5 steps

I’ve heard mixed reports about the work Gloucestershire’s mental health trust, ²gether, does to promote what it calls “emotional wellbeing”. Its Improving Access to Psychological Therapies (IAPT) service, codenamed “Let’s Talk”, produces a self-help booklet, 5 steps to emotional wellbeing. The booklet is available online, on prescription from GPs, and in public libraries, so when I noticed I was passing a public library on the way to a meeting recently I called in and borrowed a copy.

There’s no agreed scientific definition of emotional wellbeing, and no agreed way to tell whether or not someone has it. Presumably anyone who currently has a diagnosed mental illness doesn’t have emotional wellbeing, but even that isn’t clear. The converse, that someone who lacks emotional wellbeing must be mentally ill, isn’t clear either. The booklet says it can be used:

…by people who have serious mental health problems through to those who have only ever experienced minor upsets. We can all improve our wellbeing.

Personally, I’d say that you have emotional wellbeing if your emotions are working properly — you feel happy when nice things happen and sad when nasty things happen, that kind of thing. I’m just using happy and sad here as examples of the many emotions that everyone has. The point is that emotional wellbeing for me means that all your emotions taken together are an accurate reflection of the reality of your life. For me, emotional wellbeing means emotional accuracy. It’s difficult to believe that we can all improve it.

Because lacking emotional wellbeing isn’t in itself an illness, there are no evidence-based treatments for it. ²gether’s work on emotional wellbeing provides treatment that isn’t evidence based for a condition that isn’t an illness, and that may not even exist. Scientifically, the whole thing doesn’t seem too far removed from using crystal healing to counteract negative energy fields — which is to say, claptrap. Socially and politically, however, wellbeing is held in much higher regard than crystal healing these days, though whether that will last is anybody’s guess.

First impressions

First impressions of the booklet are that it is for a fictional population. None of the people in the photographs works, looks after a home or goes to school. There are only adults and children, no adolescents. Ethnically, the mix seems to represent somewhere in London, yet no woman’s face is veiled. Headgear apart, everyone wears western clothing. There are no rural locations, and a male couple is seen on a sandy beach by the sea. These are not the people of Gloucestershire.

Many of the pages (nearly half — 35 out of 75) contain checklists and forms to fill in. The booklet is a reminiscent of a school workbook.

The 5 steps, it turns out, are not a sequence of steps at all but just categories in no particular order:

• Looking after your body
• Liking yourself
• Finding happiness
• Being with others
• Managing difficult days

Context

Without going into any further detail at this point, the booklet can be set in the wider context of what is called positive psychology. In general terms, positive psychology tries to correct the emphasis on mental illness that psychiatry and psychology have traditionally had, by concentrating instead on things that seem positive, like happiness.

Positive psychology is associated most closely with the American psychologist Martin Seligman, who popularized it more than ten years ago. Although the original focus of positive psychology was on happiness, Seligman soon changed his mind, realizing that there is something missing from that model. He explains it like this:

It is well established that couples with children have on average lower happiness and life satisfaction than childless couples. If evolution had to rely on maximizing happiness, the human race would have died out long ago. So clearly humans are either massively deluded about how much life satisfaction children will bring, or else we use some additional metric for choosing to reproduce.

In contrast the booklet gives no thought to whether happiness is the most important thing for everyone, all the time. It just assumes it is and moves quickly on, saying (on page 30, at the start of Step 3: Finding happiness):

Everyone wants to feel happy and fulfilled, but how do you go about achieving this?

Seligman’s latest version of positive psychology has wider scope. It includes elements like engagement and accomplishment, and strengths like courage and integrity. But the ²gether booklet doesn’t have this wide scope. It’s seems much closer to the outdated theory that happiness is at the heart of wellbeing.

The contrast is summed up by Seligman, who writes:

Positive psychology, as I intend it, is about what we choose for its own sake.

Whereas the booklet’s introduction explains:

You have to make the decision to keep well and start working at it. It can be difficult, at times painful and you may want to give up a lot of the time.

Why do you have to? The booklet doesn’t say. You just have to.

Research

Research into positive psychology has been inconclusive so far (as most research is). Even so, some studies have shown that the techniques of positive psychology can cause harm. The booklet doesn’t ever warn you about the harm that might be caused.

