Chris Costner Sizemore was famous for her multiple personalities. The Three Faces of Eve, written by her psychiatrists, told the story of her divided self and inspired an acclaimed movie of the same name—Joanne Woodward won the Best Actress Academy Award in 1958 for her portrayal of “Eve” (or Eves). Sizemore actually presented a lot more than three faces—the true number of her personalities was said to be closer to 20. Another multiple personality was “Sybil”—Shirley Ardell Mason—who had 16 different versions of herself. She too was the subject of a bestselling book, in 1973, and two TV movies (Woodward appeared again in the first one, this time as the psychiatrist).
     Recently, The New York Times revisited the phenomenon of what was at the time called “multiple personality disorder” (MPD), focusing on the story of Sybil. There’s a good 12-minute Retro Report film to go with the piece, too. Says the article:

     MPD was the hot new mental illness. Every psychiatrist wanted to work with a client with multiple personalities; a lot of ordinary neurotic clients, especially those of a compliant or suggestible nature, were coaxed, cajoled and coerced into providing them. Some clients, often under the influence of hypnosis or sodium pentothal, thought at the time to be a truth serum, were manoeuvred into a regressed or delusional state from which they “remembered” horrific childhood abuse, torture and sexual violence at the hands of parents or satanic cults. Others, meanwhile, in a bid for celebrity, concocted their various personalities and took to the talk show circuit to air them. For about a decade until the mid-1990s, there was a kind of MPD hysteria. Then the scepticism set in, the techniques of the day were called to account, and the “false memory” lawsuits piled up. In her 2011 book, “Sybil Exposed,” Debbie Nathan, who appears in the Retro Report film, says it was all a fraud.

 Community of selves
“Sybil” always swore that her story was true, that she wasn’t faking it. Regardless, multiple personality phenomena are real. And to an extent, they are part of the human condition for everyone. Don’t we all have lots of “selves,” lots of disparate strands in the tapestry of our being? We can be two-faced; we are Jekyll and Hyde. We have our home self, our work self, our social self. The self who is generous, kind and loving, and the destructive, mad and bad “shadow” self that can rear its ugly head at inopportune moments. The vacation self—if only we could be that person more often! The wild, bohemian, colourful self; the nerdy, pedantic, grey self. The child self, the adult self, the parent self. The online self. The bad-air-guitar-when-no-one-is-looking self. The self who gorges on fast food and junk TV, and the higher self who, in occasional moments of serene elevated awareness, feels some kind of spiritual wisdom. They all inhabit our being in a loose confederacy. They each have different priorities and agendas; some are stronger than others. At times, some need to step up while others step back. Don’t bring your slightly tipsy, Hawaiian-shirted holiday self to a funeral. When it’s the office party, don’t entirely give your work self the night off. Don’t send your child self off to confront the noisy neighbour. Leave your parent self at the door when you go to your salsa class.
     This community of fragmentary selves is like a rather rubbish football team—our selves don’t all get along or play together well, but they all wear the same kit and on a good day, in their own way, they all want what’s best for the team. We are able to “feel like one self while being many” as Philip Bromberg writes, through a process of normal, non-pathological dissociation—paying attention to one and benching another, as the need arises. That’s the job of our harried manager, what Kant called our “synthesizing self”; our ego.
     Sometimes, however, different “players” become problematic. We are ashamed of one or another of them; only a few players are considered presentable—“if people really knew me, they wouldn’t like me,” says the client. Or team members fall out with each other—a common scenario is a kind of mutiny, when the team finally rebels against the “sergeant major,” the authoritarian, workaholic, bullying and highly critical team captain, and they walk off the pitch: one morning, perhaps on the day of an important work meeting, the client simply cannot get out of bed. The boundaries between the selves have become too rigid. We have lost the ability, the flexibility, to pass the ball. The result is a kind of disintegration, or what pioneering dissociation researcher Pierre Janet in 1889 called “psychological disaggregation.” The team falls apart. Common dissociative symptoms include amnesia, fragmentation of identity, and feelings of detachment and unreality about one’s self, body and environment.
     Whatever your degree of dissociation, the therapy room is a place where any aspects of the self, all the shameful, bad or damaged bits, can be invited in, experienced, heard, accepted, processed, healed and encouraged to re-join the team.
     “Health is not integration” of these different selves, writes Bromberg. “Health is the ability to stand in the spaces between realities without losing any of them. This is what I believe self-acceptance means and what creativity is really all about.”
     The manager looks upon his team members not with scorn, or judgment, but with an appreciation for them all, an acceptance, an understanding—not despite their imperfections but because of them. A good manager loves their team.

