Had I met my client B today (introduced in part 1), I like to think I would support her far better than I did all those years ago. Diagnosing remains a specialism that I don’t have (one that takes specialist training and needs updating), but my improved understanding of neurodiverse minds more generally would have led me to think of hers working differently from mine.

Autism Spectrum Disorder (ASD), to give autism its medical label (with its uncomfortable ‘disorder’ definition), is, according to the NICE, a lifelong neurodevelopmental condition characterized by persistent difficulties in social interaction and communication, and stereotypic (rigid and repetitive) behaviours, resistance to change or restricted interests. Difficulty with cognitive and behavioural flexibility and emotional regulation difficulties may also be presenting features.’

It is also described by NICE as‘one of the most common childhood-onset neurodevelopmental disorders’ that describes about 1.1% of UK adults and 1-2% of children. This suggests there is an under-diagnosis of adults, as children don’t ‘grow out’ of autism, whatever maverick views may suggest. Studies have always shown a greater proportion of autistic males to females, mostly ranging from 3:1 to 5:1 but this may well be wrong as ‘diagnostic overshadowing’ means autistic women in clinical populations maybe missed – for example, when eating disorders present as a problem, clinicians may not think of autism too.

Also, data for women may be skewed by lags in diagnoses. B, like many other autistic women, had learned to ‘camouflage’ or ‘mask’ her true self – her quirks and interests and behaviours included – so that her diagnosis took longer than it might have done otherwise (and it took an autistic man, B’s boss, to recognise her mind). She camouflaged because she feared stigma, having been called out as ‘weird’ at school in her vulnerable teen years.

You have probably become far more aware of autism in recent years, reflected in an increase in prevalence rates - the first prevalence estimate in the mid 1960s was at 0.04% of adults (compared with 1.1% today). One 2021 study suggests a whopping 787% exponential increase in recorded autism diagnoses between 1998 and 2018 in the UK, with the greatest increase for women and for adults. Suggestions for an uptick in prevalence I have stumbled across include increased pollutants in the atmosphere, food and water systems, because of the older age of parents at conception, or even because autistic people are passing on their genes more than before.

However, we are also diagnosing people more than before though, such as women and girls and people who were not diagnostically ‘caught’ in the past. I’ll come to explain how the diagnosis of autism in psychiatry has expanded over the years, to include those with fewer impairments. Autism diagnoses have also replaced older diagnoses concerning intellectual disabilities (‘diagnostic substitution’), and, arguably, stigma around seeking a diagnoses is waning for some people. But it may even be that we may not be diagnosing enough.

The National Autistic Society published findings of research in early 2024 that suggests that our prevalence data (such as that quoted above from NICE) is outdated, and that in England at least, there are another estimated 750,000 undiagnosed autistic adults (aged 20 and above), alongside the estimated 700,000 already diagnosed in the UK. Autism in our older age is often missed too. The Professor of Cognitive Neuroscience at King’s College London, Dr Francesca Happe´, notes a lack of clinical awareness of autism in old age psychiatry and adult services generally. Given that autistic adults suffer higher rates of mental and physical problems, this is a concern. It seems that after decades of poor understanding (if any at all), we are catching up and have far more to catch up, and I turn to this historical context now.

The history of diagnosis

Autism was originally seen to be a rare childhood problem, and in particular, a male, and white, one too. Leo Kanner, a leading child psychiatrist of his day, is known for putting it on the psychological map when he published a case study of eleven children, ‘Autistic Disturbance of Affective Contact, in 1943. Using a term that had been used by the Swiss psychiatrist Eugen Bleuler to describe behaviours in the condition of childhood ‘schizophrenia’ (a term in early psychiatry used differently from today), Kanner’s ‘early infantile autism’ was presented as a diagnosis of its own, for the first time. The participant Donald Tripplett (‘Case 1’) became better known when he died from cancer in 2023.

Kanner worked at a time when psychiatry took the Freudian view that children’s development was largely influenced by their parenting, and he first emphasised the role of emotionally ‘cold’ parenting. He later adjusted these views to suggest ‘constitutional inadequacies’ could be of cause too – such as inheritance or birth trauma – and some say he became regretful of the upset his earlier views caused. Whatever people may think of Kanner now, and he has his detractors, he spoke against the practice of ‘mercy deaths’ for children with severe intellectual disabilities in the USA, writing in 1942, ‘Psychiatry is, and should be forever, a science dunked in the milk of human kindness.’

Kanner later corresponded with a psychologist, Bernard Rimland, who pushed back against the idea of parenting effects, and blazed a trail for new thinking along biological lines, which set the stage for the later genetic studies in the field. (A 2023 study from the Flatiron Institute - that has yet been peer reviewed, nor used to guide clinical practice - analysed the genetic and phenotypic data from more than 5,000 autistic children to suggest there are four ‘subtypes’ of autism, each associated with specific genetic variants that influence gene expression at different stages of development.)

Despite Rimland’s insights, the psychologist Bruno Bettleheim insisted on emphasising parental causation. His 1967 book, The Empty Fortress: Infantile Autism and the Birth of the Self proposed that autism was caused by a lack of maternal warmth and affection particularly during infancy (popularising the guilt-inducing phrase ‘refrigerator mother’). He even recommended removing children from such parents ( a so-called ‘parentectomy’), and many allegations of his abusive behaviour linger to this day.

This notion of parental ‘fault’ for autism hasn’t entirely evaporated, which is why my friend used to dress her autistic son, when he was young, in a hoodie with ‘I’m not badly behaved I’m autistic’ printed on it. When he felt overwhelmed, he could scream loudly, and hit her, or himself. She became too tired of being repeatedly upset by unsolicited explicit and implicit judgements from others, some of which suggested she should ‘take more control’ of her son.

Waves of concern and guilt amongst parents were also provoked in 1998, when the now disgraced doctor Andrew Wakefield published a paper in the influential Lancet journal that linked the MMR vaccine to autism. Thousands of parents refused the vaccine (notably in London’s Hackney area where I live) and the cases of measles subsequently increased, and by 2008 measles were endemic - ie constantly present - in the UK for the first time in 14 years. A recent flare up in early 2026 reminded us of the lack of herd immunity.

This early work on autism remained the preserve of child psychiatry for decades, and even in the 1980s, autistic adults were largely invisible to clinicians and research, with many sent to institutions or group homes if they had intellectual impairments or other social problems (as Raymond Babbit in Rain Man was for twenty years). They may also have been described as having other conditions instead – such as ‘childhood schizophrenia’, ‘childhood psychosis’ or a phrase that I came across in my own childhood, ‘mental retardation’.

The landscape for autsim changed when ‘Infantile Autism’ became a formal, and separable diagnosis in the 1980 DSM-III. Six diagnostic criteria were required, including its ‘onset before 30 months of age’, ‘gross deficits in language development’, and ‘peculiar interest in or attachments to animate or inanimate objects.’ This was revised comprehensively again seven years later, showing how the clinical field was (very) slowly catching up in its understanding of autistic minds.

This 1987 revision introduced the uncomfortable sounding term ‘Autistic Disorder’ which looked at qualitative impairments in social interaction and communication and restricted, repetitive, and stereotyped patterns of behaviour, interests, and activities. Another leap was made when the DSM-IV was published in 1994, with the creation of four new ‘subtypes’ of AD: Asperger’s Disorder, Pervasive Developmental Disorder NOS (not otherwise specified), Rett’s Disorder, and Childhood Disintegrative Disorder.

Asperger’s became the best known (the ICD called it a ‘syndrome’), following a seminal piece of research by Lorna Wing and Judith Gould known as the ‘Camberwell study’ (published in 1979). Named after Hans Asperger, a Viennese pediatrician working at the same time as Kanner, this came to be understood as a type of ‘high-functioning’ autism (an uneasy term I’ll come onto), associated with ‘awkward nerds’ who are often articulate (far from the stereotype of an impaired communicator). Wing drew on Asperger’s observation that autistic children were markedly different from each other – a sad reflection how, previously, autistic people may have been ‘lumped together’.

Although Asperger’s contribution to thinking has been huge, his legacy, like Bettleheim, is tainted. There is evidence suggesting he collaborated with the Nazi ‘racial hygiene’ laws and that he referred children with disabilities to a facility where they were murdered. Unsurprisingly, some people don’t want to use his name, but others choose to, such as the academic and autism advocate Temple Grandin who says the term is the best one to convey her experience and personal history.

The Camberwell study also proposed that autism should be understood as a spectrum of conditions rather than as a single discrete entity – paving the way for more nuanced thinking. Wing’s analogy was with a spectrum of coloured light: diverse but also continuous. Her studies also identified what became known as ‘Wing’s Triad of Impairments’ or the three core areas of difficulty that characterise autism: social interaction, social communication and social imagination/flexible thinking.

In 2013, the DSM-V shifted the thinking of autism again. It created a single diagnosis of ‘Autism Spectrum Disorder’ (ASD), replacing the subtypes and drawing on Wing’s ‘triad’. This allowed for a broad presentation: with or without intellectual disability, with or without language impairment, and with severity levels ranging from ‘requiring support’ to ‘requiring very substantial support’. The criteria focus on two main areas (both of which need to be present for a diagnosis): ‘social communication and social interaction deficits’ and ‘restricted, repetitive behaviors, interests, or activities.’

This new definition of autism was seen to be far wider than it had been, and the DSM explicitly allowed for late recognition of characteristics, allowing for more adults to present for diagnosis than ever before. It also provoked worries that the wording of the criteria were too vague and too open to subjectivity which would lead to errors in diagnosis, including ‘diagnostic inflation’ (or, ‘over diagnosis) which could stretch the paltry resources available.

In the days when I thought autism largely affected young boys, my ignorance was confirmed by my working with C, a single mother of a non-verbal autistic son. He was ten when I met her and had severe intellectual disabilities, as well as sight and hearing problems. When he felt overwhelmed, he would physically attack C – sometimes resulting in bruises and deep scratches - and when he was happy, he would often physically attack her too.

C had one tiny room in her flat that she could lock, inside which was her ‘sanctuary’ with things unbroken or unspoiled, but she could only get there when her son was at school, as she had to be by his side when he was awake, which sometimes lasted two days at a stretch. Despite her son’s high needs, her immediate family, who were very religious, were convinced that he would ‘grow out’ of his problems if she prayed hard enough.

C was always fighting for more help for her son, and I dread to think how scarce her local services have become all these years following repeated public funding cuts. Her son was at a specialist school, but it often had staff shortages, and she had no respite from her round-the-clock care at weekends and holidays. Once she waited weeks for her son’s hearing aid to be replaced after he tore it to bits and she always worried about the help she had phasing out.

C’s son’s needs were clearly different from my client B and as Dr. Stephen Shore, Autistic Professor of Special Education wisely said, ‘When you have met one autistic person, you have met one autistic person’. There is a growing idea that we should think of ‘autisms’ as opposed to relying on a monolithic ‘autism’, or indeed, that it even lies on a ‘spectrum’ at all. Caroline Hearst, an ‘autism trainer and consultant’ takes issue with the word and prefers the metaphor of a ‘constellation’ which avoids any implication of a progression from ‘low’ to ‘high’ functioning of autism that a spectrum may suggest.

As with nonautistic people, skills and competencies change over a lifetime, and not in a necessarily predicable way, and it is very difficult to predict how an autistic person will develop with any confidence. The idea of a constellation also suggests that autism involves multiple dimensions: social skills, sensory sensitivity, and cognitive ability included, each of which will be expressed idiosyncratically.

Profesor Happé, who I mentioned above, has researched autism for thirty years. She also advocates for a ‘dimensional view’ of autism that moves away from thinking about it as either ‘present’ or ‘absent’. She also suggests that the accepted ‘triad of impairments’ might be more separable than we thought, and that different genetic and cognitive mechanisms might underlie autism-related traits.

Happe´ observes that these traits can exist independently, rather than always clustering together, and that they exist on a continuum in the general population. As she thinks there is no clear demarcation between ‘autistic’ and ‘non-autistic’ (we all have some degree of these traits), it is possible, in her view, to be ‘a bit autistic’, at least at the behavioural level. This is a provocative phrase that could land badly for autistic people who have fought hard for a diagnosis, and the recognition of their suffering. If so, this might be better framed as ‘having autistic traits.’

Steve Silberman’s seminal 2013 book NeuroTribes popularised the important point that autistic traits have been, and are, greatly advantageous to the world, and with that, they should not necessarily be seen as ‘impairments’, but ‘differences’. He details how autistic people have shaped some of our greatest advancements, such Alan Turing’s work cracking the Nazi enigma code, and the inventor Nikola Tesla. The tech brilliance of Silicon Valley is owed to many autistic people who have pioneered digital communication and thriving online communities, as well as spearheading the world of gaming to socially connect.

A more nuanced approach to thinking about autism in this way also pushes hard against its historical treatment as a ‘medical’ issue, or a ‘problem’ that needing fixing, or at its worst, treating people with autism in non-human terms. Such dreadful views rest upon binaries that still linger in our language though, beyond the words ‘disorder/non-disordered’, but to others too, such as: ‘abnormal/normal’, ‘healthy/unwell’, ‘disabled/non disabled’, ‘typical/non-typical’ and ‘deficit/non-deficit’. Autism doesn’t have ‘symptoms’ that are ‘suffered’, nor is there, as Trump’s Health Secretary suggests, ‘an epidemic’ out there.

My own learning was informed by the notion of ‘person-first’ language. In 1999, Jim Sinclair, inspired by the disability rights movement, wrote a powerful, and influential, blog on his website: Why I Dislike ‘Person First’ Language in which he explained why, ‘I am not a “person with autism.” I am an autistic person.’ In three succinct paragraphs he explains how autism cannot be separable from a person but is integral to their identity and how they relate to others and themselves, in the same way that deaf people tend to describe themselves as ‘deaf’ rather than a person ‘with deafness’.

Sinclair also noted how stigma can be perpetuated by ‘person first’ descriptions. ‘It is only when someone has decided that the characteristic being referred to is negative that suddenly people want to separate it from the person.’ However, there may well be some who choose to describe themselves as a person ‘with autism’, just as Temple Grandin chooses to use ‘Asperger’s’, so we need to listen closely, and be curious, as to what words fit best. In the same way that we ask anyone, ‘what would you like to be called?’ when it comes to using their name.

Other descriptors that imply a value to autistic people are also troublesome, such as ‘high-functioning’ (at one end) or ‘low-functioning’ or ‘severe’ or ‘bad’. My friend took her ten-year-old son to the GP with an ear infection. She told the GP that he was autistic, and without looking at him, she asked, ‘How bad is it?’ Unsurprisingly, she and her son felt aggrieved and insulted. Adam Walton, an autism advocate, tackles a similar point on his website, The Art of Autism, ‘mild autism doesn’t mean one experiences autism mildly....It means YOU experience their autism mildly’.

The careful use of language is crucial for researchers too, most of whom are nonautistic (which is a welcome, and long overdue, change from research being wholly steered by nonautistic people). Kristen Bottema-Beutel and her colleagues wrote a paper in 2021, in which they suggest asking a number of questions when talking with an autistic person or community in research studies. They are useful for us all, and I include four:

Would I use this language if I were in conversation with an autistic person? Does my language suggest that autistic people are inherently inferior or suggestive of them being ‘non-human’? Does my language suggest that autism should be cured or fixed or avoided or controlled? Does my language suggest that autism bears no relationship to characteristics of nonautistic people?

These questions also highlight our ‘double empathy problem’, a concept promoted by autistic sociologist Damian Milton in 2012. Historically, communication challenges between autistic and non-autistic people have been seen to be a problem of, and for, autistic people. Milton shifted this thinking so that they become mutual - ie two groups of people not fully understanding the other’s communication style. This also challenges the assumption that non-autistic people have an empathy that autistic people lack, and helps reduce the stigma associated with autistic people’s ‘social misunderstandings’.

This stigma is one core driving force behind the neurodiversity movement, which I come onto in the next post.

I used to work at a low-cost counselling service in East London that took referrals from nearby GP practices. A young woman, B, was referred to me with ‘high anxiety’, since starting her new job as a project manager. She lived with her long-term boyfriend and was close to her parents and brother. Her referral letter also told me that that she had a history of anxious episodes that had begun at secondary school. Nothing else stood out for me to think about.

When I first met B, she was clearly completely overwhelmed. She spoke quickly for our fifty minutes about her many worries: sleeping through her alarm (her new job meant waking earlier than she was used to), her journey to work from a train station she didn’t know well, the noisy and distracting open-plan office, and the new work protocols she had to learn. She was particularly concerned about the prospect of travelling to meetings all over the UK.

I found it very difficult to ask my usual questions of an initial meeting - such as those about her current relationships and general health, how her symptoms played out for her, if anxiety ran in the family and what her experiences of growing up had been like. I wanted to have some ideas of how her anxious mind may have been forged. However, B’s preoccupations were clearly flooding her, and I had no choice but to leave my investigations until later.

Over the following weeks of our meetings, I didn’t learn much more about B’s hinterland, but I did learn how exhausting B’s ruminative mind, and emotional troughs, were for her. When not at work, she was often lying on her sofa, and her boyfriend would have to coax her out for a walk, or to get her to help with cleaning up their flat. I suggested she go back to the GP for blood tests, to check on her iron levels, but they came back fine.

I was struck by the level of detail B narrated her worries to me. She recounted her to-do lists and grappled out loud with train times. I assumed this sprung from a hypervigilance that often goes with anxiety, and I focused on teaching her my best anxiety-busting skills. I kept hoping to learn more about her past experiences to understand why it was that she might be so worry-prone.

Knowing that she had struggled with anxiety in secondary school gave me one clue. I wondered if she had experienced bullying, or weighty pressure to succeed from her parents or teachers – both of which can encourage an anxiety around not being ‘good enough’. But I found out that B was close to her parents, with no history of conflicts or problems at home. She didn’t think anyone in her family had suffered from anxiety or any other mental health conditions.

