want to. Note that this is sometimes also a sign of religiously induced sexual shame.
  • Making sexual choices that consistently undermine a relationship.
  • Being unable to succeed at work or school because of a preoccupation with sex.
  • Needing to have progressively more sex to get the same “rush” that less sex once offered.
  • Abusive or aggressive sexual behavior, such as coercing people into sex or having sex with underage children.

Seeking Help for Problematic Sexual Behavior

A therapist can help with problematic sexual behavior in many ways. Those include:

  • Discussing sexual values, the role of childhood experience in sexual values, and how religious and cultural norms can affect sexual behavior.
  • Helping a person engage in sexual behavior consistent with their values.
  • Supporting people in relationships to negotiate sexual boundaries and recover from sexual transgressions.
  • Reassuring clients that “normal” sexual behavior comes in many forms.
  • Offering a safe space to explore sexuality and move beyond sexual shame.

Some mental health diagnoses can affect sexual behavior. For example, people with bipolar may become hypersexual during a manic episode. Therapy can also help with these symptoms.

Finding a therapist who shares your values about sexuality is important. To begin your search, click here.


  1. AASECT position on sex addiction. (n.d.). Retrieved from https://www.aasect.org/position-sex-addiction
  2. Karila, L., Wery, A., Weinstein, A., Cottencin, O., Petit, A., Reynaud, M., & Billieux, J. (2014). Sexual addiction or hypersexual disorder: Different terms for the same problem? A review of the literature. Current Pharmaceutical Design, 20(25), 4012-4020. doi: 10.2174/13816128113199990619
  3. Keenan, J. (2013, July 24). Is sex addiction real or just an excuse? Retrieved from https://slate.com/human-interest/2013/07/sex-addiction-study-ucla-researchers-find-that-sex-and-porn-might-not-actually-be-addictive.html
  4. Kuzma, J. M., & Black, D. W. (2008). Epidemiology, prevalence, and natural history of compulsive sexual behavior. Psychiatric Clinics of North America, 31(4), 603-611. Retrieved from https://www.sciencedirect.com/science/article/pii/S0193953X08000725

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Free Webinar: Narcissistic Personality Disorder: Everything You Wanted to Know

This is an interesting article I found on: www.psychcentral.com

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(Please note: This free live webinar will be recorded and a copy made available to all who register.)

“Narcissistic personality disorder — one of several types of personality disorders — is a mental condition in which people have an inflated sense of their own importance, a deep need for excessive attention and admiration, troubled relationships, and a lack of empathy for others. But behind this mask of extreme confidence lies a fragile self-esteem that’s vulnerable to the slightest criticism.” (By Mayo Clinic Staff)

However, as people, we are not as “transparent” as we like to believe. We are complicated. We are triggered by different events. We wear masks. We can be brilliantly malevolent and one is none the wiser. Our reactions to situations and people are dictated by our upbringing, experiences… The combination of environment, genetics and neurobiology makes this disorder particularly difficult to treat.

It isn’t easy to spot narcissists in ordinary interactions with them. They are not “conceited” in the sense that it is one behavior that is so evident we can retreat. As adults, they are well-rehearsed in seduction in order to hide what they have learned (not realized as a self-reflection) is unacceptable. Many times, a person involved with narcissists will realize who they are dealing with later in the relationship, when the narcissist is sure that they have secured your trust and feel they have enough control over you to satisfy their needs.

Three Take-A-Ways From Narcissism Webinar:

1. Viewers will learn about narcissistic traits.

2. Viewers will learn how narcissistic traits manifest themselves in someone and in relationships.

3. Viewers will learn about what it means to partner with a narcissist.


Nancy Kalina Gomez Edelstein, NBCC, LPC completed her graduate doctoral course requirements in Psychodynamic Psychology at The George Washington University and received a Master’s in Clinical and Counseling Psychology at Columbia University.

Nancy is a bilingual (Spanish/English) licensed and certified (New Jersey) clinician with over two decades of experience treating and assessing patients/clients for services. She has worked as Clinical Director managing staff, case direction, grant guidelines and agency policy. She has worked in both the United States and South America with the following populations: Triply diagnosed (HIV+/Substance Abuse and mentally ill), gang members, abused/neglected children and their families, domestic violence (victims and perpetrators), severely mentally ill, transgender/transitioning, LGBTQ.

This webinar is a live, 45-minute seminar with a PowerPoint presentation followed by a Q&A moderated by Gabe Howard, host of The Psych Central Show podcast. There is no charge for the webinar, but registration is required. All registrants will receive a link to the recording.

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Could Schema Therapy Help Treat Narcissistic Personality?

This is an interesting article I found on: www.goodtherapy.org

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Narcissistic personality disorder (NPD), or narcissism, as it’s often called, is one of the cluster B personality disorders, or emotional/impulsive personality disorders.