Possessed by spirits
Sometimes, the dissociation can be extreme, as a result of something bad happening. There is abuse or trauma of some kind. The psychic injury—the internal conflict or external shock—is simply too hard to bear. It can’t be processed; there is no room for it in our conscious mind. “Eve” attributed her fragmentation to having witnessed, within three months as a small child, two deaths and a horrifying accident. An afflicted self is split off; we attempt to lock it away. Dissociation has been described as an escape when there is no escape. It is a creative solution to a terrible problem, a way of preserving some kind of temporary stability, a frozen state of purgatory, a desperate, anxious compromise—like having one foot hard down on the accelerator and the other hard down on the brake.
     At this extreme, as perhaps with Eve and Sybil, different selves become entirely self-contained, unknown to and incompatible with the others, and we enter the territory of multiple personalities, or what these days is called “dissociative identity disorder,” the defining feature of which is “two or more distinct personality states.” (The prevalence of dissociative identity disorder is about 1.5 percent, according to the Diagnostic and Statistical Manual of Mental Disorders.) The symptoms are acute and may involve sudden switches from one personality state to another; physical problems with no organic cause such as seizures, paralysis or loss of sensation; hearing voices; and chronic amnesia. Sufferers may find themselves in a different part of town or even in another country with no recollection or idea of how they got there.
     Some research claims there can be psychophysiological changes between different personalities within the same person. “Eve” as Eve Black, for instance had an allergic reaction when she wore nylon stockings; when she was “Eve White,” she supposedly did not. Some of the other purported differences between a person’s personalities are in handedness—one personality might be left-handed, another right-handed. Or differences in various kinds of allergies and skin reactions, heart rate, respiration, EEG patterns, speech, handwriting, visual acuity and other sensual changes, talents, skills and interests. In some cultures the afflicted person is thought of as being possessed by spirits. Some of a disordered person’s personalities can have that quality, as if they came from nowhere—as if they were players transferred in from a completely different team on a completely different, alien league, as with those bizarre stories when someone regains consciousness from a coma or a blow to the head to find themselves speaking fluently in another language (called “xenoglossy”), or transformed into a musical genius. If we believe in such things. 
     These claims inhabit the realm of the transpersonal, the mystical, the paranormal, and as such are derided by a certain kind of “science,” the kind that tends to miss the idea of a wood through being so busy examining the bark on the trees. Jung popularised the notion of the “collective unconscious"; before him, 19th century philosopher-psychologists like William James and Frederic Myers also believed that we are far more than our rational, conscious, individual selves. We are instead open systems, interconnected, interacting with and being influenced by each other and a field of psychic energy that extends way beyond the confines of our physical bodies. Whether we like the idea or not, we are all both in and out of our minds.

• Short-term counselling ‘could reduce repeat suicide rates by 26 percent’
A new study led by researchers from the Johns Hopkins Bloomberg School of Public Health in Baltimore, MD, suggests that short-term psychosocial counseling could significantly reduce rates of suicide attempts and deaths among individuals who have already tried to take their own lives. (Medical News Today)

• Nurses warn of cuts in mental health services causing strain
Staff cuts and bed shortages are leaving mental health services “under unprecedented strain” says the nurses’ union. The Royal College of Nursing says there are now 3,300 fewer posts in mental health nursing, and 1,500 fewer beds, than in 2010. At the same time demand has increased by 30%, the RCN said. A Department of Health spokesman said mental health was a “priority” for the government. (BBC News)

• Clegg to establish cross-government taskforce for mental health services
Nick Clegg will on Monday pledge to take mental health out of the shadows and to end “outdated attitudes” by establishing a cross-government taskforce to improve services across the country . . . the deputy prime minister will say that more needs to be done to target help at the young after figures showed that three children in every classroom have diagnosable mental heath conditions. He will say that only a quarter of people with a common mental health problem receive treatment while 90% of prisoners have at least one mental health disorder. (The Guardian)

• Pulling together to extend the lives of people with serious mental illness
Each year, 12,000 people with serious mental illnesses, such as schizophrenia or bipolar disorder, die prematurely from heart disease – on average 20 years earlier than the general population, which gives them a similar life expectancy to the 1950s. In addition, 18,000 people with common mental health problems such as anxiety and depression will also die early. This connection between physical health and mental health was noted in the British Medical Journal as long as 60 years ago. Yet only last year the Mental Health Foundation reported that NHS physical health and mental health care were largely disconnected, and that, though integration was supported in principle, it was not delivered in practice. (The Guardian)

• Human rights abuses leave a third of Libyans with mental health problems
“Widespread and gross” human rights violations in Libya, including disappearances, arrests, torture and deaths, have left nearly a third of the population suffering from mental health problems as violence and lawlessness continues, according to a new report . . . Research by Dignity – the Danish Institute against Torture – shared with the Guardian, paints a devastating picture of the human consequences of the regionalism, tribalism and factionalism that have wracked the north African country since the overthrow of Muammar Gaddafi three-and-a-half years ago. (The Guardian)

• Canada: men's psychological wellbeing in the workplace—addressing an unmet need
Mental health problems in the workplace are a growing public health concern, costing Canadian companies $20 billion annually. Researchers know that women are twice as likely to suffer depression than men — but that does not mean men are immune to depression. A new Canada-wide research project, led by the University of Calgary, is the first to specifically target men in the workplace to address their attitudes towards e-health solutions for mental health. (ucalgary.ca)