It was when I learned that B had been bullied however, that I thought I had a potential reason for the seeds of her highly anxious self. B had spent most of secondary school avoiding her peers, some of whom picked on her for being ‘nerdy’ and ‘weird’. She had one good friend, but she often spent her breaks and lunch hours in the library, or in an empty classroom. Things improved in sixth form when she left and went to a different college, which gave her more freedom, and a more diverse cohort of peers.

I wondered if B’s dreadful and ongoing experience of exclusion had corroded her sense of self so much that she continued to fear making any mistakes, and that this may have fuelled an ongoing fear of making mistakes. However, we didn’t talk about this potential link as B’s sessions filled up with her ruminations, and distress and I concentrated on fire-fighting the worst of her symptoms each week. I couldn’t understand why she was so stuck and seemingly unwilling to take on my ideas about her past, and I used supervision to vent my frustrations at her unwillingness to go with my flow.

One week, she arrived in floods of tears, and the most anxious I had seen her. A colleague had been rushed to hospital with a burst appendix which meant she would have to step in and deliver his presentation to clients, in a place she hadn’t been to. We spent the session talking about how she would plan her journey, while I tried to encourage her to spot her ‘catastrophic thinking’ and to remember her self-soothing skills.

We stopped meeting quite soon after this, when B was offered workplace counselling for free. I knew I had failed her miserably, not least because her anxiety was still a problem for her, and our ending was abrupt. I desperately hoped she would find better support than I – or indeed my supervisor at the time - had given her.

About ten years later, B found emailed me. She wrote that she had thought of me often since moving into a flat near where the (now closed) counselling service had been. She wanted to tell me that she had been diagnosed with autism after we had said our goodbyes, as her boss had suggested she pursue a diagnosis. He had been diagnosed a few years earlier, and had recognised some of her struggles.

B wrote that her diagnosis had been very helpful for her. She could now understand why she had felt different from others all her life, and that the fallout of trying to fit in – ‘camouflaging’ as she put it – had contributed to her anxiety, and extreme exhaustion. She had become firm friends with her boss and through him, found communities online who had brought also brought her new friendships and support.

I was very grateful for B’s email, as it brought home to me how my way of working with her had been so wildly misattuned and inappropriate: her struggles were less about a ‘root cause’ in early experiences, as I had been taught to tilt toward, and more to do with B living in a world of minds that worked differently to hers.

When I first met B – 15 years ago now - my understanding of autism had been woefully limited. Autism wasn’t on the curriculum of my training and ‘neurodiversity’ was a term not as mainstream as it is now. My books from those days that deal with ‘common presenting issues in counselling and psychotherapy’ don’t touch on autism or neurodiversity either. Neither are a reason in themselves to end up in therapy of course, but being autistic in a non-autistic world, can bring mental health difficulties that sends people for support – such as B’s anxiety did.

My understanding back then was also tangled up with damaging myths that can still persist – such as it is typified by men with extraordinary abilities (like Raymond Babbit in Rain Man) or that autistic people wouldn’t seek the relationship with a therapist, or have a long-term boyfriend like B did. Also, in between the narration of her worries, B could make very funny quips and insightful self-reflections – again, things I (then) wrongly assumed autistic people couldn’t do.

We have come some way since my time of ignorance, inside and outside of consulting rooms, helped by autistic people – including celebrities and social media influencers - speaking up and showing up in TV shows and books. Research into the experience of being autistic has increased rapidly, and begun to include autistic researchers. Workplaces, schools and universities screen for, and support, differences more than ever before (with a dire lack of resourcing to deal with this though). However, we still need a greater understanding as to how our minds and bodies process the world differently from each other.

In following posts, I look at the beleaguered history of autism in psychiatry, and how its understanding has shifted from a very limited view to a far more expansive one that looks like it might expand even more. I will then visit the expanding landscape of neurodiversity, which is a description and a social movement. As is the case with all collectives of humans over time, differences of opinion and views have emerged within it. Paradoxically, a movement aiming to level us all may have ended up creating bumps.

I will then look at one ubiquitous seeming neurodiverse ‘condition’ or diagnosis, of Attention-Deficit/ Hyperactivity Disorder (ADHD). People with ADHD can suffer dreadfully as I’ll explore, and end up in therapy as a result, but I’ll also talk about the sceptics who cast their eyes up to the sky on hearing the term mentioned. To quote one unreconstructed friend, ‘ADHD is made-up for people who are overwhelmed with modern life and want an excuse to be late or to forget things.’ Some psychologists have gone on the record to (sort of) agree with him, while the waiting lists for assessments for those who struggle stretch further.

While PTSD as a diagnosis isn’t easy to pin down, it also does not capture the colloquial and broader use of the word ‘trauma’ that we have commonly come to use. Some see the horrors of 9/11 and growth in social media as sparking our increased use of the language of trauma, along with the very many (seemingly growing) reasons to feel unsafe, deeply sad and angry, confused and anxious – and traumatised. However, others say our culture has been interested in trauma for decades now.

One example of our interest in trauma lies in how popular literature has become more interested in thinking about how the past influences our present. I remember reading Dave Peltzer’s harrowing memoir of abuse at the hands of his mother - A Child Called It - in 1995 and like many others, being struck by its candour. Child abuse was relatively taboo back then, but some say his book shifted things and launched a new genre of hard-hitting memoirs that thrives.

You may well have read fiction with characters shaped by past traumas that drive the plot - perhaps experiencing flashbacks or responding to revelations or behaving in ways that are driven by psychological damage. Just two examples are Gabrielle Zevin’s 2022 Tomorrow, and Tomorrow, and Tomorrow, and the staggering, relentless, exhausting past and ongoing traumas of poor Jude in the 2015 A Little Life (I can’t quite forgive Hanya Hanagahira for putting him through so much).

The US literary critic Parul Sehgal wrote an influential article in The New Yorker in 2021, The Case Against the Trauma Plot where she pushed back on ‘the master plot of our time’. She linked this to a number of cultural shifts of the 21^st century, especially after 9/11, which also saw a boom in memoirs and confessional writing. Sehgal wrote how the ‘trauma plot’ came to replace other literary devices, such as one of marriage, and worried how it risks reducing characters to their wounding with predictable, or even mechanical, storytelling. Rather than making trauma the centrifugal force of a story, she called for a more nuanced approach to characters’ psychological complexities.

Alongside memoirs, and ‘trauma plotted’ fiction, two practitioner-authors have also helped to shift our cultural understanding of trauma: Bessel Van der Kolk (mentioned above), and the prolific Canadian physician Gabor Maté. Van der Kolk’s The Body Keeps The Score catapulted to the top of the New York Times bestseller list in early 2021 seven years after publication, as the pandemic brought misery and loss to millions. By April 2024, it had sold three million copies and had been translated into 43 languages. I have lent my copy out so many times, it has become the most dog-eared book I own (one client memorably bought ten copies to distribute to colleagues and friends).

Echoing the ACEs studies, Van der Kolk writes about the impact of childhood trauma on later development, mourning how this took a pitifully long time for clinicians to realise. Like his colleague Judith Herman, he also wrote about the unrecognised notion of collective as well as individual trauma too. But, as his title suggests, he came to be known for explaining the impact trauma has on our brain and body, and emphasising treatments that use the body to help us heal – including EMDR which I had stumbled across all those years ago. His scientific rigour has not escaped criticism however, especially in the context of his research into repressed memories.

Gabor Maté has also had a huge influence in un-restraining the notion of trauma internationally, with a competing marketable brand in the making. He stakes trauma at the centre of his approach to understanding addiction, chronic stress, and childhood development. One of his five books, The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture has sold over a million copies, and his talks sell out fast. Maté believes that trauma is much more common than we generally recognise and seems to suggest that most of us carry some level of unresolved trauma from our past: either our personal story, or from historical pain passed down the generations (‘transgenerational trauma’).

If you digested the Van der Kolk/Maté literature, you might be hard pressed to define trauma succinctly. Online, you will find many definitions too. For example, the UK Trauma Council has one that chimes with the diagnostic ideas of PTSD while, MIND, the UK’s leading charity for the support of mental health is a little more expansive, stating trauma is ‘when we experience very stressful, frightening or distressing events that are difficult to cope with or out of our control. It could be one incident, or an ongoing event that happens over a long period of time.’ It goes on to say, ‘There’s no rule about what experiences can be traumatic. It’s more about how you react to them. What’s traumatic is personal.’ The charity defines ‘trauma’ as a ‘mental health condition’, along with a separate condition of PTSD. The NHS website only describes PTSD, without ‘trauma’ as a separate condition.

Following MIND’s suggestion, trauma is likely to occur in many more places than the site of bombings. Maybe some of us were traumatised by Liz Truss too (rather than hitting the PTSD diagnostic criteria). However it is defined, it is certainly the reason many people come to therapy.

A recent search on the database of the British Association of Counsellors and Psychotherapists – the largest professional organisation for counsellors and psychotherapists in the UK (with over 50,000 members), shows that 22, 491 registered members offer their services for ‘trauma’, which compares to 17,087 for ‘addiction’ and 13,003 for ‘grief’. My guess is that each one of my colleagues would describe trauma a little differently from the next – as I imagine you might from your friend.

Concept Creep

The social psychologist Cliodhna O’Connor and colleagues, at Queen’s University, Belfast, wanted to gauge how non-clinicians think of trauma (in the UK, which might well differ from other countries). In 2023, they sent an online survey to 214 participants to rate the traumatic nature of 80 listed adversities. Forty of these represented ‘prototypical’ precursors of trauma (such as ‘murder of a loved one’, ‘physical assault’ and ‘sexual abuse’), while the rest referred to events that aren’t usually considered to be associated with trauma (such as ‘exposure to information about climate change’, ‘feeling inadequate in comparison with others on social media’, ‘giving birth without complications’ and – as my client G experienced - ‘rejection by a romantic interest’).

The survey found that expert and lay conceptions of ‘typical’ trauma were more or less aligned, but it also found that many ‘non prototypical’ ones were anticipated to cause a relatively high degree of trauma: 76% of the 80 listed adversities were ranked above the midpoint of a scale from ‘no trauma’ to ‘extreme trauma’. The authors conclude (while acknowledging a need for further research into the effects of age, politics and ethnic backgrounds on people’s views), ‘This suggests a readiness amongst the lay public to anticipate trauma responses to a wide range of adversities.’ They also support the view of Nick Haslam, a professor of psychology at the University of Melbourne, that the concept of trauma seems to be ‘creeping’ beyond its original meaning.

Haslam notes, in his 2016 paper, how the definition of trauma has gradually expanded to encompass new kinds of phenomena (‘horizontal creep’) and less severe phenomena (‘vertical creep’). He concludes, sounding weary to me, that now, ‘A traumatic event need not be a discrete event, need not involve serious threats to life or limb, need not be outside normal experience, need not be likely to create marked distress in almost everyone, and need not even produce marked distress in the traumatised person, who must merely experience it as “harmful.”’

More recently, in 2023, a student of Haslam, Naomi Baes, sought to track this ‘vertical creep’ as defined in published psychology articles. She assessed an English-language body of 825,628 ‘abstracts’ (summaries of research papers) from 1970 to 2017 and concluded that the term ‘trauma’ has come to be used in less severe contexts, and that this trend may be linked to it being used more and more by more and more of us.

Some, like Haslam, worry that this ‘creep’ runs the risk of treating ordinary or expected life challenges as events that need special attention, when they may not. In turn, this could lead to over-diagnosis of PTSD or related mental health problems (such as anxiety or depression that are closely linked), and even the creation of a sense of vulnerability or victimhood. At worst, if ‘trauma’ loses a distinct meaning of suffering, it might make it harder to identify and prioritise the needs of people who need our – precious because they are so limited - resources. Perhaps we need to use more words than just ‘trauma’ too.

As against the potentially negative effects of the expansion of ‘trauma’ there are positives. It has also allowed for a greater acknowledgment of emotional and psychological suffering that have been previously dismissed or ignored – just as the development of the PTSD and c-PTSD diagnoses has done. Black Lives Matter, #metoo, and neurodiversity and gender equality movements have rightly emphasised the egregious mental health toll of repeated social rejections and microaggressions, and transgenerational traumas. The acceptance of ‘cyber trauma’ has also benefited from this broader conceptualisation of trauma too.

But whatever we deem as a ‘trauma’, we need to take care in assuming that it we become unwell automatically - we may be tougher than our cultural fondness for trauma suggests.

Resilience

We do have an innate ability to bounce back from adversity. I mentioned above that the happening of a ‘trauma’ and the experience of PTSD are not synonymous – not everyone who was involved in the Manchester bombing suffered like my client Ben (introduced in part one of these posts). The World Health Organisation quotes an estimate that around 70% of people globally will experience a potentially traumatic event during their lifetime, yet only a minority (5.6%) will go on to develop PTSD. They may well experience some of the symptoms of PTSD - like persistent negative mood or problems with concentration and sleep - without meeting the criteria for a diagnosis - there’s a good reason why we wait a month after an incident to diagnose.

George A. Bonanno, a US psychologist and director of Columbia’s Loss, Trauma, and Emotion Lab is a loud proponent of the view that we are tougher than we think. He has pioneered studies of ‘resilience’ which show that most people are able to cope effectively and recover under their own steam without formal intervention. In other words, resilience is our ‘default response’. (I digress here to note that an emerging thread of research suggests that such ‘resilience’ in the face of trauma may be calibrated differently for autistic people).

Bonanno coined the phrase ‘coping ugly’ which refers to the many, and varied, ways in which we can cope with extremely stressful events that may go under the radar – some of which may even seem odd, or counter-intuitive. I know I’m not alone in using morbid humour in extreme times, to the discomfort, and confusion, of others who have assumed I’m ‘in denial’, or even uncaring. However, I know that my ‘coping ugly’ helps me let off the steam of fear, and shock, and that it helps me to adapt to a new difficult reality.

Bonanno also makes the case that various strategies that may look like a trauma response, such as temporary denial or suppression and selective remembering, can be very helpful in the short-term and are good examples of how well we can adapt and bounce-back and resilience. The titles of his books speak volumes: The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After a Loss, and The End of Trauma: How the New Science of Resilience is Changing How We Think About PTSD.

When I first started working, my frame of reference for what defined a traumatic event was made up of ones that Ben (in my previous post) and my colleague had endured – these might be called ‘big T’ trauma events, a term used by the US psychologist Francine Shapiro who founded EMDR therapy. These are events that would be very difficult to cope with for almost everyone – such as war or acts of terrorism, natural disasters, car accidents, and rape (and resembled those described in the diagnostic manuals). They are, also, highly unlikely to be described as just ‘stressful’.

Shapiro also identified ‘small t’ traumas that refer to events that are more broadly defined, and generally understood to be less objectively, or obviously, dramatic or intense than the ‘big Ts’. However, they can still cause significant, and lasting, symptoms of distress - such as bullying or being exposed to warring parents, or the disruption of moving around a lot as a child. Many of my clients ask my help with dealing with the legacy of such experiences, with an increasing confusion as to how to use the ‘t’ word with me: some use it freely and generously, some use it very cautiously (for fear of exaggerating their pain), and some – like Ben - won’t use it at all. One question that puzzles many is at what point does a ‘small T’ trauma become a ‘tiny T’ trauma or a ‘microscopic T’ trauma, or just a ‘no T’ trauma at all (and a stressful or distressing event instead)?

Trauma has become increasingly defined through the eye of the beholder and as a therapist, this matters to me because I want to ensure I’m thinking about my client’s best interests when it comes to their support, and treatment. This might mean referring someone on to more specialist treatment, as I did with Ben, but it might also mean guiding a client toward their innate, and intact, resilience – as I did with G.

The history of ‘trauma’ in psychology

It’s worth winding back to the beginning of the idea of trauma to understand its innately amorphous nature. The word itself derives from the ancient Greek word troma, which is related to the terms titorskein (to wound) and tetrainein (to pierce). It was originally associated with acute bodily injury, and the physical pain this caused. This isn’t to say the ancient Greeks didn’t suffer psychological trauma, but it would have been articulated differently. With a modern lens, some have referred to Homer’s epic poems the Iliad and Odyssey as referencing ‘trauma themes’ such as grief, isolation, alienation and survivor’s guilt, as well as that of ‘post-traumatic growth’ (more on traumatic themes in Greek literature later, when I look at ‘trigger warnings’).

This visceral link to trauma remains in medicine, and a ‘traumatologist’ is concerned with the serious effects of events on the human body, such as a car crash, or fall from a great height. ‘Traumatology’ more generally involves the expertise of orthopaedics and specialist surgeons, and these days, treatment includes (if all goes well with the hospital resources), the emotional impact of what the surgeons fix too.

‘Trauma’ became a subject of scientific enquiry in the mid 19^th century, when both research and the professions of psychiatry and psychology began to emerge more clearly. British medics wrote up their cases of a new presentation of ‘railway spine’, which were an unhappy outcome of accidents on the new railways. Patients sought help with their physical problems such as convulsions or pain but had no obvious injury or wound to show. The leading, and influential, German neurologist Hermann Oppenheim thought these cases related to an inflammation of the spinal cord, and without scans, this was a hard view to challenge.

Some sceptics challenged the truth of these patients’ stories, suggesting they were fabricated for the potential of financial compensation (echoes of which linger in today’s suggestions that some people fabricate psychological symptoms for welfare benefits, paid time off work, or extra time for exams). Others also challenged the idea that the condition was related to a physical problem at all, most famously, the French neurologist, working in the late 19^th century, Jean-Michel Charcot who is distinguished for having significantly shifted the concept of trauma from its visceral roots.

Charcot studied and treated female patients with symptoms of ‘hysteria’ at the Paris asylum, the Salpêtrière (originally a 16^th century gun factory that he restored). These poor women had similar symptoms to those in Britain with ‘railway spine’, such as ‘convulsions, contortions, fainting and impairment of consciousness’. He challenged the then contemporary idea that they suffered from their ‘wandering wombs’ (an idea persisting from ancient Greek medicine), not least because of many of the British patients were men.