Narcissism is one of the least studied personality disorders. Different subtypes of narcissism present with varying features, making diagnosis challenging. People with narcissism may also see no need for counseling and consider it pointless or beneath them. If they do begin therapy, they may react angrily when faced with challenges, try to manipulate their therapist, or find it hard to consider things from other perspectives. They often leave therapy early, especially if they don’t see any benefit in it.

Recent research aims to identify new therapy approaches that can help people living with personality disorders achieve lasting change. Schema therapy, one such treatment, is considered helpful for people who don’t respond well to other types of therapy. It’s proven effective in treating borderline personality, another condition long considered difficult to treat.

Research looking at schema therapy for narcissism is still in the early stages, but existing clinical data suggests it has promise.

People living with narcissism have a deep need for admiration and recognition and draw self-esteem from the praise and positive regard of others.

The Roots of Narcissism

Personality disorders are characterized by rigid, long-lasting patterns of behavior that affect life and relationships, causing distress and making it difficult to function. People living with personality disorders may not always recognize that some of their behaviors cause problems or affect others negatively.

Like other personality disorders, narcissism is a serious mental health issue. Many consider it more serious and harmful than most other personality disorders, since people with narcissism generally lack empathy and may not care about the effects of their actions.

The causes of narcissism aren’t fully understood. Some potential factors in development may include:

  • Having a parent who is extremely adoring or overly critical, or a parent who switches between these modes
  • Having a parent with narcissism
  • Inheriting certain traits that increase risk for personality disorders
  • Experiencing trauma, abuse, neglect, or indifferent parenting

People living with narcissism have a deep need for admiration and recognition and draw self-esteem from the praise and positive regard of others. Since connecting with people on an intimate level requires a level of vulnerability, people with narcissism may avoid meaningful relationships in order to protect their illusion of grandiosity and keep an unstable self-identity from being revealed.

Researchers have identified four main subtypes of NPD. It’s possible to have features of multiple subtypes or shift between subtypes at different points in life.

  • Overt narcissism most often involves entitled, attention-seeking behavior. A primary feature is an exaggerated sense of self-importance. People with this subtype tend to be charming and arrogant and often exploit others. They may do fairly well in the workplace but struggle to get along with others or do tasks they consider demeaning or otherwise beneath them.
  • Covert narcissism may include anxiety, significant emotional distress, and extreme sensitivity to criticism or perceived insults. This subtype is often characterized by shyness, even social isolation. People with covert narcissism tend to have an internal sense of superiority and fantasize about their talents being recognized while speaking modestly about themselves, even putting themselves down.
  • High-functioning narcissism involves similar traits to overt narcissism, but people with this subtype can generally function well in society and may not appear to have a personality disorder. They are often able to adapt narcissistic traits such as charm and competitiveness in order to achieve success and may have relationships that are shallow but lasting. Criticism, perceived failure, or age-related challenges such as poor health or perceived loss of attractiveness may cause distress or crisis.
  • Malignant narcissism, considered the most severe subtype, involves overt narcissism traits along with traits of antisocial personality and paranoia. People with this subtype may lie and manipulate others easily, behave in aggressive ways, enjoy intimidating others, and avoid any work or task unless it benefits them in some way. They often have no desire to change, so treatment may be very difficult.

Narcissism often involves symptoms that are less known than grandiosity and lack of empathy, including:

Most people with narcissism struggle to maintain employment and personal relationships, changing partners readily when they don’t receive the admiration they need. It’s also common for people to fantasize about being recognized for their superiority and humiliating people who have “wronged” them.

When therapy can help address these concerns, particularly vulnerability and self-esteem, narcissistic behaviors may improve.

Schema Therapy: An Effective Treatment for Narcissistic Personality?

Even when people with narcissism do seek therapy, whether for distress related to narcissism or other mental health symptoms, treatment can be complicated. Believing a therapist has insulted them, failed to recognize their specialness, or isn’t skilled or reputable enough to treat them leads many people with narcissism to quit therapy early in treatment. Research suggests therapy progresses more slowly for people with narcissism, leading to slower improvement of symptoms.

Schema therapy, however, may have increased potential to treat NPD. Schema therapists offer support and validation while helping people work to understand and address the emotional mindsets causing problems in their life. For narcissism, this is often the persistent, private sense of inferiority and fear of failure.

Schema therapy combines elements of cognitive behavioral therapy, emotion-focused therapy, Gestalt therapy, and psychodynamic therapy, among others. The idea behind this approach is that schemas, or patterns of thought and behavior, develop as a result of unmet emotional needs and other early childhood experiences. These schemas are reinforced throughout life by challenges, abuse, trauma, and other negative or harmful experiences. Unless they’re addressed in positive ways, they contribute to the development of harmful or unhealthy methods of coping. These coping styles can affect behavior throughout life, often in ways that cause distress.

Schema therapists offer support and validation while helping people work to understand and address the emotional mindsets causing problems in their life.