• Psychiatrist to the Taliban tells all
Afghan psychiatrist Nader Alemi spent many years counselling militants struggling with the effects of war. He was even summoned to see the second-in-command to the group’s spiritual leader, Dr Alemi told the BBC World Service’s Outlook radio show.
     Mullah Akhtar was hearing voices and screaming in his sleep, suffering from delusions and not recognising those around him.
     “This man had been on the front line for goodness knows how long, and seen goodness knows how many people killed in front of him,” said Dr Alemi.
      “All those explosions and screams may still have been echoing in his head, even sitting in the comfort of his office.”
     Others would visit Dr Alemi for depression or anxiety, and he would offer them counselling or medicine to ease their symptoms. (NEWS.com.au)

• Counselling offered to player whose bowl led to Hughes's death
The player who bowled the ball which led to the death of Australia batsman Phillip Hughes is to be offered counselling. Test international Hughes died in hospital, two days after being struck in the back of the neck by a delivery from Sean Abbott. The pair were recent teammates for the national side. (Newstalk)

Nearly two years ago, Adam Lanza, 20, shot his mother in the sleepy Connecticut hamlet of Newtown, drove to the nearby Sandy Hook Elementary School, then killed 20 children and 6 teachers before turning the gun on himself. Last week’s report on the massacre, the result of a yearlong investigation by the Connecticut Office of the Child Advocate, targeted Lanza’s serious mental health issues which had largely gone untreated for years. He had been diagnosed with autism, anxiety, and obsessive-compulsive disorder, and at the time of his death was said to be suffering also from anorexia and depression. The damning report implicates Lanza’s parents, teachers and medical professionals in failing to address his psychological dysfunction and deterioration.
     Incidents like this—there are many other examples such as the recent shooting in the Florida State University library—reinforce the idea that people with mental health problems are violent and dangerous. Potential psychopaths, perhaps. People who should all be locked up in places like Broadmoor.
     But while in hindsight it’s very easy to view the Lanza as portrayed in the report as a mass murderer waiting to happen, mental ill-health is in general a very poor predictor of violence. Jeffrey Swanson, professor of psychiatry at Duke University, has extensively researched the link between the two and generally found it wanting. Much better predictors of violence are being male, unemployed, poor, living in a disadvantaged community, using drugs or alcohol, having suffered from “violent victimization” in the past, and having previously shown violent behaviour.
     “Most people with mental illness are not violent, and most acts of violence are not committed by people with mental illness,” Thomas Insel, director of the National Institute of Mental Health, told a workshop on mental health and violence in February in Washington, D.C. “People with untreated psychotic illness are at increased risk of irrational behavior, including violence, especially directed at family and friends. This usually happens at the onset of illness and before diagnosis or treatment. However, once treatment starts, these people have no higher risk of violence than the general population and are more often victims of crime.”

A rant about guns
But the prejudice persists. More people in America think mass shootings represent a failure of the mental health system rather than a failure of gun control. The Child Advocate report acknowledges “the significant role that assault weapons and high capacity ammunition clips play in mass murder,” yet the focus is firmly on Lanza’s mental health. Concludes writer Maria Konnikova: “Mental illness is easy to blame, easy to pinpoint, and easy to legislate against in regards to gun ownership. But that doesn’t mean that it is the right place to start in an attempt to curtail violence.”
      Guns are an integral part of America’s don’t-mess-with-me, “get off my lawn” identity, which takes in cowboys, John Wayne, Travis Bickle, and Grand Theft Auto. Guns are big business, and owning one is seen as an inalienable right, set in stone, enshrined in the Constitution. (In fact “the right of the people to keep and bear arms” comes from the Second Amendment to the Constitution in 1791, which was referring not to individuals but “a well regulated militia.” The world was very different 223 years ago. Time, surely, to amend the amendment.)
     Today, a third of Americans own a gun. There are about 300 million of them across the land. Lanza often went shooting recreationally with both of his parents, and had easy access at home to numerous firearms and high capacity ammunition. Individually and collectively, the presence of guns changes the psychology of Americans and America. There is something called the “weapons effect”—a much-repeated piece of research in 1967 showed that the presence or even suggestion of a gun can lead to an elevation of aggressive behaviour. No wonder gun owners and the gun lobby are so shrill in their defence of their pocket-size weapons of destruction: not only are they carrying guns—they are packing extra psychological heat as well.
      One study shows you’re much more likely to kill or be killed if guns are in the house, which seems so obvious that it hardly need be researched. In 2011, just over half of the 39,518 suicides in the U.S. were carried out with a gun—19,990 self-inflicted fatal shootings. The number of gun suicides in the U.K.—admittedly with a population five times smaller—in the same year? A grand total of 93. Similarly, of the 16,238 homicides in the U.S. in 2011, 11,068 were done with a gun. The number of gun homicides in the U.K. was 38.
     The National Rifle Association claims, with a straight face, that guns make America safer—their solution to the problem of so many people being killed by guns is more guns. Homicide and suicide are much more likely if the means to those ends are to hand. For example, half of the suicides in the U.K. used to be carried out by sticking your head in the oven and turning on the gas, the method chosen by poet Sylvia Plath while her children slept next door. When coal gas was phased out in the early 1970s and ovens no longer provided a quick exit, the suicide rate dropped by a third—and this reduction has endured over time. Putting obstacles in the way of killing reduces killing. The easier it is to buy guns, the more will be bought and the more people will be shot and killed.
      Violence is impulsive, and we all have our moments of madness. A gun and a hair-trigger temper is a bad combination. Likewise an Uzi and a 9-year-old. Or a gun and a toddler (it’s amazing how many news stories there are about 4-year-olds shooting each other). Or a pistol and an angry, tired, stressed and possibly racist policeman—unarmed black kids like Michael Brown are gunned down and the killer walks free.
     Or a gun and a moody, disaffected teenager. Sandy Hook was a terrible, sickening massacre. But since then, there have been another 92 shootings in American schools—almost one a week. Mental ill-health doesn’t shoot people—guns do.