Charcot was the first to suggest that non-physical reasons could be at issue here, and he hypothesised that one neurological condition could account for these two sets of confounding cases. He became interested in hypnotherapy, and he noticed that his patients’ symptoms could often be reproduced, and relieved, when he used it with them. This helped him make an important, and new, psychological connection to symptoms, coining the (French equivalent) terms of ‘traumatic neuroses’ and ‘traumatic hysteria’ into his more general work with female ‘hysteria’.

Charcot’s student Pierre Janet developed these ideas further and has been credited with discovering a key concept of trauma work today: dissociation, where the mind splits off an event that is so overwhelming that it can’t settle into consciousness. He noted how harrowing memories of traumas could be so difficult to talk about that they were re-enacted in the form of intense emotions, aggressive behaviours, and bodily pains and states.

Then we come to Freud, the father of many of our well-known psychological ideas. He had also studied with Charcot at Salpêtrière, and he became convinced that we have a few psychic mechanisms that help us to deal with trauma, such as repressing memories of the event (these could be re-activated later on). In 1896 he published The Aetiology of Hysteria which outlined his theory of why his female patients were traumatised: childhood ‘seduction’, or what we would now preferably call ‘sexual abuse’. This idea didn’t go down well with his colleagues however, and Freud later claimed to doubt the universality of such abuse. Some claim he backtracked to save professional face, and that his denial of the dreadful (and believable) levels of abuse was regrettable. I’ll come onto how history repeats itself when the psychologist Bessel Van Der Kolk’s views of the prevalence of childhood sexual abuse were shunned in the 1970s.

Freud’s ideas about the roots of trauma then shifted toward his well-known ‘Oedipus Complex’ instead, which suggests we have unconscious sexual desires for our opposite-sex parent, and rivalry with the same-sex parent. He continued to develop his understanding of the role of these complex internal conflicts, and they competed with the role of other traumas, but all of this is to show how the concept of trauma has never existed in a vacuum, and is always located in its culture, time and context. After Freud, it re-calibrated again in response to the horrors of war - the First World War, the Second World War, and the Vietnam War – as well as the political energies of second wave of feminism.

During the First World War, the brutality of trench warfare, artillery shelling and machine guns introduced unprecedented horrors to civilians-turned-soldiers. Many returned suffering ‘shell shock’, with symptoms likened to ‘hysteria’, as well as exhaustion, memory loss and ‘agitation’. Some medical professionals held onto old beliefs that these symptoms were due to physical causes alone, such as head injuries or even poisoning from shells, and some even accused soldiers of cowardice or malingering.

However, others influenced by Freudian thinking linked shell shock symptoms to psychology, and a condition of ‘combat neuroses’ was identified that could be treated with a form of psychoanalysis, as experienced by the poet Wilfred Owen at Craiglockhart War Hospital. Much later, in 1941, the psychoanalyst Abram Kardiner wrote about his experiences of treating shell-shocked soldiers in The Traumatic Neuroses of War, and his thinking was foundational for later clinical criteria for PTSD.

Some lessons were learned after the so-called ‘Great War’, and the military prepared soldiers for the battles of the Second World War with more effort to both train and screen soldiers. However, many returned with psychiatric problems nonetheless (known by then as ‘combat stress reaction’ or ‘battle fatigue’), and those sent to Northfield Hospital in Birmingham met psychiatrists developing the idea of using groups to heal. This was based on the idea that just as in war, a soldier was part of a unit, so it was important he became part of a small community in treatment too. These so-called ‘Northfield experiments’ played a crucial role in the development of group therapy, and the later field of social psychiatry.

Trauma as PTSD

After the Second World War, many ‘battle fatigued’ soldiers returning to the USA needed psychiatric care, and in response to a growing problem, the US military devised a classification of mental disorders, that ushered in an important acknowledgement of the psychological toll of warfare. As with most of psychiatric thinking at the time, the so-called ‘Medical 203’ (or, to give it its full name, ‘Technical Medical Bulletin number 203 of the United States Army 1945’) was heavily influenced by Freudian thinking. Four years later, the World Health Organisation published its manual on the global causes and consequences of disease and mortality – the ICD-6, and it included descriptions of mental disorders for the first time.

Influenced by these two publications, the APA published the first edition of the DSM in 1952, which included a diagnosis of ‘Gross Stress Reaction’. By 1968, a new condition of ‘Transient Situational Disturbance’ took over. Both ‘medicalised’ new conditions emphasised the temporary nature of a stressful event and its distress, the diagnosis of TSD included three limited examples of ‘disturbance’: unwanted pregnancy with suicidal thoughts, fear linked to military combat, and a form of psychosis amongst prisoners who face a death sentence.

It took the horrors of the Vietnam War to re-shape these ideas though, and to lay the foundations for how trauma came to be understood by the time I started clinical work. When thousands of physically and psychologically wounded veterans returned to the USA, they were met with a resistance to what had become a very unpopular war. Many felt isolated and ignored, which made their suffering so much worse. The advocate group Vietnam Veterans Against the War joined forces with other activists, researchers and clinicians (including Bessel Van Der Kolk who I come onto) to lobby the APA for better recognition and treatment of these poor men and feminist activists, and concentration camp survivors also campaigned with similar wishes.

The APA listened, and in 1980, the third iteration of the DSM created a new diagnosis of PTSD (which was included in the ICD-9 twelve years later). This mapped the idea of a traumatic cause to suffering, rather than previous ideas such as a moral failing, or psychological weakness of a patient. This cause was first seen as a catastrophic stressor that was outside the range of usual human experience and would be considered distressing to almost anyone. The authors had in mind events such as war, torture, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters and factory explosions. The normal vicissitudes of life were not in mind, such as divorce, serious illness, bankruptcies and deaths.

The formulation for PTSD continued to evolve in later DSM editions (1987, 1994 and 2000) and in 2013, it shifted significantly from its place amongst ‘anxiety’ into a new category of ‘Trauma and Stressor Related Disorders’. PTSD has now become a flagship diagnosis, and probably the one we mostly hear about – either in its diagnostic sense, or more casually as a nod toward a distressing or unpleasant event – Liz Truss’s budget included. So, PTSD has a specific diagnosis, while the term ‘trauma’ refers to this, and much more too.

You may well know about PTSD because we have been recognising it more clinically and talking about it more. PTSD UK, a charity dedicated to raising awareness, estimates that 4 in 100 people in the UK have PTSD at any given time (excluding the allied diagnosis of C-PTSD that I’ll come onto). This translates into well over 2.5 million people, and the data suggests the prevalence is rising, with women more likely to screen positively.

For a diagnosis under the DSM (which is used in the USA, and in research and differs slightly from the UK approach), PTSD must follow being exposed to actual or threatened death, serious injury, or sexual violence. It’s interesting to note that other DSM diagnoses - like Generalised Anxiety Disorder - doesn’t require an exposure to an anxiety-inducing event to exist. So, if you don’t develop PTSD from exposure to an undeniably traumatic event– and most people don’t – this raises an interesting question as to if you suffered a ‘trauma’ after all.

The notion of ‘exposure’ has become increasingly complex, and not entirely clear to all. It includes directly experiencing a traumatic event; witnessing, in person, the event as it occurred to others; learning that the traumatic event occurred to a close family member or friend (and the events must have been violent or accidental), or repeated exposure to the details of it (as is the case with emergency workers). Following the strict logic of the drafting, this means that you can’t get PTSD if you repeatedly learn about dreadful events happening to people from the news cycle or social media feeds, unless it is an integral part of your job. Also, would a Facebook friend or Instagram follower suffice as a friend?

After exposure, you must also experience symptoms from each of four ‘clusters’: intrusion (e.g., flashbacks, nightmares), avoidance (of memories, thoughts, external reminders), negative alterations in cognition and mood (e.g., guilt, detachment) and hyperarousal (e.g., irritability, hypervigilance). At least one intrusion, one avoidance, two cognition/mood, and two arousal symptoms must last for over a month (my italics).

Soon after the expanded 2013 definition of PTSD was released, the researchers Galatzer-Levy and Bryant grappled with its complexity – in a not dissimilar way to how Fried responded to the diagnosis of Major Depressive Disorder, I wrote about in an earlier chapter. Using statistical analysis way beyond my ken, they concluded there was an impressive 636,120 ways to be diagnosed with PTSD (compared to a previous 79,794 ways before the 2013 update). This doesn’t mean there are 636,120 distinct types of PTSD but goes to show how PTSD presentations can vary so much. This paper seemed to prompt discussions about the need for a more nuanced approach, and the 2019 ICD-11 simplified things a bit, and introduced a separate, and important diagnosis of ‘Complex PTSD’ or ‘c-PTSD’ which refers to multiple, long-lasting, repeated or continuous traumas.

Complex PTSD is not in the DSM, despite many calls for it to be so, thirty years ago. The American psychiatrist and trauma expert Judith Herman, and her colleague Bessel Van Der Kolk were two loud advocates. Herman’s 1992 book Trauma and Recovery was groundbreaking at the time (and essential reading in my training), for challenging her contemporaries’ understanding of trauma, and for her feminist and political lens. She called for a recognition of traumas that had previously been ignored or normalised – such as intimate partner abuse, and the neglect of children.

Herman’s work was endorsed by the seminal US 1998 Adverse Childhood Experiences Study (or ‘ACEs Study’) that you might have heard of. This gathered data from 17,000 people to highlight developmental traumas for the first time: ‘The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described.’ Seven categories of ACEs were investigated: psychological, physical, or sexual abuse; violence against mother; living with household members who were substance abusers, mentally ill or suicidal; living in a household with an imprisoned member; and parental separation or divorce. It has since been shown that people with a high number of ACEs are more likely to suffer chronic diseases, mental illness, substance misuse, and reduced life potential in adulthood (and that the more ACEs someone has, the greater the risk for these outcomes).

Later research formulated the ‘expanded ACEs’ which goes beyond family adversities to include community-level stressors such as bullying, community violence, racism, living in foster care and neighbourhood safety. This expansion mirrors the development of our ‘trauma-informed’ thinking more generally: we increasingly see the ‘here and now’ through the lens of the adverse ‘there and then’.

More in my next post….

In the second year of my training, I worked on a placement at a student counselling service at a university in London. This was my first experience of being a therapist, rather than pretending to be one with my fellow trainees. One of the first students I was allocated to see, Ben, was ‘mature’ at 28, and not much younger than I was then. He wanted my support with adjusting to a new city, and the challenges of studying again after a decade’s break. Twenty years on, I remember Ben well. He had lived through a significant event in British history, and one that no-one would challenge as a traumatic one to have been through.

Before I first met, I knew nothing of his trauma. I had read his assessment, made by a senior practitioner and its scant information told me that he had moved to London from Manchester as he wanted a fresh start, and a new career in law. He reported having a close family, many friends and no history of depression or anxiety. Nothing unusual or outstanding stood out from the other answers to the checklist of questions concerning life experiences and health.

The relevance of the assessment information paled on meeting Ben for the first time. When I asked him if he wanted to add anything else to what he had disclosed, he shut his eyes and put his head into his cupped hands. He then told me that he had not wanted to ‘dump and run’ with the other counsellor and that he wanted to have time to talk about something that had happened in the past, that was haunting him again. He hadn’t really talked about it before.

Ben then told me about his experience of being seriously injured in the 1996 Manchester bombing by the Provisional IRA, eight years previously. This is thought to be the biggest bomb detonated in Great Britain since the Second World War. Amazingly, no-one died, but over two hundred people were injured by flying debris and glass, and the impact of being thrown – including Ben. Shards of glass lacerated one side of his body, and he was knocked unconscious with a head injury. He woke up hours later, in hospital, and in great pain, with his family around him, obviously devastated by what had happened to him, and their city centre.

Ben bore physical scars that he, understandably, hated and I would never see. However, he was concerned that his mental scars were opening again as he was re-experiencing things he thought he had successfully ‘put to bed’. Since the September 11 terrorist bombings of the World Trade Center in New York, he had begun to have nightmares that threw him into such a state of wakefulness that he couldn’t return to sleep. Unbidden memories of his time in hospital, the shock of pain of his body’s wounds, and seeing the images of the wreckage on the television, all returned too. ‘It’s like it’s happening all over again.’ He was exhausted, anxious and unable to concentrate or be his usual gregarious self.

I had learned enough in my training at this stage to know that being the victim of a terrorist bomb would be confidently described as traumatic, and that he was also a likely candidate to experience Post Traumatic Stress Disorder (PTSD), as defined by diagnostic criteria used by medical professionals back then. PTSD is set apart from other mental health diagnoses as it has a specific cause to it (unlike, for example, Major Depressive Disorder) - ie a trauma - and victims of terrorist attacks were in the minds of those who drafted its criteria.

I supported Ben as best I could over a few weeks of talking, using my best efforts to help him handle his symptoms, but knowing I wasn’t helping enough, and with the help of my supervisor, I referred him to a colleague, who was practicing a ‘new’ (and ‘wacky’ to some of my colleagues) type of therapy tailored specifically for traumas like the one Ben had experienced known as Eye Movement Desensitisation and Reprocessing (EMDR).

My colleague had discovered EMDR in the wake of his own recovery from the horror of being held at gunpoint, while travelling in Colombia. Like Ben, he had found himself ‘stuck’ back in the hours of his terror so vividly, and so often, that he had to stop work. A psychiatrist tried EMDR with him, and it helped so much, he trained in it himself and re-pivoted his life to help others. EMDR is now well-evidenced, and mainstream in trauma treatment.

When I met Ben, the terms ‘trauma’ and ‘PTSD’ as I understood them involved experiences like his: exceptional and objectively grave ones. These days, the definition of ‘trauma’ in therapy has diffused and it describes many more experiences of distress. The term now means so much more to many more people, including psychiatrists, psychotherapists, counsellors, trauma-informed practitioners, neuroscientists, teachers, social workers, yoga practitioners – and the very many of us who don’t think about it directly for their work.

This expansion of the meaning of trauma has been a very good thing, in many ways. It means previously ignored adversities such as trans-generational, historic and systemic traumas are now considered seriously, which brings the hope that we can acknowledge, and support the distress of so many more people than before. Many trauma therapists had to fight woefully long and hard for the clinical recognition of trauma amongst adults with abusive childhoods.

However, I will (in separate posts) go on to note how some say the meaning of the word has expanded too much, and too fast, so that it risks becoming meaningless. According to one podcaster I heard, ‘if you are hurting, you have trauma’ which may be an example of this. Another is a Times newspaper headline on 1 November 2024, reporting the Labour minister Darren Jones’ assessment that ‘Britain has PTSD from Liz Truss’s budget’. While he clearly wasn’t being literal, his comment does show how this dreadful condition has come to also mean something less dreadful in our popular minds, and far from that suffered by the very many veterans deployed to Afghanistan or Iraq by Jones’ previous governments.

In writing about our understanding of the term ‘trauma’ today, I will offer a short historical detour into its origins as a psychological concept. This sets the scene for its rolling expansion but also highlights how the notion has always been informed by cultural, political and social influences. While the Vietnam War had a profound effect on the diagnosis of PTSD for example, our catastrophic world events and their discourse in the media, online and IRL have been, and are also influencing our ideas of trauma more generally.

I then look at another, newer iteration of a trauma: a ‘trigger’ and its associated ‘trigger warning’ which aims to protect us from the risk of becoming traumatised by a trigger. Trigger warnings have been, and can be, at the cost of irritating those concerned with the parameters of free speech, and breadth of learning, and worry some that our emotional resilience to the inevitable slings and arrows of life will become weakened by their persistent use. At least one researcher sees no benefit in them at all.

I also note a paradox of sorts. While the notion of trauma seems to have expanded over the years, to include adversities that may have previously deemed ‘stressful’ or uncomfortable, there are still remain others that our culture decides to keep away from the realm of trauma, and can feel to be relegated, misunderstood or ignored.

One of the highlights of my professional career was being interviewed on BBC Radio 4’s Woman’s Hour. I slept terribly the night before, had no appetite for breakfast, and ended up going for an unplanned run at 6am to calm my jangly nerves. Following the advice of a ballet teacher (not mine), I lined up my butterflies in size order. This could be described as a very mild and appropriate level of worry or stress – and in this case, was ultimately a useful response. The adrenaline coursing through my veins sharpened my senses and helped me to think quickly and talk coherently without becoming a dribbling wreck.

In many other situations, my useful anxiety response has pulled me away from real dangers rather than (one of) the imagined ones of Radio 4 listeners thinking I am the most boring human on the planet. Most days I leap out of the way of oncoming toddlers on scooters, or cars ignoring me as I attempt a zebra-crossing. Anxiety is helpful when it’s helpful, but not when it tips into a consuming state of being that robs us of any ease or sense of safety in the world.

Anxiety is a very common ‘presenting issue’ for mental health professionals and according to the UK charity, the Mental Health Foundation, in 2022/23, an average of 37.1% of women and 29.9% of men reported high levels of anxiety, as compared to data spanning 2015-19 suggesting figures of 21.8% and 18.3% respectively. The rates are rising and seem to be affecting women (young women) more than ever. It’s certainly the most common issue I talk about in my consulting room, and with my supervisees, and it tends to present to psychiatrists most usually as a part of a bigger picture of another mental health condition – such as OCD or Panic Disorder (unlike depression which often presents to psychiatry on its own).

The author Scott Stossel’s depiction of his sometimes ruinous version is laid out with little to spare in his brilliant 2014 memoir, My Age of Anxiety. His account of his suffering has such a nuanced level of detail that this itself powerfully conveys his anxious desperation to ‘get it right’ for the reader. It is a moving, and exhausting read. He begins describing his wedding day, an event anyone would expect a bride or groom to have nerves about. However, after he makes his vows to his wife, arguably the worst bit is over, yet there is no respite to his suffering.