The goal of the approach is to help people identify needs that weren’t met in childhood and learn how to get them met in healthy ways that don’t cause harm, either to themselves or to others. To help clients achieve this goal, schema therapists group schemas and coping responses into modes and use a range of strategies to address them, including roleplay, interpersonal techniques, and cognitive behavioral approaches. Therapists may set limits, as a parent would, within the bounds of the therapeutic relationship to help clients confront schemas.

The schema modes commonly associated with narcissism are:

  • Detached Protector/Self-Soother: This avoidant mode involves behaviors that are soothing, stimulating, or distracting—anything that helps turn off emotions. These behaviors might include substance abuse, risky sex, gambling, fantasizing, or overwork. It’s also common to shut out or reject people as well as emotions. Typical function isn’t always affected, but it may seem almost mechanical and lack any personal investment.
  • Self-Aggrandizer: A mode in the overcompensation category, this involves many behaviors typically associated with narcissism—superiority, entitlement, and manipulative tactics. People in this mode tend to show little interest in anyone but themselves, boast of real or inflated achievements, and openly seek admiration to avoid revealing hidden vulnerabilities and insecurities.

By confronting these modes and working through them with the help of the schema therapist, people in therapy can begin to access the Healthy Adult mode, which helps heal the vulnerabilities of early childhood and fosters healthier modes of coping. After reaching this mode, people may be able to begin functioning at a more typical level and be more able to take responsibility for their actions and see how they affect others.

Schema therapy has been successful in the treatment of other personality disorders, including borderline personality. Clinical trials on its use with narcissism are still forthcoming, but research and clinical observations suggest schema therapy could help people with narcissism have more success in treatment.

Why Do Narcissists Seek Therapy?

People living with NPD often believe themselves superior and struggle to consider the feelings and needs of others. This can make their actions particularly hurtful. Narcissism also often involves intentional manipulation or emotional abuse—behaviors that cause significant pain to partners of people with narcissism. In fact, many therapists specialize in helping the partners of people with narcissism heal.

The typical traits linked to narcissism, along with the tendency of many with NPD to see nothing wrong with their behavior, have contributed to the belief that therapy can’t treat narcissism. But therapy can help people with narcissism improve—if they want to change.

Andrea Schneider, LCSW, a therapist in San Dimas, California, explains what might prompt a person with NPD to seek counseling. “Typically,” she says, “Someone … with narcissistic personality may have some flexibility with some behavioral change when they are confronted with significant stressors (like a relationship ending or other crisis).”

People with NPD may not ever seek therapy for symptoms associated with narcissism. Instead, they might decide to get help for other symptoms or issues. These could be co-occurring conditions or long-term mental health effects associated with narcissism. In many cases, it’s these challenges that contribute to the desire for change.

People with narcissism may seek help for:

Narcissistic personality and associated conditions can significantly impact quality of life and emotional well-being. Addiction and stress can cause health concerns, for example, while the inability to sustain a relationship could lead to complete isolation.

To date, few studies have looked at treatment for narcissism because people with NPD don’t seek therapy often. If they do, they may only do so because someone else has urged them into it. Therapy can still have benefit, but the person with narcissism must recognize the problems with their behavior and make efforts toward change.

Finding a Schema Therapist

People who don’t see a need to address their behavior are unlikely to be able to make lasting change. But research on schema therapy suggests the approach could benefit people living with narcissism when other types of therapy don’t help. Experts do agree that narcissism often poses treatment challenges for therapists and can make progress in therapy difficult.

Schema therapy involves validation and empathy for a person’s difficulties and distress. When people with narcissism approach therapy with a willingness to change, or at least to make an effort to address harmful behaviors, the mode work involved in schema therapy may help them learn to confront the vulnerabilities they fear in a healthier way.

It can be difficult to find a schema therapist, especially if you live in a smaller city. But many therapists may be trained to incorporate elements of schema therapy into treatment. If you or a loved one has symptoms of narcissistic personality disorder, consider reaching out to a therapist who offers schema therapy or practices mode work. Don’t be discouraged by the myths about narcissism—change is possible for anyone. Begin your search for a trained, compassionate counselor today.

Author’s Note: If you’re involved in a relationship where there is intimate partner abuse of any kind—physical, emotional, or sexual—relationship therapy is usually not recommended. We encourage you to review our crisis page and reach out for support.


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  6. Ekselius, L. (2018). Personality disorder: A disease in disguise. Upsala Journal of Medical Sciences, 123(4), 194-204. doi: 10.1080/03009734.2018.1526235
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  8. Ritzl, A., Csukly, G., Balázs, K., & Égerházi, A. (2018, September 13). Facial emotion recognition deficits and alexithymia in borderline, narcissistic, and histrionic personality disorders. Psychiatry Research, 270, 154-159. doi: 10.1016/j.psychres.2018.09.017
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© Copyright 2019 GoodTherapy.org. All rights reserved.

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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