• Pregnancy and childbirth: why mental health care for parents is important
In a new series of articles published in The Lancet, researchers highlight the importance of mental health care of parents during pregnancy and after childbirth.
     More than 10% of women in high-income countries experience prenatal and postnatal mental health disorders.
     Louise Howard, professor of Women's Mental Health at the Institute of Psychiatry, Psychology and Neuroscience at King's College London in the UK, and lead author of one of The Lancet papers, says: “For many parents, the arrival of a child is a challenging time. The stigma around [pre] and postnatal mental illnesses can prevent people from getting the help they need.” (Medical News Today)

 • Free relationship counselling for parents to rescue marriages
New parents will be given relationship counselling by health visitors under government plans to instil “basic concepts such as love, compassion and trust” and prevent marriage breakdown, Iain Duncan Smith has said. (Telegraph.co.uk)

• Deciding whether to disclose mental disorders at work
While celebrities and others who have publicized their mental health problems have to some extent reduced the stigma, that is not true in the place people spend most of their waking hours — on the job.
     “We’re seeing changes in the broader culture, but we’re not seeing it in the workplace,” said Mary Killeen, a senior research associate at the Burton Blatt Institute at Syracuse University.
     In one recent study of 600 people with disabilities, roughly half involving mental health, about a quarter of the respondents said they received negative responses to revealing their problems — such as not being promoted, being treated differently or being bullied. (The New York Times)

• Unabomber's brother makes plea for better mental health services
David Kaczynski told dozens of social workers, attorneys, law enforcement agents and others at the Collin County Mental Health Symposium on Thursday how he turned in the “Unabomber,” his own brother. Making sure mentally ill people get treatment is important because their problems are not just a public health issue but also a public safety issue, Kaczynski told attendees.
     “What makes me sad is that my brother’s case adds to the stigma,” he said. (Dallas Morning News)

• Counseling proves most effective in meaningful weight loss
In a meta-analysis, patients who received counseling achieved a maximum weight loss of about 14lbs compared with a top weight loss of about 4lbs for those who did not participate in these programs. (Diabetes In Control)

• Bad news about sitting: It may harm workers' mental health
New research demonstrates that sitting for longer than 6 hours a day at work not only carries a physical toll, but may also increase risks of mental health issues, such as anxiety and depression. (Association for Psychological Science)

• Opinion: Is therapy just a really expensive best friend?
Therapy. The most expensive best friend you can buy. I laughed because I've had my socks knocked off by how many people around me are dropping a couple of hundred dollars every week to have someone listen to their mundane problems . . . Look out, not in. (WA Today)

If you’ve received any psychological care from the NHS, the likelihood is that it would have involved cognitive behavioural therapy (CBT).
     Since 2006, CBT has been the fuel that drives the government’s mental health initiative, the “Improving Access to Psychological Therapies” scheme: 6,000 new CBT therapists have been trained since then, and in 2012, the government spent £213 million delivering CBT through the NHS. CBT is the default non-pharmaceutical service offered by the NHS for most common forms of mental distress. Other kinds of therapy get squeezed out.
     CBT has faced heavy criticism over the years. Now author and psychologist Oliver James is leading the charge, calling on the government to take a more holistic approach that embraces other talking treatments such as psychodynamic therapy. Why? Because, says James, CBT simply doesn’t work.
     He writes: “A quarter of us suffer from a mental illness at any one time, mostly anxiety or depression. The cost to our economy is enormous—£105 billion a year, never mind the personal anguish—and for too long the only treatment was pills. What a tragedy, then, that the first attempt to provide talking therapy to patients nationwide is using the wrong kind: cognitive behavioural therapy.”