‘Drenched in sweat, I walked down the aisle, clinging gratefully to my new wife, and when we get outside the church, the acute physical symptoms receded. I’m not going to have convulsions. I’m not going to pass out. But as I stand in the reception line, and then drink and dance at the reception, I’m pantomiming happiness. I’m smiling for the camera, shaking hands – and wanting to die. And why not? I have failed at one of the most elemental of male jobs: getting married. How have I managed to cock this up, too? For the next seventy-two hours, I endure a brutal, self-lacerating despair.’

As Stossel describes, anxiety plays out in both our mind and our body and to varying degrees of both: the former refers to ‘worry’ which tilts toward future dreads – such as, ‘I’m going to be late with a report, my boss will sack me, I won’t be able to pay the mortgage and then my wife will leave me’. Meanwhile, visceral feelings of ‘panic’ arise that tend to map in us all in similar ways (racing heart, feeling hot and sweaty, stomach pains, light-headedness). In the extract above, Stossel’s worries included a fear of having convulsions in public and passing out (severe anxiety often involves worries about experiencing the symptoms of anxiety), while his body prepared him for his imagined threats – the so-called ‘flight or fight’ response.

Wherever our anxiety sits on the severity scale though, it can find its way, and latch onto, a wild array of ideas: that we offended someone (my recurrent fear, so let me apologise to you now), or we come across as boring/stupid/dreadful, or a spider will appear, or our loved one will come to harm, or that you have left the oven/heater/air conditioning on. These typical ways of imagining threat are reflected in the list of clinically recognised anxiety ‘disorders’ - such as generalised anxiety disorder, panic disorder, social anxiety disorder, PTSD, phobias and OCD (the latter I’ve looked at in another post).

How we understand anxiety is a response to our culture and society. Medieval and early modern records saw it in relation to an imbalance of bodily ‘humours’ (following Ancient Greek and Roman thinking) or from metaphysical forces, or because God needed to keep us in moral check. Anxiety as a coherent concept in psychology didn’t really exist until Sigmund Freud, when he saw its varied symptoms and behaviours as those of the mind rather than linked to another condition in the body – such as the ridiculous and misogynist notion of female ‘hysteria’ being tethered to a ‘wandering womb’.

However, for a very long while after this it was viewed as a symptom of other psychological conditions rather than an issue on its own, until the diagnostic-shifting DSM-III of 1980 created Generalized Anxiety Disorder (GAD). This has evolved significantly since then, and in the UK too. According to recent NHS data, GAD affects about 5-6% of the UK population at any given time, while Social Anxiety Disorder may be as high as 12% (with overlap between the two). ‘Mixed Anxiety and Depression’ is often reported as the most common mental health problem though, affecting up to 8-10% of people.

My client Y was diagnosed with Generalised Anxiety Disorder by her GP before coming to see me for help with its pernicious symptoms. She continues to reign in, with varying degrees of success, the incessant stream of disproportionate worries about anything and, sometimes, everything (hence the ‘generalised’). Her worries became ‘clinical’ because they were chronic (not occasional), severe (her imaginings always become catastrophic), and could be very disruptive (sometimes she couldn’t sleep or eat or enjoy her days), and despite her best efforts – like the author Stossel – they were way beyond her control.

Anxieties like Y’s also tend to behave like a relentless game of whac-a-mole. With Y, one worry mole screams that she will poison her bloodstream if she uses any shampoo apart from one specific one that she can only find online. She whacks this only to release another worry mole who rants about the enormous (imagined) hole in her roof. In between the whacks, there’s a constant hum of dread and she often braces her body for a catastrophe, with physical symptoms of headaches, jaw pain (from clenching), nausea and ‘fizzes and jangles’.

Often, I meet Y online. This may be because she is exhausted from lack of sleep because of her racing mind and wakeful body, or because of a newly forged worry grabs the steering wheel of her mind: about contamination from fellow passengers on the bus, or that leaving the house would allow for burglars. She often feels imprisoned by a persecutory mind that she also knows is behaving irrationally, ‘If only I could convince it that it’s always over-dramatising!’

Y also hates how her behaviours and need for reassurance can land on others as a burden, and she is concerned for her partner who suggested she seek therapy in the first place. She had reached the end of her tether at endlessly reassuring Y and picking up the pieces of Y’s avoidance of socialising and general withdrawal from life. The author Daniel Smith’s lament in his 2012 memoir of anxiety, Monkey Mind is similar: ‘Anxiety compels a person to think, but it is the type of thinking that gives thinking a bad name: solipstic, self-eviscerating, unremitting, vicious’.

With GAD, Y is more prone to feeling panic and even having a panic attack, although we are both grateful that these are rare events for her. A panic attack is not a symptom of a mental illness on its own, but if you repeatedly experience one, and one of them is followed by at least a month of worry about having another (so that you adjust your behaviour to reduce your risk), this could become a diagnosable ‘Panic Disorder’.

Panic attacks are far from experiencing a shock or surprise. Granted, I didn’t inhabit my young friend’s body when she bumped into her old head teacher, but I’m prepared to wager a big bet she didn’t suffer a panic attack as she described – she seemed to have bounced back immediately and found it funny. A panic attack is an overwhelming and dreadful experience that can last as long as twenty minutes, and when it hits for the first time it can take a while to bounce-back to feeling ok again. They tend to respond to immediate threats - rather than imagined future ones – but the only one I suffered (thankfully a mild version) came completely out of the blue and I’m still puzzled why.

Panic involves heightened symptoms of anxiety: you can feel so short of breath that you can compensate by hyperventilating, which only makes us feel worse. If our exhales increase, the carbon dioxide in our blood decreases which means light-headedness, nausea and a pain or tightness in the chest that can make people believe they are dying or having a heart attack. A paramedic I talked to once told me they are a relatively common reason for A&E visits, especially among younger adults (statistics are very hard to nail down as they aren’t often recorded as such).

When I was a young teen, my friends and I used to write to each other in notebooks each evening and then distribute them to each other before the school day started, so creating a 1980s IRL version of WhatsApp, with the trade of immediate messaging for the use of a coveted gold/silver/coloured gel pen. We wrote to each other about how ‘boooorrrring’ lessons or teachers were, but our repetitive hyperbolic prose was also littered with descriptions of being ‘depressed’ or ‘deppy’ (just as, I learn, ‘depressy’ or ‘menty b’ or even, ‘suey’ circulate amongst teens now).

I know I wasn’t depressed back then – not just because I readily exchanged the word for many others, including ‘fed up’, ‘pissed off’ or ‘upset’ - but also because, a few years later, I did suffer a major depression, which felt categorically, all-consumingly different. A day of feeling stroppy and out of sorts in no way compares to my later persistent and pernicious despair. We have been sloppy with the use of the word ‘depressed’ and ‘depression’ for many years already but defining ourselves as ‘depressed’ still needs some care.

The World Health Organisation states that depression is the leading cause of disability in the developed world, and the Mental Health Foundation estimates that 3 in every 100 people will experience it in any given week in England. Like anxiety, it shows up in my consulting room frequently, such as with my (fictional) client J who came to see me in fear of a return of her ‘black dog’ - a metaphor Winston Churchill used to describe his own depressive episodes that, in turn, referred to a (nasty) Victorian expression to describe an unlikeable child.

J had experienced extended depressive episodes three times before – roughly each decade from her mid-teens. Aged 46, she detected the warning signs of her recurring illness: a rise in negative thinking, a creeping heaviness of her body, and a growing lack of motivation to do the things she usually loved. ‘I can feel the healthy me seeping away, bit by bit, each day’. Understandably, J wanted my help to stem, and stop, the seep.

J’s symptoms were different from mine – and will be different from another’s and another’s: depression is experienced in myriad ways, and because of different reasons. I slept little, J slept loads. I threw myself into manic levels of activity to stave off my self-lacerating ruminations, while J felt paralysed and unable to act much at all. Her heaviness and acute feelings contrasted with my numbness and sense of isolation and suffocation, summed up so well by Sylvia Plath’s metaphor for Esther Greenwood’s depression in the title of her book, ‘The Bell Jar’.

Despite my best efforts with J, as the weeks progressed, her symptoms worsened, and she was signed off work for six weeks and prescribed the anti-depressants that had helped her in the past. Despite an increased awareness and compassion for mental ill health at her workplace, she still felt guilty for increasing the workloads of others, and a ‘failure. Yet again’. Despite variations, there are commonalities of depression like this rock-bottom self-worth, which makes it very difficult to respond to the illness with the care, and kindness it desperately needs.

By the time J was signed off for another six weeks, she had slipped further into debilitating feelings of despair, and utter misery and it was particularly hard to hear how images of various ways to kill herself plagued her waking hours. I was very grateful for her insistence that, despite these, she couldn’t act on her thoughts knowing the impact her suicide would have on her close friends and family who had rallied around to support her. When the effort of words was too much, sessions were made up of an agonising and heavy silence – sometimes from her bed, under a duvet, on the phone.

Like anxiety, depression was also variously blamed in our historical past on evil spirits or witches, imbalanced bodily ‘humours’ (maybe referred to as ‘melancholia’), or God’s ire. Its understanding shifted in the late 19th century though, when thinkers like Freud and Emil Kraepelin sought a more scientific approach to understanding mental health. This emergence of psychiatry as a profession, meant that illnesses such as ‘melancholia’ were reframed in more medical terms (although ideas of ‘moral failings’ of patients didn’t entirely disappear).

By the time the first DSM was published in 1952, the notion of depression was heavily influenced by Freudian thinking and seen as a more severe form of mood disorder that usually involved hospitalisation. It was linked to psychological mechanisms and unconscious conflicts and this approach lingered until the seminal DSM-III of 1980 which moved towards a more descriptive, symptom-based approach to all diagnoses. A new ‘Major Depressive Disorder’ (MDD) was created and has been refined over the years in subsequent DSM editions (the latest in 2022 aims to consider more factors such as biology and socio-cultural factors).

Diagnosing depression is another fraught topic amongst mental health campaigners, including the psychologist and researcher Eiko Fried at Leiden University who studies ways to understand, measure, model, and classify mental health problems. In a 2022 paper written with colleagues, he challenges the DSM method of diagnosing MDD, not least because despite being ‘one of the most frequently measured constructs in the scientific literature’, the prevalence and global disease burden of MDD has not decreased. He notes, ‘we have put a man on the moon, invented the Internet and created powerful computers small enough to fit in people’s pockets’ yet our treatment for depression remains woefully lacking.

The authors note how more than 280 measures of MDD have been created in psychology and psychiatry, including the well-known Beck Depression Inventory, and the Hamilton Rating Scale for Depression – all of which, they conclude, rest on shaky theoretical, and methodological, foundations. An earlier paper of Fried’s suggests a pre-existing note of despair: ‘52 symptoms of major depression: Lack of content overlap among seven common depression scales’. They believe the real problem lies in the fact that depression should be seen as a constellation of symptoms that interrelate - as a network behaves - rather than existing passively, and independently of one another. So, for example, if you are deprived of sleep, this will affect your levels of fatigue and appetite, and you may feel less inclined to socialise.

Furthermore, the latest DSM requires at least 5 out of 9 possible symptoms for a diagnosis of MDD (with at least one being either depressed mood or loss of interest/pleasure), which can lead to - and I have to trust the maths here -1,497 different combinations of symptoms, making it a ‘diffuse’ diagnosis to say the least. As an alternative, Fried suggests an ‘iterative exchange’ between theory and measurement, and that depression might be better understood as a syndrome or even multiple disorders that manifest with overlapping symptoms.

Fried is not alone in his thinking that the understanding and treatment of depression needs a wholesale re-vamp. We now also know that our genes play a role, as do our life experiences, hormones, diet, and environmental stressors. New research is emerging to distinguish types of depression too (eg chronic vs acute) .It often hits with other mental health conditions such as anxiety, and we can respond differently to treatments which suggests there may be distinct underlying mechanisms (some of my clients respond well to SSRI anti-depressants, others to exercise and diet, and others to changing jobs or relationships). Many other advocates suggest that it is better to think of depression as several distinct illnesses rather than a singly, loosely defined, one.

I have looked at a few terms that have snuck out of therapy consulting rooms and psychology books into everyday conversations. We can use them easily because they nestle in a culture of increased psychological, and emotional awareness that didn’t exist in the same way when I started work as a psychotherapist. We notice, acknowledge, and advocate more for our emotional and mental needs, and prize our ‘wellness’ or ‘wellbeing’ or ‘welldoing’ more than I have ever known. Some of this depends on others, while the rest depends upon our ‘self-care’. But what this term means partly depends on the meaning of ‘self’ and partly on what ‘care’ is.

I’ll come onto look at the view that our new emphasis on ‘self-care’ reflects our increasing individualism, as a culture, or even that it is a designed outcome of Western neoliberal economies that encourage consumption and production. In other words, the very many products, services and practices of ‘self-care’ fuels a need, and responsibility, to tend to ourselves. At worst, ‘self-care’ can be asserted to avoid someone you’d rather not face, and the idea often includes advice to define our ‘boundaries’ well. My friend was irritated by an ‘out of office’ message from a colleague that told her there would be a delay to a much-needed response, because she was ‘attending to my wellbeing’. She sigh-said, ‘This is self-care gone too far.’

I then go on to look at how self-care relates to another, longer in the tooth one of ‘self-help’, both of which might help us understand what we have come to mean when we think of ‘self’ these days. I touch on the contemporary idea of ‘self-optimisation’ too. After looking at these, I move on to looking at how self-care has been conceived politcally.

While some think the popular notion of self-care runs the risk of unthinkingly trumping others’ needs, another view runs parallel that I look at: that self-care is also necessary. It might be our only option of care at all and can encourage a healthy dose of resilience and self-reliance. The MIND website now has a page for ‘self-care for mental health problems’, linking to another: ‘How to improve your mental wellbeing’. Neither existed when I started offering help for the same, but neither did ‘wellbeing’ or other related terms.

While the advice on both pages makes good sense (such as spending time with friends, and in nature, and attending to good sleep habits), our NHS, MIND, and many other mental health charities, are struggling to cope with demand for their support. Despite successive governments promising more help and support for mental health issues, it remains thin - often vanishingly so - on the ground. And, despite repeated promises for more public spending and structural improvements that would help people’s distress – good public housing, better transport links, schools and funding for the NHS – ‘Shit Life Syndrome’ to use a cynical term, makes self-care, as best as can be done, our only option. It also means that our practice of ‘self-diagnosis’, that has come up in other chapters, is both one of necessity and as of one of concern.

I finish looking at how self-care has mapped onto our NHS, and end on a note of hope springing from one area of healthcare in our communities. I wonder if we have an opportunity to diffuse our sense of self. From the work that I do as a therapist, I now know with confidence that self-care works best when it relies less on supplements and wearables and diets, and more on plugging into positive relationships with others – our friends, families, communities and Mother Nature.

Self-Care commodified

Looking after ourselves physically and mentally is obviously not a new or radical idea, and before any social system of healthcare existed, we tended to ourselves and each other with knowledge passed down and between generations. We absorbed ideas from early physicians and wise folk – such as the Ayurvedic text Charaka Samhita, the ancient Chinese Yellow Emperor’s Classic of Internal Medicine or, in the West, the works of the Ancient Greek physicians Hippocrates and Galen. My Colombian grandmother learnt from hers – including making rose water skin tonic after leaving petals out in the glow of a full moon.

Some point to the Taqwīm as‑siḥḥah (‘maintenance of health’) as the earliest example of a ‘self-care’ manual, written by the 11th-century Iraqi Christian physician Ibn Butlan. This was later translated into Latin and became known in Europe as the Tacuinum Sanitatis (‘Tables of Health’). Much of its advice echoes contemporary ideas of holistic health, and in reverse, many contemporary health practitioners like to emphasise the ancestral wisdom they learn from. Acupuncturists rely on ancient Chinese texts, yoga practitioners learn about the Sutras of Patanjali and David Hoffman, the author of my well-thumbed book of Welsh herbs, derives his wisdom from the 13^th century Physicians of Myddfai.

The Tacuinum Sanitatis encourages (free) measures to both keep us well but also offers advice to ward off disease and illness, guiding the reader to make wise choices in six essential areas: air quality and environment (for the sake of the heart), food and drink (with advice on seasonal eating and remedies), exercise and rest, sleep and wakefulness, states of mind (managing joy, anger, fear and distress) and the ‘secretion and excretion of the four humours’ (the body systems then thought to govern our health).

A thousand years later, at least five of these essential areas have birthed their own thriving industries with brands jostling for prime position. (Our four ‘humours’ have been replaced, after many centuries of use, with our modern knowledge of the human body, which can’t always be said to apply to modern products concerning the other five areas of health). So, for example, and taking each ‘area’ in turn: we have air purifiers, de-humidifiers and crystals, we invest in dietary hacks and supplements, we pay others to teach us exercise regimes (with yoga and Pilates reigning supreme) and buy tech and supplements to help with our sleep.

Our states of mind are now helped by an exponentially growing profession of assistance – bar the obvious ones of psychiatry, psychology, counselling and psychotherapy. We also have variously described wellbeing practitioners, and ‘therapists’, meditation experts and a glut of specialist coaches (for divorces, for infertility, for eating, for finances) and other wise folk sharing their experiences of coping or survival.

My profession of psychotherapy and counselling has ballooned with new specialisms in the past two decades – guesses vary wildly from 250 to 500 – and some are territorial, competing with each other or claiming one-upmanship (for instance, long-term therapies emphasising ‘relational depth’ between a therapist and client don’t tend to like ‘mental health boot camps’ and short-term therapies like CBT).

The massive market in self-care means that clients tell me more and more about their new potentially game-changer products. (I take the point, which makes me uncomfortable, that I also benefit from this market, as it encourages therapy). Some have ‘wearables’ that track heart rates and steps, (forging a new cohort of heart rate variability experts), some buy home blood-testing kits to measure nutrients and minerals, and others go to branded gym or yoga studios. I’ve lost track of which specialist diet works best and I have resisted the encouragement of one person I met to buy a £1000 magnetic mattress topper.