An article by an American professor of psychology, Is Positive Psychology For Everyone? New Research Raises Doubts, illustrates the problems, and the article was written long before the booklet. For example, a study at the University of Waterloo in Canada found that when people tried to improve their mood by telling themselves positive things, it sometimes backfired and made them feel worse. The booklet includes this potentially harmful technique on page 69, calling it “Wise words”:

Some people find it useful to make a list of statements they can say to themselves when they are having negative thoughts.

The examples given in the booklet include things like, “I am a good person. I am loved”. These are just the kind of statements that caused harm when they were used by people who were having negative thoughts in the research study. What the booklet says, is true — some people do find this technique useful. What the booklet fails to make clear is that some people find it harmful.

Another research study found that pessimistic thoughts can improve people’s ability to cope with challenging situations. When pessimistic people were encouraged to look on the bright side of things, they didn’t perform as well. This suggests that people who are pessimistic may have learned to think that way because, for them, it really works. The booklet includes this potentially harmful technique on page 58, calling it “Managing your difficult feelings”:

Here are some ideas on how to think and act differently when you get depressed, anxious or angry.

The implication is that feeling depressed, anxious or angry is always wrong, that these feelings are never appropriate. There’s no suggestion that feelings like these are ever normal or healthy, and no warning that suppressing these feelings might be harmful and damage your ability to cope in the way the research study identified.

Diagnosis

Even though lack of wellbeing is not an illness, the booklet starts with what looks like a diagnostic scale of the kind used to diagnose common mental illnesses such as depression and anxiety. The only difference is that there’s no threshold score given for this scale, the Warwick-Edinburgh mental wellbeing scale. In fact, there’s nothing to indicate what score you should aim for, except:

The higher your total score, the better your wellbeing.

Aiming for the maximum score, however, would give you a very weird view of life. Take, for example, the only three indicators of your relationships with other people. They ask about whether you are feeling interested in other people, close to them and loved. You could achieve the maximum score on these without having any reciprocal relationships at all. That means someone with a severe personality disorder could achieve the maximum score.

On the other hand, a minimum score would not necessarily mean there is anything wrong. The scale asks about the last two weeks, and over such a short period of time anyone passionately involved in some task might easily focus on the task to the exclusion of relationships.

Of course these extreme examples, people with personality disorders and people who are passionately involved in something, will probably never see the booklet. The only people who see the booklet are people who are seeking help for some reason. For some of these people the reason they are seeking help will be relationships, and the booklet’s underlying values tend to suggest that relationships are best handled in a calculating and one-sided way as if you have a personality disorder.

Another example from the wellbeing scale is its three questions about your future. You score highly if you feel optimistic, confident and have an interest in new things. It doesn’t ask how accurate and appropriate these feelings are. Someone who suffers from severe bipolar disorder and happens to be in a manic phase of the illness would score maximum points even though in reality their life is falling apart. Someone who is coping very effectively with terrible bad luck would score few points.

The flaw

This is the booklet’s fundamental flaw. The booklet imposes a set of values on people who are vulnerable because they are seeking help. It’s not that the advice in the book is necessarily good advice for everyone or bad advice for everyone. It’s that the values embedded in the advice undermine and disempower vulnerable people.

For example, consider the advice on page 10 to:

Drink plenty of water throughout the day…

The fundamental problem with this is not whether or not it’s good advice. (The idea was fashionable once but has since been debunked, and some people have suffered brain damage, occasionally fatal, after forcing themselves to drink huge amounts of water.) The fundamental problem is the message that what you drink should be determined by advice in some booklet rather than by whether you feel thirsty.

The booklet extends this principle of disempowerment to dozens of areas of everyday life, telling you not to be an authentic individual but instead to live your life according to the things you read in booklets, even if it is “difficult, at times painful and you may want to give up”.

Feedback

As I wrote at the start, I’ve heard mixed reports. What I’ve heard, and what I’ve now read, tend to make me think two categories of people generally come into contact with this booklet.

Some people face difficulties in their work or relationships which they wish to avoid confronting. This booklet tells them that the difficulties are in their values and their lifestyles, not in their work or relationships. They think the booklet is good because it confirms their belief that they can’t confront their difficulties, and it distracts them with other things to do instead.

Some people face difficulties in life that they want to confront, but their emotions get in the way. These people are mentally ill, although perhaps only slightly. The booklet either does nothing at all for them or makes things worse, because it doesn’t address the inaccuracy of their emotions. These people may feel betrayed by the NHS, and they may even be discouraged from seeking proper help.

So I can understand how a proportion of people who use this booklet think it is good, and another proportion think it is useless.