What is CBT?
In the 1950s, Aaron Beck became disillusioned with the-then prevailing approaches to psychological treatment. On offer was either psychoanalysis, which suggested clients were at the mercy of their unconscious processes, or behaviourism, which suggested they were at the mercy of their external environments. Beck felt little consideration was given to people’s power as conscious beings able to make good choices. In working with clients with depression, he came to understand their condition as arising from unhelpful thinking or “cognitive distortions”—negative thoughts which are fed by underlying beliefs or assumptions or “rules for living.” CBT was an unlikely marriage in the 1970s between this cognitive approach and more traditional behavioural ideas.
      These days, CBT takes a broader approach, considering emotions and the body, too. All four “elements of life” interact with each other, often in a negative spiral. So while a person’s thought and behaviour patterns are the focus of CBT—considered the twin engines in creating and curing psychological distress—practical, skills-based steps to improving emotional and physical wellbeing are also encouraged, such as exercise, sleep, meditation, yoga and nutrition. CBT has evolved and expanded and branched off, too, incorporating other ideas and practices. Some of the new “third wave” forms are mindfulness-based CBT, Dialectic Behaviour Therapy; compassion-focused CBT, Schema therapy.
     In a course of standard CBT treatment, typically anything from 2 to 12 weekly, 50-minute sessions, you and your therapist will break down your problems into their separate parts using worksheets such as Padesky’s “hot cross bun.” Unrealistic or unhelpful thought and behaviour patterns will be identified, and together you will come up with better alternatives. These will be practised during sessions and also between sessions with “homework” assignments such as keeping a thought record or carrying out behavioural experiments where you try to expose yourself to feared situations. Says the NHS: “The eventual aim of therapy is to teach you to apply the skills you have learnt during treatment to your daily life. This should help you manage your problems and stop them having a negative impact on your life—even after your course of treatment finishes.”

The case for CBT
• It offers a common sense, structured, systematic approach with a focus on problem solving in the here-and-now. No need to spend years (and fortunes) in analysis, lying on a couch ruminating about your childhood. CBT is a practical, non-threatening approach, especially for clients experiencing psychological treatment for the first time.
• It’s easy to grasp, and offers clients some certainty, clarity and an action plan. In the midst of the storm of a crisis, that can be very comforting.
• It’s short-term, and can therefore be delivered economically.
• It’s an evidence-based treatment. Since the days of Beck, it has been subject to extensive testing, especially in the form of randomized control trials. This research claims CBT is an effective treatment for anxiety, depression, panic disorder, personality disorders and many other forms of psychological illness, including some psychoses.
     According to the National Institute for Health and Clinical Excellence: “CBT’s evidence base, short-term nature and economical use of resources have made it attractive to clients, practitioners and service purchasers."

The case against CBT
• CBT is an absurdly simplistic, quick-fix approach. It’s just common sense—thinking and behavioural hygiene—dressed up as something grander. At its worst it offers little more than Bob Newhart’s comic “Stop it!” therapy. The idea that a person’s complex distress will be resolved after a few sessions of having their thoughts and actions challenged is laughable—like putting a tiny sticking plaster on a deep, long-standing and festering wound.
• CBT only targets symptoms rather than underlying causes. There are deep unconscious processes at play, often forged in childhood, and unless these are explored, brought to light and processed—this is the domain of psychodynamic therapy—nothing will ever really change.
• It’s a manualised, one-size-fits-all method that is imposed “top-down” on the client, rather than starting with the client and their experience and working together in a “bottom-up” way. Unlike physical diseases, psychological distress does not so easily lend itself to being pigeon-holed into different, neat and tidy “diagnoses”—one person and their “anxiety” for instance, might be very different from another, and they might benefit from very different approaches.
• It’s patronizing and disrespectful to the client to imply they should have “recovered” after a few sessions of CBT, which blithely attempts to whitewash over difficult childhoods, traumas, hardship, and the very real consequences of the oppression resulting from a deeply unequal, divided society. The “blame-the-victim” ethos that’s inherent to CBT—all your problems are the result of your faulty thinking and behaviour—only makes people feel even worse when the treatment inevitably fails to make a difference.
• CBT comes from a narrow, ethnocentric world view, making assumptions for instance that all individuals are rational, autonomous, in charge of their own destiny, disregarding for instance those who might be more collectively-minded, or generally less amenable to logic, homework, psycho-education and the cognitive model.
• The “evidence” for CBT is highly questionable. Any positive effects of CBT in research tend to be very small. The few long-term studies show little or no lasting benefit. And some favourable research is biased, bogus and politicized—often it’s a somewhat rigged, circular process in which CBT looks for and finds results that portray itself in a favourable light, like a schoolboy left to mark his own homework. It is doubtful that CBT is at all effective in the long term in the real world of clinical practice, especially for chronic, complex, or long-term conditions. Writes James: “After two years, those given CBT have no better mental health than ones who have been untreated.”
     Concludes psychiatrist and writer Jeremy Holmes: “It is hard to escape the suspicion that cognitive behavior therapy seems so far ahead of the field in part because of its research and marketing strategy rather than because it is intrinsically superior to other therapies.”