Many commentators critique this commercialisation of our self-care industry, usually citing Gwyneth Paltrow’s company Goop’s supply of jade eggs for the vagina as a, ahem, seminal example. The artist and author Jenny Odell, who I mentioned in my Introduction, writes cynically about the grabs at our attention by digital market forces in her book. She notes how the idea of a ‘self’ that this industry targets tends to conflate it with the idea of a ‘personal brand’ too. ...’I don’t know what a personal brand is other than a reliable, unchanging pattern of snap judgments: ‘I like this’ and ‘I don’t like this’, with little room for ambiguity or contradiction.’

Dr Pooja Lakshmin, a US psychiatrist also writes questioningly about the stratospheric rise of the self-care market in her 2023 book Real Self Care (Crystals, Cleanses and Bubble Baths Not Included). She responds to what she sees as plentiful ‘faux self-care’, that are actually ‘quick fix’ commodities that do little good in the long run, although maybe some good in the moment. She worries that such ‘care washing’ ultimately serves to avoid some profound societal and structural issues that are the cause of so much distress.

Y, my NHS nurse client who I wrote about in the post about burnout comes to mind as I write this. She was fed donated cakes and biscuits during her hospital shifts in the pandemic and wore PPE both made and donated by women sewing it in their homes. Much of what I suggested to her in order to look after herself felt futile, and frankly embarrassing, given the obvious ways to alleviate the most of her distress - such as more staff, consistent messaging from the government, more and better equipment, more time off, and emotional support paid or provided for, rather than voluntarily given by people like me.

Lakshmin also thinks that many activities or products that are promoted can wind up increasing our stress or guilt if and when they don’t help, and while ‘crystals, cleanses and bubble baths’ aren’t bad per se, marketing them as solutions to mental ill health, can be. I see how this messaging often plays out for my female clients struggling, and desperate, to conceive or have a live birth. Their vulnerability makes them more likely to be susceptible to persuasive marketing language. Not only do they have to deal with a medical systems that has, historically, valued a woman’s reproductive efforts higher if they conceive and birth easily (in my case, my ‘incompetent’ cervix meant a ‘failed’ pregnancy), but they also receive the idea that they have to do more to ‘succeed’ in making babies. Ironically, this might also mean doing less, as the ‘fertility industry’ promotes the impossible task of having to banish stress.

When I was desperate to remain pregnant after many losses in my 30s, I ate almonds, carried an amethyst in my pocket, and borrowed a friend’s Ugandan ‘fertility mask’ to hang on my bedroom wall. My clients now download guided visualisations that help create a ‘receptive womb’ or ‘positive mindset’ and invest in fertility clinic ‘add-ons’ that are not backed by good evidence. Some dietary supplements make good scientific sense, but others make outlandish claims for their worth, with no evidence to back them. The sum of many of these marketable parts is often a weighty pressure to purchase, and the creation of a rich seam of guilt if they aren’t.

Self-help

While it seems to me that self-care has become a global commercial industry, its sibling ‘self-help’ industry has been around longer, and between the two of them, we might sift out some idea as to what ‘self’ has come to mean in these contexts - well outside the lofty realm of philosophical circles.

While the notion of self-care generally pivots around tending to ourselves in the moment, self-help has tended to refer to more active and goal-oriented change. It looks at growth for ‘personal development’, and improvement of, for example, our time-management, presentation skills or destructive or unhelpful habits of mind (such as negative thinking or worrying). Much of the messaging seems to boil down to increasing our ‘productivity’ though, with some ideas specifically targetting quantifiable ‘success’, such as earning X million or gaining Y social media followers (regular spam emails tell me I can buy the latter).

The original self-help ‘thought leader’ (to use another recently coined identity-making noun) is often quoted to be the Scottish government reformer Samuel Smiles who wrote the best-selling Self-Help, in 1859. He emphasised the Protestant ethics of perseverance, hard work, and personal responsibility as a route to success, as opposed to relying on help from others or the state.

Less than a century later, the best-selling self-help genre was set to launch with Dale Carnegie’s evergreen 1936 How to Win Friends And Influence People, which has estimated to have now sold over 30 million copies (one of which I have of course). Authors have made millions from their books, courses and academies and ancient texts have been revived in print too: the ancient Chinese military treatise Sun Zsu’s The Art of War is used to advance business strategies, and various editions of the Roman emperor Marcus Aurelius’ Meditations have been pressed into my hands of late.

The academic sociologist Daniel Nehring has an interest in self-help literature, as a part of his wider thinking about ‘therapeutic cultures’ like ours, a term he describes as referring to the ‘transfer of psychotherapeutic knowledge, concepts and terms into places outside of consulting rooms, such as family life, government and the media’. In 2024, he wrote an article for Sociological Research Online: ‘The self in self-help‘ in which he analysed the ideas of ‘self’ and ‘self improvement’ as conceived in bestselling self-help books sold in the UK from 2008 to 2022. He wanted to understand if the 2008 global economic crash had influenced the view that scholars had taken that ‘popular therapeutic narratives promote neoliberal accounts of an autonomous, masterful ‘entrepreneurial self’, able to thrive in the world on its own.’

Nehring’s conclusions extends previous ones and he discerns the emergence of a new strand of ‘therapeutic discourse’ that involves ‘alternative, survivalist and spiritual’ themes, such as ‘self-making’ (such as Dale Carnegie’s still-selling book and James Clear’s Atomic Habits), ‘survivalism’ (such as Ant Middleton’s Military Mindset and John Parkin’s F**k it books) and those illustrating an ‘inward turn’ (such as the memoirs of Fearne Cotton and Ruby Wax).

Nehring sees a central feature of self-help today as depicting a ‘thin self’, divorced from wider structural, social and community issues. He defines it as ‘a de-socialised self, faced with overcoming purely personal troubles on the basis of its own intrinsic capacities’, and offers a ‘tentative explanation’, lying in the fact that our therapeutic culture largely emerges from our increasing numbers of commercial channels, including the ‘adshel’ (bus stop advertising) by my house which promoted online therapy. Our very many ‘therapeutic entrepreneurs’ foster a focus on individual consumers who are seeking individual solutions to individual problems (my emphasis).

Therapy as thin self

As a psychotherapist, I could also be challenged for thinking that overly focuses on individuality, and self-improvement. The theories taught to me over two decades ago all had their roots in Western philosophical traditions of autonomous selfhood, which tilt toward the life of the individual mind. In turn, these emphasise personal agency over collective experiences and responsibility for each other.

I learned how Freud and Jung battled out their different views about our mind’s internal conflicts, while Gestalt (pioneered by Fritz Perls) and existential schools (such as one that Irvin Yalom led) tune into understanding our individual ‘lived experiencing’. Carl Rogers, the founding father of person-centred psychotherapy also wrote about the importance of ‘self-actualisation’. All of these ideas of ‘self’ diminish others held by many other cultures that prioritise family, community and our earth above the ‘I’.

In the early days of my practice, when I worked in an area of East London with a very high South Asian population, I tended to think of the ‘self’ as defined by the edges of our body. I talked to more than one young woman, secretly dating, or in love, with a white man who they knew their family would disapprove of and they came to me stuck painfully between two cultures. My ignorance meant that I encouraged them to think along the lines of ‘what do you want?’ without understanding that the ‘you’ I referred to meant one inextricably bound up with their parents, siblings, uncles, aunts and extended family beyond them.

Change is, at long last, taking place, and psychotherapy trainings are beginning to reflect broader cultural values. While family therapy has always considered individual suffering in a wider context or system (and I discussed Minuchin’s work in the post about boundaries), trauma-informed therapies, narrative therapies and feminist therapies also think about our broader contexts. The influential notion of ‘intersectionality’, coined by legal scholar Kimberlé Crenshaw in 1989, also provides wind to these sails. This describes how we need to consider that the usual ways we categorise and oppress each other - such as via gender, race, class, sexuality, and disability – all relate, and intersect with each other to forge unique experiences of suffering.

Intersectionality means that people’s lived experiences can’t be fully understood by looking at one aspect of their identity in isolation – for example, the experiences of Black women must consider both racial and gender discrimination, and how the two relate to each other. I return to the idea of self being part of something bigger after a return to ‘self-help’ in its latest guise.

Self-optimisation

A newer iteration of self-help (or indeed self-care depending on how you cut it) has emerged in recent years, influenced by tech break throughs, and Silicon Valley performance culture - ‘self-optimisation’. A decade ago, we were excited about micro-dosing LSD or psilocybin to deal with stress, mental health issues and underperformance, but now we invest in ‘superfoods’, supplements and regimes that claim to do wonders to our brains and bodies, and ‘wearables ‘ that track our heart rate and blood content, such as rings and watches and patches. Our human body can now be seen as a system to work with, or ‘bio-hack’, so we can become more healthy, productive and long-living. A pioneer of this pursuit is the US entrepreneur Bryan Johnson who has invested millions of dollars into his attempt to extend his (and by extension, others) life as long as possible. ‘Project Blueprint’, as he calls it, hit the headlines when he transfused his plasma with his son’s, but it proved to lack benefit, which was a relief to me.

This increased emphasis on productivity in our contemporary ‘self-help culture’ sits uneasily with me, not least because I talk to people every day about how this corrodes mental health. The author Oliver Burkeman who spent 14 years as a Guardian columnist writing about self-help (and writes a lot on this platform), also challenges this zeitgeist in his 2021 book, Four Thousand Weeks: Time Management for Mortals. He homes in on our relationship with time, because it lies at the heart of our modern urge to squeeze every moment for productivity’s sake.

Burkeman grapples with the ‘paradox of limitation’ that is at root of our contemporary distress: ‘The more you try to manage your time with the goal of achieving a feeling of total control, and freedom from the inevitable constraints of being human, the more stressful, empty and frustrating life gets’. Instead, he suggests, deriving ideas from ancient wisdom, that we need to square up to our existential woes: life is finite, and we are imperfect.

I often see how this quest to ‘do’ and ‘perform’ and ‘improve’ sets people up to fail in my consulting room. I meet clients drowning themselves with ideas to flourish rather than languish – just as my clients desperate to conceive might. Often though, as Burkeman suggests, these commitments tend to backfire. In the ‘doing’, there’s less scope for ‘being’ and tuning into what matters far more to people than ticking off lists.

Burkeman reminds us that the average human lifespan is, as his book title says, ‘four thousand weeks’, and rather than attempting to wrestle with time, as if it is some outside force, it is far more helpful to accept its constraints. We just can’t do everything we want, or think we want. The tasks of life are Sisyphean and there’s no way to ‘optimise’ to make them any easier or to vanish. He concludes that it is far better that we accept our limitations, consciously choose what to do and leave undone, and focus on what really matters to us - and in my experience, this involves nourishing, reciprocal, human connections.

Self-care as a political act

The cultural sway of self-care that I’ve been writing about so far sits very far removed from the idea as it was conceived by the Black Panther Party in 1960s US, and also interpreted by other marginalised groups around the same time. To use the phrase from Dr Lakshmin’s book title, ‘crystals, cleanses and bubble baths’ were not on the minds of Black Americans who were, and still are, fighting for dignity, justice and equality in all areas of their lives. Self-care can be framed as both an indulgence, or a necessity.

The BPP viewed health care as a fundamental right for people, and this became part of their broader agenda for social justice, and for the promotion of self-determination. Their notion of self-care was deeply integrated into this political philosophy and was a major part of their community work, particularly through ‘community survival programs’ that responded to the immediate needs of the oppressed Black community.

Alandra Nelson’s 2013 book, Body and Soul: The Black Panther Party and the Fight Against Medical Discrimination looks closely at the BPP’s important relationship between health activism and racial justice. She charts their many free initiatives, such as breakfast clubs for children, supplementary education about Black history and empowerment, clothes and shoes supplies, medical clinics, and education of the systemic medical neglect Black people suffered. They also launched campaigns to research sickle cell anaemia, testing for hypertension and lead poisoning, and helped people with housing and employment problems.

Nelson concludes that the BPP’s ethos laid foundational ideas for our ongoing health activism, with its emphasis on community-led interventions, culturally sensitive care, and an urgency to address structural inequities in healthcare. Applying these to a context I know well, this form of activism has shown up recently in our maternal health care in the UK.

At very long last, attention has been drawn to the disgraceful fact that maternal mortality for Black women is nearly three times higher than for white women, and significant disparities also exist for women of Asian and mixed ethnicity. A House of Commons Committee report in April 2023 notes the role of activism in bringing this to light, ‘These disparities have existed and been documented for at least 20 years, but only received mainstream attention and Government action since around 2018. Considerable credit for putting the issue on the political and public health agenda goes to campaigners, such as Five X More and Birthrights, who have worked to publicise the issue.’

The author Audre Lorde’s famous exhortation from her 1988 book of essays, Burst of Light, connects to this radical tradition of care: ‘Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare’. She wrote this as a Black lesbian feminist, with cancer, and her words determined that her self-care was a survival strategy against oppression. Like the BPP, she also emphasissed the inextricable link between self-care and human connections, stating ‘without community, there is no liberation’ - an idea expanded on by the philosopher Myisha Cherry’s in her 2020 powerful essay, Solidarity Care: How to Take Care of Each Other in Times of Struggle.

Cherry argues that caring for each other is essential to long-term, effective activism and as a necessary component of social justice. She writes, ‘Being aware of social injustices can cause existential and mental pain; comes with a burden; and may impede a flourishing life. However, I shall argue that this is not a reason to despair or to choose to be willfully ignorant. Rather, it’s a reason to conclude that being conscious is not enough. Rather, during times of oppression, resisters must also prioritize well-being.’

The second wave of feminism similarly focused on empowering women – and Black women - to join forces with each other, in mutual self-care, to better advocate for improved mental and physical healthcare. One good example - that men really hated - was Carol Downer’s lead on women’s self-examination, along with the campaigning she and others did for abortion rights and reproductive choices. The 1973 book Our Bodies, Ourselves by the Boston Women’s Health Book Collective can also be seen in the same light (and one battered copy introduced me to my cervix for the first time).

These issues persist, half a century on. The Women’s Therapy Centre was originally founded by feminist psychoanalysts Susie Orbach and Luise Eichenbaum in 1976 as a response to a desperate need to support women facing unwanted pregnancies, abuse, and other forms of misogyny. It is as busy as ever.

The reality of mental ill health

While our increased psychological awareness may do us a dissservice at times – for example when we define ourselves too narrowly, or categorically, or inaccurately - I hope to also emphasise that there is also an undeniable swell of suffering in the UK, and a dire lack of public resources to deal with this well. It makes sense that self-care – in its various iterations - may be the only option for many.

According to November 2024 data from the Department of Health and Social Care levels of anxiety of over 16-year-olds in England has increased from 21.7% in April 2012, to 23.3% in April 2023. Patients with recorded cases of schizophrenia, bipolar affective disorder and other psychoses have increased from 0.84% in April 2013 to 0.96% in April 2024. Deaths from suicide and ‘injury of undetermined intent’ increased from 10.3 per 100,000 (2001- 2003) to 10.7 (2021 –2023). In a population of 57 million or so, these small looking shifts translate into significant numbers of lives.

Our 18-24 year olds are widely reported to have the poorest mental health of any age group in the UK. Two decades ago, the opposite was true. (I felt some tiny relief in learning that hospital admissions for intentional self-harm in people aged 10 years to 24 years decreased a small amount from 347 per 100,000 in April 2012 to 319 per 100,000 in April 2023).

Our young are growing up in a world with an uncertain future, a competitive job market, a cost-of-living crisis, the legacies of a pandemic (including ongoing illness and grief), prohibitively expensive housing in many cities and a digital life that can bring harmful influences. You probably know of particularly long waiting lists for talking therapies, eating disorder services, child and adolescent mental health services and of lengthy waits for crisis care response times.

There are also significant staff shortages across mental health services, high vacancy rates for psychiatric nurses and psychiatrists, and burnout and retention issues among the staff that hang on in there. Anecdotally of course, every psychotherapist or psychologist I know who worked for the NHS has left to work in private practice in recent years, feeling that they have run out of the goodwill that kept them there.

The ‘postcode lottery’ amongst care also means that I can speak to clients in one London borough getting quicker, and more, support than others in the neighbouring borough. The help that is on offer to families and individuals has also been getting slimmer and slimmer, to dangerously thin. When I began in private practice, the parents of unwell teens that I talked to would be encouraged by the weekly psychotherapy offered to their child, and regular family meetings that kept them in the loop. These days their teen may get a handful of counselling sessions (often not weekly) and their parents next to nothing, bar guidance as to how to support their teen.

In June 2024, the charity Rethink published the results of a survey of 656 people who had attempted to access mental health services in England within the last two years. The woeful findings add to longstanding (ie pre-pandemic) concerns that under-resourced mental health services are unable to provide timely, or consistently effective care. A staggering 80% of respondents experienced a deterioration in their mental health as they waited for support. Of these people, 25 % attempted suicide, 42 % sought urgent and emergency care, and 22% had contact with the police due to their distress.

Furthermore, 66 % of people reported that they did not receive mental health support for enough time, and 35 % who were lucky, reported it to be too brief (or cut short) to be effective. The survey also suggests that people may be falling between the gaps too: 41 % reported that they were denied support because their condition was considered not severe enough, while 35 % reported the opposite - that they were denied it because their condition was considered too severe. Despite our ongoing cost-of-living crisis, 35% of respondents were pushed to seek help privately, which certainly chimes with my experience in recent years.

Self-care between the private & public realms

I have noted how ‘commercial’ self-care has blossomed and thrives, while the public resources for mental health treatment and support suffer from an opposing trend. Self-care has always played some role in the medical management of our physical health, and its current iteration in the NHS could be seen as supportive of the fact that most of us want to feel as much in control of our bodies, minds and treatment by medical professionals as we can. We hope that this is supported by a system that offers and promotes resources for when we can’t care for ourselves though – which you probably know isn’t always the case.

After the NHS was launched in 1948, self-care was largely viewed as a patient’s role to manage their medication, and monitor their basic health markers, particularly in relation to chronic conditions such as diabetes. The idea of ‘patient autonomy’, and of educating patients about their health, and conditions was far more limited, and ‘doctor knew best’, even when he didn’t (it was likely a ‘he’ for decades).

Nursing care has its own notion of ‘self-care’ with Dorothea Orem’s ‘Self-Care Deficit Theory’ (or ‘Self-Care Theory’) of huge, and lasting, influence. First developed in the US in the 1950s, Orem’s ideas rest on the premise that patients want to care for themselves, but often can’t or only in a limited way, which creates a ‘self-care deficit’. Our ability to look after ourselves is partly learned from our family and culture, but it is also heavily influenced by factors like age, privilege, wealth and education. So, for example, as a white, privileged, educated woman working in the mental health field, my ability to look after myself outweighs some of my neighbours who don’t speak good English, have no disposable income, and no access to reliable internet.

Orem sees the goal of nursing as one to help patients become as independent as possible in meeting their self-care needs, with a nurse stepping in when a gap emerges between what we need to do, and what we can do. She identified three types of needs: universal (our basic human needs), developmental (our age-related needs), and health-deviation (our illness-related needs) and three nursing practices to fill the gaps: wholly compensatory (complete care), partly compensatory (shared care), or supportive-educative (guidance and teaching).

These days the NHS tries to avoid complete care where possible, after a growing recognition of patient expertise and our right to be more involved in our treatment options. There has also been a broader push for a focus on preventative care, with the 1992 ‘Health of the Nation Strategy’ explicitly setting targets to reduce preventable diseases, like heart disease, strokes, and cancers. This relies on our self-care and, if all goes well, treads the line between respecting our autonomy, and stepping in when necessary. So, my friend who tracks her infant daughter’s diabetes, also knows she has expert help at hand if something goes awry.

These ideas were reflected in the 2019 NHS Long Term Plan, commissioned by Theresa May’s government, which aimed to reduce lifestyle-related diseases, improve vaccination rates, and address obesity and mental health issues (including those of their own employees). We already have digital health tools such as symptom tracking and apps for insomnia and anxiety, and there are ambitious plans for an expanded digitised (and AI) NHS future ahead. The Plan has been scuppered by the pandemic, change in government and economic outlook, and as I write, its status remains unclear.

While researching this post, I stumbled across the annual NHS backed ‘Self Care Week’ (themed ‘Mind & Body’) promoted by the Self Care Forum which, I discovered to my surprise, has been running below the radar since 2011. The aim, stated on their website, ‘is to further the reach of self-care and embed it into everyday life. We also hope to create a self care movement, an evolutionary shift towards people being more informed and empowered to look after their own health and their family’s health and to understand when to self care and when medical intervention is necessary’.

This seems to strike the balance between welcomed autonomy and appropriate intervention, or, another way of looking at it, a balance between individual responsibility and collective responsibility – although the latter needs to go far beyond the NHS. A young man I recently met with a perpetual leak in his council-owned flat may manage his stress better with an app for anxiety and to exercise more, but a far more effective treatment would be for the roof to be fixed.

One remarkable NHS response to the complexities of mental health problems, along these lines, is the ‘Deep End’ GP movement, with its first network forming in Scotland in 2009, using a metaphor from a swimming pool. It focuses on addressing healthcare inequalities in very deprived areas, where needs are high, yet access to healthcare resources are low (the so-called ‘inverse care law’ coined in 1971 by the doctor and campaigner Julian Tudor Hart).

‘Deep End’ thinking prioritises working collaboratively with local community resources to help address issues that have profound effects on our mental and physical health - such as loneliness, financial and housing insecurity, and health literacy – and literacy - gaps. It draws on the wisdom of the people ‘in the know’ of both local issues and its barriers to create solutions for better health outcomes. ‘Deep End GPs’ actively share their knowledge with each other (my GP friend is on a WhatsApp group of hundreds of colleagues) to promote a community-driven sense of responsibility toward health and well-being.

In Johann Hari’s popular 2018 book Lost Connections, he argued that the real causes of depression and anxiety, both of which he suffers with, are to do less with ‘chemical imbalances’ of the brain or ‘biomedical’ ideas, and more to do with our many ‘lost connections’. His chapters address nine of them, including nature, a secure future, meaningful work and values, and those with each other. He highlights the pioneering work of the Bromley by Bow Centre, in East London, which is aligned with the Deep End GP ethos.

The Centre offers medical services, but also others that treat their patients holistically, as members with a role in their community. They have pioneered ‘social prescribing’ - where people are seen to benefit from courses or activities such as swimming, gardening, volunteering and other community-led initiatives. It also seeks to address some of the root causes of health issues, like a leaking roof or mould, unemployment, and social isolation. ‘Patients’ are not seen individually, so while their needs are high on the agenda, so is the desire to address systemic changes that benefit underserved groups more generally.

Like the ‘Deep End’ GPs, my work also tells me how the ‘self’ in ‘self care’ can thrive best is if it is one that sustains positive relationships with other humans, and our natural world. On the occasion that a client thanks me for my help in their feeling better, I will never know how much I really did help them. However, I do know that I may well have helped them to turn toward other relationships in perhaps new, or renewed, and nourishing ways, which is the real healing agent for positive change.

This happened with E. When I first started working with her, I struggled to push my tired, private, responses aside, while she moaned about everyone, everything and anything. (Therapists do judge, but if all goes ethically well, we take care to think about this means with our colleagues and supervisors). E found my room too cold or too hot, or my sofa pillow too scratchy, or my water too tepid. Her boss was a ‘psycho bitch’, her sister ‘personality disordered’ and her flatmate ‘a pathetic zombie’.

In the early weeks of our talking together, I struggled to get E to see beyond her nose. But I also knew enough about narcissistic traits to tell me that her unlikeable aspects were busily working to defend against unbearable feelings of unworthiness. Over many months of weekly meetings, E did eventually allow me to be with her more vulnerable parts, and I discovered how, as a very young girl, she had learned to be worthy in her parents’ eyes only by being ‘beautiful’ and ‘clever’. These two qualities were prized above all else, meaning all the many other aspects of her personality were ignored or sometimes denigrated.

As an only child, E shouldered both her of parents’ projected desires, and when I heard stories of her being ignored or overlooked, they were heartbreaking to hear. She wasn’t allowed to cut her hair short (not pretty), follow her passion for art (not intellectually robust enough) or see her friends out of school (her mother would get lonely or bored without her company). The only times she remembered her father stopping to notice her would be if she had a good school test result to please him with, or if she wore something he liked.

I found out about E’s childhood because a part of her became willing, and courageous enough, to confront her painful past. We talked about how her sense of self was built on shaky foundations, and that she had buried them deep under a need to feel worthy by being superior to others around her. In readily judging others, she kept topping up her tiny well of esteem, but this also kept herself isolated from nourishing connections with others, and intimacy.

E softened toward me, and those around her, over time. She described her flatmate, her sister, her boss, and others in broader and kinder terms. As she empathised with others more, she deepened her relationships, and made new ones. She began to party less (being ‘popular’ kept her buoyant), and take more interest in the wider world. I also noticed how she wore far less make-up and relaxed into her chair as she spoke with me about her expanding world.

Without any prompting by me, E also began to volunteer in a local foodbank, where she made friends with people who she would have avoided when we first met and thought further afield about the community she lived in. These new bonds boosted her confidence, and she began to believe that she was worthy for being her true self. This made her feel the best she ever had before.

My client Y hadn’t been able to get the bus to see me for our weekly session one time because she was consumed with a fear of contamination. This was one of her very many and varied fears, and it didn’t last too long, nor latch on too tightly. If her thoughts of this fear had become intrusive and repetitive (‘obsessive’), and if they meant she felt she had to act out rituals or think other thoughts (ie ‘compulsions’), Y might have a devastating and debilitating mental illness. As tempting as it is for us to describe being organised or liking books to be lined up neatly as being a ‘little bit OCD’, we shouldn’t be flippant about this illness. Nor is it possible to suffer from it ‘a little bit’, in the same way that, in my fertile days, I could never have been a ‘little bit pregnant’.

Although OCD is categorised as its own disorder in the latest DSM, and is distinct from anxiety disorders, it shares many similarities with them, and many people suffer with both. Anxiety is a core experience of OCD, as the obsessions involved cause such distress and anxiety. The charity OCD-UK estimate that about three quarter of a million people in the UK live with it, and ‘contamination’ fears are only one type of many more: OCD can spin from thoughts on any subject, on any person, on any fear, although it frequently fixates on what’s important in a person’s life. So, a primary school teacher I worked with had obsessional fears of her harming children, while another client battled with thoughts of blasphemy despite being a committed Christian.

While we can’t suffer from OCD ‘a little bit’, it is possible to suffer it mildly, that allows for day-to-day functioning, albeit with great effort and distress. My client P struggled with fears of causing a fire by leaving plugs left in or not switching appliances off properly. Often the last one in the office at the end of the day, he would check, double-check and then triple-check that he had unplugged his computer and turned off all the lights (it didn’t seem to bother him that other lights in the building couldn’t be turned off, as is often the way with the irrational logic of anxiety). At home, P performed safety rituals around his house before going to bed, unplugging devices that his mind told him were the most dangerous. For years he, and his family, had lived his relatively stable level of checking without it really getting in the way of things. Other than this ‘quirk’ of his, he was relatively happy.

P came to see me for help when the triple-checks began to triple and then triple again. By the time we met he was getting home from a long day at work later and later, and going to bed later and later. He was, unsurprisingly, extremely anxious, fed up with his mind, and exhausted and it took many weeks for us to loosen the grip of his obsessional mind.

The level of distress for P was bad enough, but OCD can ramp up to another dimension of illness with a very long road to recovery: it can keep people in bed because of a fear of meeting airborne insects (to the extent of bed sores developing), it can hospitalise people with kidney problems from dehydration when they fear drinking poisoned water, or involve 24-hour nursing care because the hell of bearing the symptoms makes them at risk of suicide. So all of this is to say is to say ‘OCD’ without knowing what it can involve risks minimising a way of being that needs compassionate treatment.

However, ‘burnout’ in the sense that it first emerged as a psychological issue is rooted to a particular context: the workplace. Strictly speaking, this means that you can’t suffer burnout from partying too hard or renovating your house or looking after children - unless you are a professional party-goer (yet to meet one), renovating your house as a service to someone else, or you are a teacher or nanny. Many women spoke of ‘burnout’ during the pandemic because they were working three jobs simultaneously: (interruption with chat GPT’s illustration)

the one that earned them money, the one that educated their children, and the one that cared for the home.

Although the symptoms of ‘burnout syndrome’ or ‘occupational burnout’ or, simply put, ‘burnout’ can resemble those of depression, the experience is distinct because it refers to someone’s response to chronic work stress that, by definition, develops over time. You may reach the end of your tether after a stressful meeting or spat with your boss, but if you can shake it off by the next day, you aren’t burned out. Another way of looking at it is that you can’t recover from burnout by taking time out of work and then returning to the same workplace situation.

The writer Jonathan Malesic wrote The End of Burnout (2022), after experiencing a dreadful episode during his academic job at a university. I will come onto how the ‘syndrome’ has been quantified by researchers and clinicians, but his description of burnout as ‘an ailment of the soul’ captures the deep anguish it can cause. He suggests that burnout occurs ‘not because we are exhausted but because our hearts are broken. Our love for work went unrequited – it did not love us back. And nor did it bring us the dignity, purpose and recognition for which we hoped.’

Malesic sees burnout as a cultural problem for the millions of us working in the neoliberal economies of the West which prize productivity and consumption above the values that most employees I know care more about – such as being treated with fairness and dignity, having concern for the environment and future generations, as well as nurturing a sense of purpose and autonomy each day at work. If burnout is, as Malesic describes, the ‘chronic experience of being stretched between ideals for work and the reality of your job’, it remains an inevitable fall-out or our workplace culture today.

Most of us work because we need to earn money, but also, if all goes well, we try to choose a role that fulfils something else that matters to us. We may want to prove ourselves to be competent, or to show our family and friends or community that we are useful or helpful or accomplished. We may also view work as an extension of our values, which is immediately obvious for those on the frontline of humanitarian work, or maybe we want to be fulfilled on a deeper spiritual level, such as becoming a yoga teacher or rabbi - or psychotherapist.

A cynical view of burnout sees it as a convenient label to encourage, to sustain the very system that creates it. In other words, if we are at risk of ‘burning out’, which arguably any of us who work too hard without enough pay or respect or leave or parental cover could be, we need to think about fending it off. The logic goes that this risk keeps some businesses going: yoga retreats, meditation apps, self-help books, dietary supplements and wearable health devices. (I return to this in another post on ‘self-care’).

Malesic also wonders if we may be unrealistically pouring too many of our abstract ideals into jobs that no longer care about us, which only sets us up for disappointment. My son’s experience in the gig economy as a delivery courier was, luckily for him brief, but enough to feel the inklings of an unrequited love. He loves to ride his bike, enjoys the puzzle of route-making and was seduced by a friendly ‘onboarding’ and ‘free’ branded merch - as well as the promise of earning enough to buy a (worryingly cheap) car. The reality was starkly different, and each shift even more demoralising than the previous one: his employer didn’t care about him or his fellow riders in the slightest.

Burnout can involve dreadful, and unmanageable symptoms that ultimately cause many people to become very unwell, and to leave work. Before and during the pandemic, it became a serious issue amongst our healthcare workers, and in a 2021 report, the cross-party Health and Social Care Committee in the UK warned that workforce burnout across NHS and care systems had reached ‘emergency level’, which was risking the future functioning of services.

Like many of my colleagues during the pandemic, I volunteered to offer free therapy sessions to NHS workers. Over the course of six months, I spoke online most weeks to a nurse, V, who was, without doubt, by the end, burnt-out (to be clear, V is a composite of many clients I spoke with and her words are not hers). When we said goodbye, she had resigned from her post with a plan to ‘do nothing’ for the three months she could just about afford to take, while she contemplated setting up a business on her own. She was heartbroken to leave a job she had loved for over fifteen years, but felt she had no option. ‘My goodwill has run out, and I have nothing left for anything or anyone, which is a big worry to me. I need to take stock and find something that gives me more back than I’ve been getting’.

V used to love her job as an A&E nurse. She enjoyed the fast pace, the teamwork and the challenge of having to quickly respond to all sorts of people and problems. ‘It was far from perfect, and none of us are paid nearly enough, but I had great colleagues, learnt a lot and most days I felt valued.’ But when the pandemic hit hard in March 2020, her good feelings soon evaporated. She spoke of the chaos of changing protocols, the lack of protective PPE and preparedness, the terror of catching the virus, and the shame of it when she inevitably did (as this meant time off work, and more pressure on her colleagues who were all buckling under the weight of it all).

V also spoke of how her levels of care were corroded by the the unprecedented number of patients she had to deal with each shift. ‘I hate the idea that I ended up not caring about my patients in the way that I used to. I can get over the exhaustion, but I can’t forgive myself for losing compassion.’ She also had to make decisions that she didn’t want to make – such as having to choose which patient to prioritise, because of lack of equipment or staff. V couldn’t offer enough emotional support to her patients either, which was especially dreadful when their lives were precarious, and she had to forbid their loved ones from seeing them. ‘Every bit of my body felt it was cruel and wrong. I couldn’t walk away or complain or break the rules. We were all in the same boat, watching each other in agony.’

V’s experiences of having to act against her values can also be described by the relatively new terms of ‘moral distress’ or ‘moral injury’. These also describe forms of work-related anguish that are related to, or often a part of, burnout. Some academics use the terms interchangeably, but the British Medical Association discern a difference, with ‘moral distress’ described as: ‘... the feeling of unease stemming from situations where institutionally required behaviour does not align with moral principles’, while moral injury, ‘can arise where sustained moral distress leads to impaired function or longer-term psychological harm.’

While we tend to use the term ‘burnout’ loosely, there’s no unified definition in the research, or clinical literature either. The World Health Organisation does not view it as a ‘medical condition’ as such but defines it in their 2019 ICD-11 as an ‘occupational phenomenon that results from chronic workplace stress has not been successfully managed’. Some countries - such as Denmark, Estonia, France, Hungary, Latvia, Netherlands, Portugal, Slovakia and Sweden - accept that ‘burnout syndrome’ could amount to an occupational disease though, deserving of compensation to those suffering it.

Graham Greene’s 1960 novel A Burnt-Out Case is often suggested to be the first popular depiction of the experience, telling the story of an architect who no longer found any meaning in his work, nor any joy in his life. However, it emerged as a mental health concern in 1974, when the psychologist Herbert Freudenberger wrote about the burnout he witnessed amongst colleagues working in a free clinic for drug addicts. He described states of exhaustion, fatigue, and frustration that looked like depression, but were intrinsically linked to the stresses of the job, and he made a link with those in the helping professions.

Two years later, the American psychologist Christina Maslach’s work with social care professionals put burnout on the psychological map as a gradual process of fatigue, cynicism, and reduced commitment. She joined forces with a colleague Susan Jackson and their research led, in 1981, to a reformulated idea of a syndrome, using the Maslach Burnout Inventory (MBI) to quantify it (which is now reflected in the ICD-11 criteria).

The MBI assesses three dimensions, that were familiar to me from my work with V: emotional exhaustion (which is of a chronic sort, not mended by sleep), a sense of ‘depersonalisation’ (a type of cynicism that can tip into a lack of feelings or empathy for others, or even a disengagement or indifference), and ‘reduced personal accomplishment’ (feeling ineffective). Later versions were adapted to their context, such as for teachers and students and medical professionals, although it is accepted that burnout can debilitate workers in almost any field – business, law, technology and closer to my home, mental health practitioners…..