The case for integration
There is something to be said for CBT. It has a place. It’s a good starting place for a lot of clients; a way in. The benefit of symptom reduction can’t be underestimated. I have incorporated some CBT into my work as a counsellor, particularly some CBT ideas around assessment, formulation, psycho-education, self-monitoring and reality testing. Considering each client through a CBT lens is a worthwhile exercise and should be a part of any therapist’s toolkit.
     But overall I tend to agree with James. CBT is rather too superficial, pedantic, and highly directive, sometimes oppressively so. Rather than imposing fixed goals and tasks on the client, I prefer a more open-ended, collaborative way of working, one which allows the encounter to unfold organically, with a sense of exploration. “Being with” is better than “doing unto”; allowing a therapeutic relationship to emerge is preferable to attempting to batter away a client’s symptoms with a CBT bludgeon.
     Human dis-ease is as varied as humans are, and clients rarely come seeking goal-oriented solutions to tangible, well-defined problems. And symptoms often exist for very good reasons. They serve a psychological purpose—and so we defend our neurosis, as Freud said: “like a lioness defends her young.” Untangling unconscious and conscious motivations, intrapsychic and interpersonal conflicts, and environmental constraints and challenges—it’s a tricky business. Better to go with an integrative, flexible, and reflective therapist who has had plenty of therapy of their own than an insensitive, dogmatic CBT evangelist who demands that you get with the program. Better for the government to offer a flexible, pluralistic, comprehensive therapy service than only a simplistic, dogmatic, ineffective one.

You spoke to no one today. The sun came up, moved across the sky, then went down. Nobody cared what you wore, what you did, what you thought, how you felt. You came home to no one. No messages. You imagine that you could die tonight and no one would discover your corpse for days, maybe weeks. You try to keep busy, or you slump in front of the TV, then you go to bed for another restless night. The world is utterly indifferent to you and your existence. You’ve never felt so alone.
      Haven’t we all had days like this? Certainly we’ve all felt the bitter sting of loneliness. You’re definitely not alone—we’re all in it together. Britain is the loneliness capital of Europe. Five million Brits have no friends. Nearly 30 percent of households in the U.K. now consist of one person. This has been called the “Age of Loneliness.” We’ve become an alien-nation, isolated from each other—and our own selves. The cup of human kindness is empty these days.
     What exactly is loneliness, anyhow? We might define it as a painful subjective experience borne of insufficient human contact and intimacy. The subjective part is important: Only you can judge whether or not you’re lonely. There is no external standard; no required threshold of Facebook friends. It’s possible to have a life filled with people and feel very lonely. It’s possible, too, to feel completely content with a solitary existence. (Possible, but not very likely—as Sullivan wrote: “There is no way that I know of by which one can, all by oneself, satisfy the need for intimacy.”)
      A significant contribution to our understanding of loneliness came from British child psychiatrist John Bowlby in the 1950s, who claimed that contact and intimacy are basic needs in themselves, as vital as food and water to our survival both as individuals and as a species. He used the term “attachment,” which he defined as “lasting psychological connectedness between human beings.” We are social animals. We seek connection; it is through what Cozolino calls the “social synapse” that we develop and grow, certainly as babies but throughout our lifespan, too. As Sue Gerhardt writes in the excellent Why Love Matters: “My understanding is that human beings are open systems, permeated by other people as well as by plants and air and water. We are shaped not only by what we breathe and eat but by our interactions with other people.”
      Loneliness, then, could be thought of as useful information akin to hunger or thirst. It is a call to arms, a warning, a klaxon in the dark night. We can tolerate it for a while and carry on, but the more socially starved and weakened we become, the harder it’s going to be to rectify. And we do need to address it. Because loneliness can be a toxic companion. It is bad for your health. Ever since Émile Durkheim’s 1897 book Suicide, we’ve understood the dramatic negative impact of social isolation. “We know that loneliness shaves about eight years off your life expectancy,” says Dan Buettner, author of The Blue Zones, which are those places around the world known for extraordinary longevity. One study claims that chronic loneliness increases your chances of an early death by 45 percent. By contrast, the opposite of loneliness—love, connectedness, belonging—promotes longevity. Love is not all you need, nor does it make the world go round. But it is certainly a vital part of being human.
     OK. Loneliness is painful enough without having additional, secondary things to feel bad about, like its impact on your health. Or anxiety that it will always be this way. Not to mention the guilt and shame of loneliness, the bitter pill that you’re not living life the way you’re “supposed” to, the way you hoped, the way others hoped for you. Calls to the Samaritans are always highest around the Christmas holidays, when the stream of TV ads depicting perfect people being nourished by perfect meals, perfect friends, perfect families and perfect gifts makes us feel so utterly starved.