Personality Disorders

I’ll never know if P’s narcissism (described in a previous post) would be deemed ‘pathological’ so that it would be diagnosable as its own type of ‘personality disorder’(PD), because I’m not trained to make such assessments. PD is another term that can be thrown around loosely in conversations, although most mental health professionals I know have learnt to dislike it. Dr Femi Oyebode, a retired Professor and Head of Department of Psychiatry at the University of Birmingham described them earlier this year on BBC Radio 4 as an ‘exceedingly problematic’ concept. If you are labelled as ‘disordered’ when you are in tremendous anguish, and probably suffering the effects of a previous trauma, this can feel stigmatising to say the least, and as if you are reduced to a ‘problem’ with little hope of recovery. On the flipside, if you told me that you had an ‘ordered’ personality, I would be concerned too.

PDs describe an enduring, chronic state of being, rather than a fleeting mood or set of feelings. In other words, they affect how we think and feel, how we respond to adversity, and how we manage all our relationships. Without support they are difficult to live with (the mental health charity Rethink suggests around 1 in 20 people live with one) and often involve suffering serious mental health problems such as anxiety or depression, or an addiction as a means of coping with unbearable feelings.

In the UK, until 2022, PDs were diagnosed according to ten different ‘types’, arranged in three clusters, bearing heavy duty - and I’d say, pejorative – names that you may have heard of. You may well find them online or still used by medical professionals, or by those who had their diagnosis given to them before the guidelines changed. Group A PDs described ‘suspicious’ types of people, namely: Paranoid, Schizoid and Schizotypal. Group B PDs described emotional and impulsive people, namely: Antisocial and Borderline (both of which I’ll come onto), Histrionic, and Narcissistic Group C PDs described people who are particularly anxious or fearful: Avoidant, Dependent and Obsessive-Compulsive (which is distinct from the condition of Obsessive Compulsive Disorder which I discuss in the following chapter). The ‘mixed PD’ and ‘PD not otherwise specified’ categories nodded toward the reality that us humans cannot be neatly divvied up.

The latest edition of the ICD aimed to make things easier for clinicians who follow this manual (the US version, the DSM is the more persuasive one that dominates research), as well as reducing stigma for patients. So, the ten PD categories were replaced with a single diagnosis of PD (so, still using the ‘disorder’ idea), which is then specified by severity: mild, moderate, or severe. Specific personality styles are also assessed (via ‘trait domain specifiers’) described as: negative affectivity (a tendency to feel negatively), detachment (withdrawal from others), dissociality (a disregard for others), disinhibition (impulsivity) and anankastia (perfectionism). The idea is that we are seen with more nuance than before, on a continuum of personality traits, rather than in categories.

While it can be insulting enough to be deemed ‘disordered’ by someone with no medical training, like your ex-boyfriend or sibling (real examples of mine), a professional diagnosis of a PD, suggests that you are not within an acceptably sanctioned range of behaviours. Many with the diagnosis feel that a PD means they aren’t ‘normal’ or appropriate. (A quick digression: The word ‘normal’ referred to a right angle in mathematics until the Belgian statistician Quetelet applied the astronomer’s ‘error curve’ to human measurements, such as height and chest measurements, in his 1835 work, On Man and the Development of His Faculties. He suggested that deviations from the statistical average were potential moral or social aberrations, so binding ‘normal’ with ‘correct’).

Mental health advocates also push for better cultural understanding of patient behaviours too, as this will have a bearing on what makes up ‘normal’. When I shadowed a psychiatrist in East London during my training, he refused to use the language of any diagnostics and told me openly how he hated the concept of PDs partly on the basis that most of his patients were South Asian, with personalities reflecting cultural norms that didn’t reflect those who drafted psychiatric guidance. Sadly, he was deemed ‘maverick’ and ruffled feathers amongst some of his colleagues. The subjective assessments involved in PD diagnostics also mean that one psychiatrist may make a different one from another, and patients can find themselves with more than one diagnosis at the same time, or over time.

Two chilling examples of how cultural constructions of mental ‘abnormalities’ played out in the past include the American physician Samuel Cartwright’s proposition (in an 1851 paper) that enslaved Africans who escaped or attempted to escape, had to be suffering from a mental illness of ‘drapetomania’. His logic was that enslavement was such an improvement to their lives, that these desperate souls had to be unwell to want to escape. The other egregious example is that, until 1973, homosexuality was deemed a psychological disorder by the APA.

Controversies orbiting our current diagnostic system reach back at least into the 1960s anti-psychiatry movement, led by figures such as the French philosopher Foucault and Scottish psychiatrist RD Laing. They railed against heavy-handed diagnoses and the abuse of the power of psychiatric practices, which many believe persist to this day. There have been some obvious improvements such as the closure of asylums and the banishment of little researched surgeries, like lobotomies, and poisonous medications, but the psychiatric system we have today is struggling to look after its patients well.

More recent advocacy from some psychologists and those with lived experience of mental illness urge more appropriate ways to formulate diagnoses. The Power Threat Meaning Network, who are affiliated with the ‘Drop The Disorder’ campaign advocates for a more holistic and humanistic approach to mental health, that avoids reducing us to simple categories and behavioural targets to achieve and seeks, in particular, to ‘drop’ the problematic ‘Borderline PD’.

The idea of a ‘borderline’ first came about before the Second World War when Freudian analysis gripped psychiatric thinking and drew a line between ‘neurosis’ (which could be treated with psychotherapy) and ‘psychosis’ (more for psychiatry and inpatient treatment). Patients who straddled the line between the two were deemed ‘borderline’. This idea was developed further by Freudian thinkers amongst themselves until 1980, when it moved onto the diagnostic roster of the DSM-III.

The latest ICD’s new ‘dimensional’ diagnostics makes the case for diagnosing BPD as a PD with a ‘borderline pattern specifier’ which captures characteristics and experiences of a patient such as impulsivity and emotional instability that could lead to self-harm, intense fear of abandonment, unstable relationships, unstable sense of self, intense anger, and periods of dissociation. Many make the case that such a profile describes an entirely appropriate response to a traumatic childhood, which should shift its understanding entirely, as well as its treatment.

In the final year of my training, I worked at a NHS mental health trust on the edges of south London. I was part of a team made up of senior practitioners and a psychiatrist, and a GP who referred clients to the psychotherapy service I worked in. I have very fond memories of my time there, and I remain grateful for my team’s commitment to my development, which was invaluable for my later role flying solo (I also had the benefit of formal training, and supervision, which most services can no longer pay for, and trainees are now denied).

However, I won’t forget how the ‘borderlines’ were talked about as the particularly bothersome patients who made life difficult for the team – contacting therapists between sessions, not turning up to them, and often threatening self-harm or suicide. I met ‘one of them’ as she walked into the staff room when I was eating lunch alone one day. She was in floods of tears and not making much sense, and I found help for her, not knowing what best to do myself. Later conversations with her group therapist (as BPD is treated with group therapy) betrayed a weariness on his part, and a sense of despair at getting her well.

He lamented how she was known to ‘split’ (ie seeing one person as ‘all good’ and another as ‘all bad’) and ‘project’ (making therapists feel the feelings she could not bear) and he seemed to think she was resistant to the help she had on offer. At best, she could be ‘contained’ or ‘managed’ by the self-help skills she was being taught. I left my placement tainted by this cynical view, and if I’m honest, fearful of working with such a diagnosis in private practice.

There is an increasing recognition that BPD expresses a legacy of childhood trauma, and urges a need to view the idea with this trauma-informed lens. The US psychologist Marsha Linehan who pioneered the development of a specialist treatment known as Dialectical Behaviour Therapy agrees, as do all those involved in work with complex trauma, which may better describe many BPD cases (as ‘complex PTSD’). Many clinicians may use different terms to distance themselves from BPD framing – such as ‘Emotional Dysregulation Disorder’ or ‘complex trauma response’ or, one I hear most, ‘Emotionally Unstable Personality Disorder’.

The psychologist Jay Watts notes how BPD is disproportionately given to women (about 75%), which nods toward a general tilt in mental health care toward problematising women’s suffering. This goes back to the days of women being labelled as ‘hysterics’ rather than being listened to (I don’t think those days are over). In a paper published in early 2024, she writes, ‘Retaining BPD as a de facto diagnosis keeps us stuck at a deadlock that undermines the voices of patients who have persistently told us this label adds ‘insult to injury’. She calls for ‘a recognition that the BPD construct often hinders access to help and ripples into unintended areas of life and that, more than 40 years after BPD was first introduced in DSM-III as a patch-work solution that pleased no one, we can do better’.

A note on bipolar

Although not a PD, I mention ‘bipolar disorder’ or ‘bipolar’, as I have often heard it to be conflated with BPD, and it’s another example of how we have ‘disordered’ suffering. (‘She’s borderline, oh no, wait, bipolar?’) Some clinicians think that both bipolar and BPD can co-occur, with research suggesting potential neurobiological connections between the two - they certainly share plenty of stigma and misunderstanding.

Originally thought of as ‘manic-depressive illness’, in the 1980 DSM-III a new diagnosis of ‘bipolar disorder’ was born, to describe the repeated experience of cycling through episodes of depression and mania. Over time, and subsequent editions of the DSM and ICD, the diagnosis has been split into ‘Bipolar I or II’ types, with diagnosis depending on the type of mood episodes, their severity, duration, and consequences.

In 1997 the psychologist Kay Redfield Jamison depicted her terrifying version in her powerful memoir about her bipolar in An Unquiet Mind. The lows of depression may be more familiar to many than the ‘highs’. She wrote, ‘Feelings of ease, intensity, power, well-being, financial omnipotence, and euphoria pervade one’s marrow. But, somewhere, this changes. The fast ideas are far too fast, and there are far too many; overwhelming confusion replaces clarity. Memory goes. Humor and absorption on friends’ faces are replaced by fear and concern’.

Empaths – light and dark

Unlike having a ‘disorder’, or narcissism, if you are tilted toward extreme empathy this doesn’t mean you have a pathology or that there’s something ‘wrong’ you. You might call yourself, or another an ‘empath’ to describe this, which is a human category that has not been around for as long as many others, but seems to resonate with many.

Being an empath means life can feel overwhelming at times, as you are often in tune with your own, and others’ emotions to such a degree that it can feel too much. This can also be pitched as being ‘overly sensitive’ - in a positive, or negative way. This means that the advice given to empaths often concerns drawing firmer boundaries between yourself and another, and to take extra care to replenish yourself.

Empath as a person-describing noun has flourished most outside mental heatlh settings, and has no formal ‘diagnosis’ to refer to, or other clinical guidance to advise you if you are one. You may well find loose and varying ways to define it online though, such as one I found: ‘You can sense negative energy in spaces’ or ‘You can instantly tell when someone is lying’ or ‘You get unexplained headaches around negative people’.

One major source of thinking and understanding of the concept comes from the US psychiatrist Judith Orloff, who differentiates between physical, emotional, and intuitive empaths. ‘Intuitive empaths’ are explored in one of her nine books, Second Sight, and she describes how they can pick up on others’ unspoken thoughts, motivations, and energy and may even sense things before they are expressed – she writes of her own premonition that a patient was going to attempt suicide.

I first understood the word ‘empath’ in similar terms as a young child in the 70s from my beloved aunt, when the term wasn’t used so much outside the ‘intuitive’ realm. She was ahead of the game in many ways – she collected and used rainwater, offered libations to the Goddess Gaia in the light of a full moon, and introduced me to the importance of recycling. She had a friend who she would describe to me in revered terms as an ‘empath’ - he communicated with spirit guides and angels and knew things he believed the most of us had shut ourselves off from.

Orloff’s other two types are probably more familiar to you: ‘physical empaths’ who are highly sensitive to physical sensations and energies, and can feel others’ pain or discomfort, or energy levels, and ‘emotional empaths’ who are carefully attuned to others’ feelings and emotions like my client K. When we first met, she described being ‘super sensitive’ and a ‘massive empath’ who would cry every day for one reason or another – hearing rousing music, reading the news, seeing a dog limp or even hearing a child cry. She found all her relationships draining (bar her partner who was very self-contained) and she would talk to me a lot about her overwhelming feelings of responsibility, concern and upset for friends, family and colleagues.

One episode brought home to me how profoundly she could feel in the face of another’s pain. Her best friend had become extremely anxious and was relying on K a lot for support, which meant K was speaking to her on the phone at least twice a day, and sometimes over an hour each time, eating into K’s work day, and downtime. In turn, K was becoming anxious, and exhausted, and our sessions would fill with what was going on for her friend. ‘I feel so wretched and drained after speaking with her, and if I can I have to lie down. I have nothing left to give.’

I learned that K’s friend was far from alone in her pain – she had a partner, a supportive family, other friends and a therapist, and this persuaded me to gently suggest K to reduce the support she was offering, or, in the language of boundaries, to strengthen the ones she had. (I also made the point that K might find that her friend had more resilience than her fears let her believe). It took a long while for K to feel able to withdraw, and she bore a lot of guilt for doing so, but K’s friend fared no worse in the end.

While Orloff’s three categories have not taken off as diagnostic ones in mental health circles, their foundational idea of empathy – as both a personality trait and ability – has been tested and researched in philosophical, biological, genetic, neurological, and psychological fields as well as in evolutionary science. This knowledge helps us understand those of us who lack it or struggle with it, and here’s hoping it helps inform our galloping development of AI. The word empathy derives from the ancient Greek word empatheia, made from ‘en’ (in) and ‘pathos’ (passion or suffering) - ie ‘in suffering or passion with’, and despite all the research, there is no settled exact definition nor fixed method of measuring it, although we do know some things about it.

So, for example we know that we are born with empathy – newborns are shown to be more distressed on hearing the cry of a fellow newborn than other sounds – and it tends to be more powerful when it concerns negative emotions, as opposed to positive ones. It is integral to the evolution of our sensory and physiological experience and relationships with others, as Obama called out when he said, ‘The biggest deficit that we have in our society and in the world right now is an empathy deficit. We are in great need of people being able to stand in somebody else’s shoes and see the world through their eyes.’

We also know that empathy isn’t sympathy. Seeing someone terrified at the bottom of a crevasse and feeling for them is sympathy. Climbing down to feel the terror with them is more like empathy. Empathy isn’t compassion either (and brain scans show the two have different neural pathways), as compassion involves a motivation to alleviate another’s suffering. So, climbing down the crevasse to rescue someone, rather than sit with them terrified, is more like compassion. Empathy can certainly help us to feel compassionate though, as we are more likely to be motivated to help if we are empathetic. And just to complete this comparison, we can also be compassionate without feeling empathy, as I could throw someone down the crevasse a painkiller and blanket, feeling sympathy alone.

The neuroscientists Francis Stevens and Katherine Taber define empathy as ‘other-oriented, as it encompasses the ability to understand and to vicariously experience the feelings of another person’ and it is generally accepted to have two key components, each with their own mapping in the brain: ‘affective’ and ‘cognitive’. (Other researchers identify a ‘motor’ component that emphasises automatic behaviours – eg smiling when smiled at).

Cognitive empathy involves being able to understand intentions, perspectives, feelings and thoughts of another and is sometimes referred to as ‘theory of mind’ or ‘perspective taking’ (and can be seen lacking in some autisms and psychopathologies). It also offers a valuable context for ‘affective’ empathy to thrive, which concerns feeling the way another person is feeling (and maps more with Orloff’s emotional empath type) - like K, who also puzzled at how I don’t burn out working as a psychotherapist which involves hearing so many stories of pain. (I look at burnout in my next chapter, and I manage to avoid it by not relying on empathy alone, but the more protective capacity of compassion which I direct to myself as well as others).

K also described to me how she experienced ‘emotional contagion’ a lot, which meant her emotional states who sync with her friend (and others), automatically and without her being aware at first. Stevens and Taber suggest this process of ‘contagion’ involves something beyond empathy they call a ‘confusion of difference’. In other words, while empathy involves knowing that you are feeling another’s feeling (even if the boundary with another feels fuzzy), contagion involves a ‘merger’ with another, with no boundary at all. This may be at play in codependence and enmeshment, which I looked at in chapter two.

If I’d met K a decade ago, I doubt she would have described herself as an empath, but she might have used the prequel term, ‘highly sensitive person’, or ‘HSP’. The two are similar, although Orloff claims an edge on her website, ‘empaths take the experience of the highly sensitive person much further. We can sense subtle energy, which is called shakti or prana in Eastern healing traditions, and actually absorb it from other people and different environments into our own bodies. Highly sensitive people don’t typically do that. This capacity allows us to experience the energies around us in extremely deep ways.’

I came across HSPs for the first time when a client lent me her much-loved book for me to read because she felt it summed her up so well: The Highly Sensitive Person by the US psychologist Elaine Aron. First published in 1996 (and now sold over a million copies in 17 languages), it has been re-issued and followed up with versions refined for particular contexts, (eg The Highly Sensitive Parent, The Highly Sensitive Person in Love). I did read it, and it did help me to understand my client’s experience of being herself, as well as many others since - Aron estimates that as many as 15-20% of us are HSPs, and her self-reporting ‘HSP Scale’ can guide you to find out if you are one of the many.

Aron suggests using the acronym DOES to spot an HSP: D for ‘depth of processing’ (eg are you unusually conscientious and ponder things others might miss?), O for ‘ overstimulation’ (eg are you sensitive to loud noises, strong smells, bright lights), E for ‘emotional responsiveness/empathy’ (eg are you more easily stressed by noise, chaotic situations, deadlines? Do you have considerable empathy for others?) and S for ‘sensitive to subtleties’ (eg Do you seem to notice things that others don’t?).

While being a HSP doesn’t mean having a ‘personality construct’ or mental health ‘issue’, in the same way as being an empath doesn’t, the ‘Sensory-Processing Sensitivity’ trait has been taken up by research (which is not to be confused with the diagnoses of the neurological condition of Sensory Processing Disorder/Sensory Integration Disorder) to improve our understanding of each other, and tailor our responses accordingly. This work also highlights sensitivity as a strength, rather than a vulnerability or a character aspect, as K remembers, that she was told was a problem.