• Sexologist: people wonder "am I normal?"
Sex three times a day. No sex at all. Asexual. Highly sexual. Scared of sex. Sex drought. Can't stop thinking about it. Am I normal? And the answer, you will be pleased to know, is almost always yes. Australia’s largest study of sexual activity and attitudes has found that people have sex less often than a decade ago but their sexual repertoire has increased. It found that people experience oral sex earlier; condom use has become more common; and an increasing percentage of people watch pornography, though this remains more common for men (65 per cent in the last year) than women (20 per cent). (Sydney Morning Herald)
 
• Cognitive therapy, mindfulness may help with menopausal depression
Psychotherapy and mindfulness techniques could help many women who experience depression during menopause, according to a review of existing research. (Reuters)

• Africa faces mental health crisis as life expectancy improves
University of Queensland researchers warn that many countries in Africa's Sub-Saharan region could be on the verge of a mental health crisis, because people are living longer. “The demographic shift has significant implications for mental health issues and substance abuse, as people aged between 20 and 54 are most likely to be represented in both categories,” said epidemiologist Fiona Charlson. (Medical Xpress)

• Broadmoor episode two: riot training, counselling and patients move out
Review of second and final part of ITV documentary on the notorious psychiatric hospital. Cameras follow patients taking part in a group drugs counselling session and capture staff taking part in riot training too. (stv.tv)

• Evangelicals increasingly putting faith in medicine to treat mental health issues
Church leaders target stigma and old attitudes: a study last year that said nearly half of evangelical Christians believe that people with serious mental disorders can overcome their illness with “Bible study and prayer alone.” (The Guardian)

• Mental health and the military
Study raises concerns about the effect of tour length on the mental health of the UK armed forces. (The Lancet). Meanwhile, in the U.S., new statistics are raising concerns among the military community: suicide became the top cause of death in both 2012 and 2013, according to the Pentagon’s medical surveillance monthly report (Fox News).

There has been a lot of talk lately about psychopaths. Yesterday saw a life sentence handed down to the boy who killed beloved Spanish teacher Ann Maguire in April—the jury at the trial was told that he had stood up in the classroom, winked at a friend, stabbed her seven times, then said to the class: “Good times.” Also yesterday was the pretrial hearing of British banker Rurik Jutting, accused of murdering two Indonesian women in Hong Kong—he was photographed laughing in the back of a prison van. Then there’s the much-discussed ITV documentary on the notorious psychiatric hospital Broadmoor—part II tomorrow night—residence to the likes of Charles Bronson, often referred to as the “most violent prisoner in Britain,” Yorkshire Ripper Peter Sutcliffe, Stockwell Strangler Kenneth Erskine, and 1950s London gangland Kray twin Ronnie Kray.
     What is a psychopath, anyway? (“Psycho Killer, qu'est-ce que c'est?") Robert Hare, who started out as a psychologist at a maximum security prison in Vancouver, has spent a lifetime studying them. They are not, he says, just the murderous, chainsaw-wielding, Hannibal Lecter characters we imagine. There are plenty of non-criminal psychopaths, too, he says—driven, high-functioning, succeed-at-any-cost characters who live among us, at loose in the wild. They can be found in all walks of life. They love power. They love to win. In his 1993 book Without Conscience: The Disturbing World of the Psychopaths Among Us, Hare estimated there were at least 2 million psychopaths in North America, with 100,000 in New York City alone—psychopaths like the bright lights, apparently.
     And the bright lights, seemingly, like them. Society applauds the non-axe-wielding kind of psychopath. They are celebrated. They are idolized. They stalk the corridors of power, finance, culture. They are our sporting heroes (is Lance Armstrong a psychopath? Oscar Pistorius?) The higher you climb in any field, the more of them you will encounter. Poor psychopaths go to jail, as they say, while rich ones go to business school.
     There’s a theory that psychopaths have a profound effect on society: Their pathologically single-minded pursuit of success makes them catalysts of capitalism—the world is run by the greed-is-good Gordon Gecko types who write the rules in their favour and happily trample over anyone that gets in their way. Jon Ronson, author of The Psychopath Test: A Journey Through the Madness Industry, writes: “Capitalism, at its most ruthless, is a physical manifestation of psychopathy. Theirs is the brain anomaly that shapes our world.”
      So what exactly is their brain anomaly? What makes a psychopath? Hare has identified 20 characteristics of psychopaths that are used in his diagnostic test, the Psychopathy Checklist-Revised (PCL-R), such as: Glibness/superficial charm; Grandiose sense of self-worth; Pathological lying; Cunning/manipulative; Lack of remorse or guilt; Shallow emotions; Callousness/lack of empathy; Failure to accept responsibility for own actions; Need for stimulation/proneness to boredom; Impulsivity; Early behaviour problems; Promiscuous sexual behaviour. (Take this quiz if you want to find out your level of psychopathy.) Psychopaths are generally considered to have been born that way. They are the bad seeds of our species. The psychopath’s less-charming counterpart, the “sociopath,” by contrast, is someone whose unpleasant habits supposedly derive more from bad nurture instead of bad nature.

Sticky labels
On balance, does the word “psychopath” really mean anything? It’s a convenient short-hand for a certain kind of cold-blooded ruthlessness; a cheap bit of lingo for slasher movie publicists. It’s a construct that might prove useful in criminal/forensic settings. But in the psychotherapeutic world it has questionable value. Like so many psychological diagnoses, it’s a vague label dressed up as a discrete, objectively-measurable, uniform condition. And it’s of course highly pejorative and demonising, offering no hope of change and restitution. Psychopathy isn’t even a disorder in the industry standard reference book, the Diagnostic and Statistical Manual of Mental Disorders—psychopathy only gets a brief mention in the description of “antisocial personality disorder.”
     ASP is defined as “a pervasive pattern of disregard for and violation of the rights of others” and includes criminal activity among its diagnostic indicators (eg. “Failure to conform to social norms with respect to lawful behaviors"). This raises the question of whether people diagnosed with ASP should be treated as ill, or criminal—are they mad, or simply bad? As Lorna Smith-Benjamin points out, “It would be circular to define a mental disorder in terms of criminal behavior, and then to excuse a person from criminal behavior because he or she has a mental disorder!" Regardless, treatment is very difficult because of what Smith-Benjamin calls “the near-impossibility of getting collaboration from the ASP, who is not at all interested in changing his or her interactive patterns."
     But the term "psychopath" is frequently used far beyond the tight, criminal definitions of ASP. There’s a sense that when you start looking for a condition, you invariably find it—to someone with a hammer, everything looks like a nail, as the saying goes. Ronson writes: “There is a terrible seductive danger in spotting psychopaths everywhere. In fact becoming a psychopath spotter turns you a little psychopathic. You start to dehumanize people, define them by their maddest edges, wedge people into the box marked psychopath. Almost every journalist I meet asks me, Is Donald Trump a psychopath? . . . How easy it is to marginalize (and lock up) anyone who doesn't agree with us.” (This summer I interviewed Trump, the billionaire property tycoon, for the American magazine Golf Digest. The Q&A is in the November issue and available online. You can read it here and make up your own mind about his psychological state.)
     People do like to pigeon-hole other people. And some people like to be pigeon-holed. Some take great comfort in a diagnosis and they wear the label like a badge of honour. It de-mystifies their symptoms, allows them to get the help and support they need and can put them in touch with other sufferers. That’s all fine. The danger is that the individual often gets overlooked—they are no longer a human being but a “schizophrenic,” “alcoholic,” “autistic,” “disabled,” “bipolar,” “psychotic.” Assumptions are made, prescriptions written, and nobody actually bothers to listen to the person’s own, unique subjective experience or thoughts or ideas. People who become patients sometimes miss the person they were pre-diagnosis, and the way they used to be treated, back when they were considered “normal.” When they stop taking their medications, it can be a doomed, subconscious attempt to return to that old self.
     Labels tend to stick. They become self-fulfilling prophecies. They limit who we are and who we can become. There are many, many other, less pathological labels that can adhere to us from a very early age. “Bad at maths” or “sporty” or “the quiet one” or “the difficult one” or the one who was “never any trouble.” One of the goals of therapy can be to take away these old, worn out labels. Sometimes the glue is so strong that they can’t be removed. Sometimes they can be, but it’s painful. And sometimes the client discovers, to their great surprise, that there is nothing at all holding the label to them, and it instantly vanishes into thin air.

• Mental health of children 'at risk in digital age'
From The Guardian: Violent video games, the sharing of indecent images on mobile phones, and other types of digital communications, are harming young people’s mental health, MPs warned on Wednesday, amid evidence of big increases in self-harm and serious psychological problems among the under-18s. Cyberbullying and websites advocating anorexia and self-harm are also posing a danger to the mental wellbeing of children and young people, the Commons health select committee says in its report.

• Men react worse than women to a cancer diagnosis
From The Times: Men react worse than women when they are told that they have cancer, but with counselling they recover faster than women emotionally, according to research by the charity Tenovus.
     Claudia McVie, Chief Executive of Tenovus, said: “It’s understandable that many men try to maintain a stiff upper lip when they’re affected by cancer, but our research shows that talking problems through with a trained professional can make an enormous difference to their quality of life. There’s no shame in accepting a helping hand to make life a bit easier.”

• Mental health services for Aboriginal Australians inadequate, inappropriate
From ABC Australia: Mental health services for Aboriginal Australians are "both inadequate and inappropriate", and immediate changes are needed to address growing rates of suicide, depression and other mental health issues among Indigenous youth, a new report says.

• Troubled kids in Chile
From Fox News Latino: One in five children and teenagers in Chile shows signs of some mental health problem, a statistic that represents a risk to the country's development, according to the authors of a report released Monday.
     “These are extremely critical figures,” public health expert Elisa Ansoleaga told Efe, referring to the findings of “Right to Mental Health: Forgotten Childhood.”

• Just in case you need an app to tell you how you feel 
From IBNLive: A new smartphone app can analyse your speech and use it to gain information about your mental health, scientists say. Researchers from the University of Maryland in US showed that certain vocal features change as patients' feelings of depression worsen.