While being sensitive or empathetic towards others is generally thought to be a good thing, it’s worth noting that empathy may not be an unqualified good or adaptive or useful trait. K’s personality could work against her at times: she could become incapacitated in the face of her friend’s distress, to the extent of lying down to recover after talking with her. It could also become a reason not to be able to engage in other people’s problems, or care for ourselves too, just as K described not having anything else to give.

The psychologist and Yale University professor, Paul Bloom advocates for more caution around the idea of empathy as a lofty goal (as Obama suggests), in particular when it is pitched as a guide to decision-making, or a solution to divisiveness. In his book Against Empathy: The Case for Rational Compassion, he notes how we have evolved to reserve our empathy for our kith and kin, and those in our ‘in’ groups (that used to be far smaller than they are today). He argues that empathy can promote biases and prejudices, as it pulls us to focus on who we care about most – ie those we identify with in the present, as opposed to more diffuse or dissimilar groups (‘women in Afghanistan’), or our future generations (as our climate catastrophe bleakly demonstrates). Recent research by Matthew Colman and David DeSteno at Harvard University concludes similarly, ‘Our findings illustrate that an empathy deficit applies not only across social and geographical distance, but across temporal distance, as well’.

Bloom worries that at worst we may become motivated to punish or inflict atrocities on other groups, as empathy is ‘malleable’ and the media can – and do - take advantage of this, rather than reporting facts impartially. This means we can make poor decisions, as they are uninformed, such as prioritising causes that get the most attention rather than those that really need it. As well as empathy that misfires, there’s also another breed of it that is wholly anti-social, and far from the ideas that Orloff describes.

A so-called ‘dark empath’ is a new category of personality (or ‘construct’) that combines personality traits from the so-called ‘Dark Triad’, a term coined by psychologists Delroy Paulhus and Kevin Williams in a 2002 paper The Dark Triad of Personality: Narcissism, Machiavellianism, and Psychopathy. (Machiavellianism describes someone who is strategically manipulative and cynical about humanity. Machiavelli was a 16^th century Italian diplomat who set out his anti-social ideas in his work The Prince and is known for the phrase ‘better to be feared than loved if one cannot be both’).

‘Dark empaths’ were birthed in a 2020 study by Najda Heym at Nottingham Trent University and are particularly interesting for challenging the received idea that the Dark Triads have low empathy scores. They are thought to have low (or selective) affective empathy while having a capacity for high cognitive empathy , which is then used for their own purposes, or weaponised. In other words, they are very skilled at reading and understanding emotions which they use for self-serving motives, and even if they do feel guilt or shame, this is overridden by their selfish wish to manipulate.

A psychopath, in contrast, lacks emotional empathy entirely and often struggles to connect with others. Their defining characteristics are coldness, impulsivity, and a profound lack of remorse or guilt for harmful actions, which is where I come to next.

Psychopaths (and sociopaths)

My client Alex, who I spoke about in an earlier post described her mother-in-law as a ‘psychopath’. I’ve talked to teenagers about their ‘psychopath’ teachers, and clients about their ‘psychopath’ ex’s, but I winced on hearing a mother describe her five-year-old as one. You may have even heard someone suffering from psychosis described as a ‘psychopath’, or the term being swapped with ‘sociopath’. As if the risk of confusion isn’t enough, the term ‘psychopathology’ - which refers to the study of mental illness more broadly – can also lead people astray.

It’s highly unlikely that Alex’s mum is a psychopath, nor indeed your old physics teacher or horrible ex: estimates suggest that 0.6%-1% of the general population can be defined this way, with far higher rates in prison populations, one estimate being 7.7% for men and 1.9% for women. Psychopaths – like narcissists – seem to fascinate us, but only at a safe distance, far away from our empathic and compassionate and non-psychopathic selves.

Maybe we keep our distance from psychopaths, as we do with other enigmatic states like psychosis, because we fear, deep down inside, that we could relate to aspects of them. As Jon Ronson wrote in The Psychopath Test, his best-selling 2011 book (which he re-booted on a 2024 tour), ‘I was starting to realise that some people really do have a kind of mental illness where they don’t connect to others emotionally, and those people are quite damaged, but as I went on, I began to feel uncomfortable diagnosing it. How many of us are a bit psychopathic in our everyday lives?’

Unlike a diagnosis of OCD or pregnancy, where there is no scope for having ‘a bit’ of either, the traits of psychopaths may show up in varying degrees of emphasis and many see the concept as ‘dimensional’ or on a spectrum, rather than a category in of itself (like other mental health conditions discussed in this book). In other words, psychopathy may well differ from non-psychopathy in degree rather than kind, as Ronson suggests too.

If you haven’t read Ronson’s book, it may well be that most of your ideas of what defines a psychopath derives from other sources instead (his book has been challenged by experts in the field for lacking clinical precision). My own early idea derived from Talking Heads and Hitchcock: my teenage self ‘sung’ the 1977 hit Psycho Killer whenever I wanted to be particularly rude about someone (while imitating a zombie-like creature stabbing at the air with an imagined knife, á la Hitchcock shower scene).

Many popular depictions have skewed us to understand psychopaths as male serial killers like Ralph Cifaretto from The Sopranos, or the chilling Hannibal Lecter in Silence of the Lambs, as well as the non-fictional Ted Bundy and Charles Manson. The ‘charming con artist’ type are typified by Bernard Madoff and Elizabeth Holmes and the ‘Wolf of Wall Street’, Jordan Belfort. They are far more than their stereotypes, and as ‘crazy’ as they may be, psychopaths are not out of touch with reality, and although they are more likely to be violent, there’s no inevitability that they will be.

While we may often get it wrong when it comes to defining a psychopath, it also seems that there is also no clear professional consensus on the meaning, definition or clinical features of ‘psychopathy’. It was put on the psychological map by the American psychiatrist Robert Cleckley’s book, The Mask of Sanity: An Attempt to Clarify Some Issues About the So-Called Psychopathic Personality (first published in 1941) where, after interviewing prisoners, he outlined the key personality traits of people who appeared to be likeable, yet underneath this, hid profound problems with emotions that help us relate well with people – such as remorse and empathy, as well as struglling to learn from experience.

Cleckley’s work pioneered subsequent research and thinking and formed the basis of the Canadian psychologist Robert Hare’s most broadly accepted measure of psychopathy: the Psychopathy Checklist (PCL), and the subsequently revised PCL-R. Although easily found online, it’s not one for you or I to play around with, as it is a specialist instrument, used in a specialist field. It also works alongside a semi-structured interview and corroborative evidence, such as forensic reports found in prison files, and needs to be assessed with cultural bias in mind (and many make the point that Hare devised the PCL based on research with white Western men).

The PCL-R is mostly used in criminal justice settings and originally rated aspects under two ‘factors’: the Interpersonal/Affective (eg superficial charm, grandiose sense of self-worth, pathological lying, cunning /manipulative, lack of remorse or guilt, shallow affect, callous / lack of empathy, failure to accept responsibility); and the Lifestyle/Antisocial (need for stimulation, parasitic lifestyle, lack of realistic long-term goals, impulsivity, irresponsibility, poor behavioural controls, early behavioural problems, juvenile delinquency, revocation of conditional release).

Subsequent research has proposed Three or Four factor models and other scales have been developed and applied to non-criminal populations (eg the ‘Levenson Self-Report Psychopathy Scale’ or the ‘Business-Scan 360’ for workplace settings). Ronson’s book highlights how psychopaths thrive in surgical theatres, corporate organisations and amongst media personalities and entertainment, and research into the presence of psychopaths in corporate settings grows. Some say humanity’s greatest problems we face today are due to psychopaths at the helm: wars, climate change, famines, trafficking, and wild global inequalities.

More recently, Ronson has tied his views on public shaming on social media (his 2015 book You’ve Been Publicly Shamed explored this), with psychopathology. He notes how some can behave in very cruel ways online, alone or with a ‘mob mentality’. He sees traits of psychopathy: lack of empathy and remorse, pleasure taken in people’s downfalls, and impulsivity which is fuelled by the fact we don’t see each other and may be type-shouting at each other across oceans. Both psychopaths and social media users can also create carefully curated ‘charming’ public personas, which are then used to manipulate others’.

There is sympathetic thinking about psychopathy though, and the late US neuroscientist, James Fallon, spoke and wrote of a more nuanced view of the old-style stigmatised category we tend to cling to. His ideas came about by accident, while conducting a study on Alzheimer’s disease (while also researching psychopathy). He planned to use brain scans of his family as a ‘control group’, but on examining them, he noticed that one brain showed low activity in areas of the frontal and temporal lobes (that determine empathy, morality, and self-control) which is a pattern typically associated with psychopathy. It transpired to be his own brain.

Initially surprised, and obviously fascinated, Fallon went on to discover that he carried genetic variants associated with aggression and low empathy (with a family line of alleged murderers), and this led him to consider the role of neuroplasticity in tempering psychopathic tendencies. In other words, he suggested that the brain can be ‘rewired’ to some extent through experiences, and conscious effort. He hadn’t killed anyone, or stepped too far out of line because, he suggested, he was loved and felt secure and had experienced a happy childhood. He candidly described himself as a ‘competitive asshole’ in interviews, and that he worked hard to be more empathetic – not because he wanted to be nice, but more because he wanted to prove that he could.

Fallon knew that people like himself can have some psychopathic traits without a full-blown diagnosis, or even behaving too anti-socially, and he introduced the idea of a ‘prosocial psychopath’ who function well in society and may even excel in certain professions that don’t harm us – such as surgery, and in his own work of psychological research.

While the edges of psychopathy with non-psychopathy shift around, so they also do with the sibling idea of sociopathy and then again, the diagnostic category of Antisocial Personality Disorder (ASPD) which I mentioned earlier - psychopathy isn’t in a diagnostic manual because it involves complex internal traits that are less observable and hard to assess, and also, clinicians have found it hard to reach consensus as to how it could be pinned down (bar the checklist used in forensic settings).

ASPD is set out in the latest DSM and re-framed as a particular type of PD in the ICD-11. It often overlaps with psychopathy but emphasises observable antisocial and criminal behaviours (such as impulsivity, aggression, and lack of remorse) rather than the internal, and often hidden, personality traits of psychopathy (like lack of empathy). People with ASPD tend to come from chaotic or unstable backgrounds, with a history of trauma or abuse or neglect, while psychopathy may have stronger biological or genetic components. It is estimated that only around 25-30% of people with ASPD are psychopaths.

‘Sociopathy’ also describes a tricky way of being and like psychopathy, it doesn’t have a home in diagnostic manuals (although it was recognised by early DSMs as ‘Sociopathic Personality Disturbance’ before being dropped for lack of evidence and agreement). Sociopaths are associated with a higher degree of psychopathic traits, such as lack of empathy, shallow emotions, and manipulative behaviour, yet there is no standard way of diagnosing them. Some mental health professionals, more so in the US, may use the PCL-R and the ASPD to guide them, and may even ignore the difference between sociopathy and psychopathy (as Jon Ronson does).

Just as Fallon wanted to promote a better, and kinder, understanding of psychopathy, the US psychologist Patric Gagne also wants this for sociopathy (a term she took from her own diagnosis by a US psychologist). In 2020, she wrote a feature in the New York Times’s Modern Love series that gained a lot of interest: He married a sociopath. Me. This led to her memoir, Sociopath in which she describes a key ‘emotional learning disability’ which involved a muted sense of empathy, and a persistent sense of apathy. She has learned to develop empathy over the years, and especially since marrying, having children, having therapy and researching how minds like hers work. Like Fallon, she believes we can ‘re-wire’ a brain we have.

As a child, Gagne had to work hard to mask and conceal the truth of her compulsions from others, copying her sister and classmates as many autistic people describe doing (she also describes herself as ‘neurodivergent’). This felt as exhausting as speaking a different language all day, and the ‘sociopathic pressure’ would build up to such an extent that she felt compelled to act out destructively - such as stealing, joyriding, lying and following people. She learned that by doing small destructive acts often could ease this pressure, and they also allowed her to see some colour in her grey world. Gagne also taught herself some rules to live by – such as not to commit violence, as she didn’t want to hurt others (although slips happened and she describes stabbing a nearby girl with a pencil).

Gagne laments the lack of research into sociopathy, and its lack of support, noting how we tend to only know of the extreme end of the spectrum which is conflated with monstrous or evil acts. She urges for a more nuanced and compassionate understanding of minds like hers and asserts that the majority of sociopaths are on the moderate end of the spectrum and can be helped, as she was. Although she has a limited access to all emotions, this doesn’t mean that she is ‘bad’, and whatever she feels or doesn’t feel matters less than what she does.

I’m guessing you have considered if there is a narcissist in your life. It seems that we have become particularly interested in spotting one, learning how to handle one or even escape from one. Narcissists seem to account for many mothers, ex-boyfriends, bosses, or high-profile celebrities who focus on themselves too much. Anyone who seems aloof or talks about themselves a lot, has too many tweakments or generally opts to choose their own path runs the risk of being vilified as one too. Like more and more of my clients, perhaps you are worried you are a narcissist too.

Narcissism isn’t just about selfishness or arrogance or self-absorption though. In clinical terms, it defines someone who is, underneath all the unlikeable bluster, feeling crushed by a desperate loneliness and a buried belief in their unworthiness and unlovability. The ugly bids for attention that alienate or anger you and I, turn out to be exhausting efforts to feel better, or more special, than the rest of humanity to cope with the hidden sense of being the least special. This means they tend to struggle to identify with any sense of being vulnerable, so are unlikely candidates for therapy. So, I tend to talk about narcissism with my clients in the context of their stories of other people’s behaviour (often described as ‘toxic’), as narcissists don’t tend to seek my help.

I’ll come onto explain in more detail how narcissism can play out in us in different ways, but our general use of the word stems from early psychology and thinkers such as Sigmund Freud who emphasised personality traits like grandiosity, domineering styles of relating, attention-seeking and entitlement. The term originates from the ancient Greek myth of Narcissus, a vain and beautiful young man who fell in love with his own reflection in a pond and lost his humanity by transforming into a flower (which bore his name, although it is more commonly known as a daffodil).

I like the description used by US psychoanalyst Jay Greenberg that narcissism is ‘an allergy to otherness’ which points to the bind narcissists can find themselves in: while they desperately need other people to shore up a sense of worthiness (eg by clapping at their performances or telling them how brilliant they are), other people also pose a threat if they get too close as they might be truly seen, including the ugly core deep down inside. The irony is of course, that if someone understood the narcissist’s true pain, they might well be liked or loved after all.

As with all descriptions of personality types, it’s possible to have one or more ‘traits’ of narcissism rather than a full-blown ‘condition’ of Narcissistic Personality Disorder, which describes someone at the extreme end of the spectrum in clinical terms. So, if like me, you can reflect on solipsistic or arrogant or even manipulative behaviours with a genuine desire to repair any hurts created, this wouldn’t amount to being a narcissist. Most people I know have moments wrestling with these traits, and I’ll come onto describe healthy doses of narcissism too.

We guess that narcissists have been around at least as long as humanity has. The stories we have of Emperor Nero, Gengis Khan and Napolean would make it likely they would score highly on some of the many inventories devised to score narcissism (I’m resisting suggesting overweight blond male politicians), while fictional stories, as a reliable mirror of cultural themes, have long explored our fascination with these captivating character types.

Flaubert’s Emma in Madame Bovary and Oscar Wilde’s Dorian Gray are often recruited as examples, while characters like the Absolutely Fabulous pair Edina Monsoon and Patsy Stone stand out as ridiculous versions of our modern narcissistic selves. Charlotte Mendelson’s success with her last two gripping novels (The Exhibitionist and Wife) are largely due to the centrifugal force of her monstrous narcissistic protagonists. We love to hate them so much, perhaps because we envy the apparent simplicity of their selfish lives.

There is also an ongoing vogue for the publication of memoirs that recount life with a narcissist – or ‘narc’ as you may know them by. Christina Crawford’s 1978 Mommie Dearest was (then) a rare exposition of an extremely narcissistic mother at the time of publication, while Jennette McCurdy’s 2022 I’m Glad My Mom Died continues the theme, alongside many narcissistic parent/partner tales and non-fiction guides of how to survive narcissistic relationships (such as Thomas Erikson’s 2022 Surrounded by Narcissists). As I write there are over half a million #narctoc posts on TikTok and along with true experts, many self-proclaimed experts ironically seeming to thrive on likes, shares and re-posts of their wisdom.

While narcissists have probably always been around, there is some debate about when, and to what extent, they became endemic in our culture, to the extent of defining a generation. Tom Wolfe, the American author coined the seminal phrase ‘The Me Decade’ in his 1976 New York Times article about America, well before the decade had ended. Christopher Lasch, the cultural historian, followed with his views, some challenging Wolfe, in his own tome The Culture of Narcissism: American Life in an Age of Diminishing Expectations (1979) which was hugely influential in launching narcissism as a mainstream idea.

Some say my generation, ‘Generation X’ mobilised the narcissism that Lasch observed even further. Coming to age in the late 80s, I would describe myself as a (then described) ‘ego maniac’ living out Margaret Thatcher’s vision that ‘there’s no such thing as a society’. I left school with a mission for single-minded success and barely a nod to my future impact on the environment, or future generations. Of course, there were plenty of broader minded (and more compassionate) young adults around me at the time, but I wasn’t alone in my individualistic drive.

William Storr’s 2017 book, Selfie: How We Became So Self-Obsessed tracks the rise of individualism and perfectionism in Western societies up until the ‘self-esteem movement’ humming in the background of my young adulthood in the 80s and 90s. He argues that we have created a ‘neoliberal self’ (reflected in millennial generation), that prizes being extroverted, attractive, individualistic, and ‘self-optimising’ (which involves industries to ‘produce and consume’ such maintenance. This is an idea I return to in another post).

As Storr’s title suggests, he notes how the arrival of social media platforms has had a profound impact upon our preoccupations: Narcissus stumbled across a pond, while we all have self-facing cameras in our hand. Our smartphones also allow us to easily platform narcissists, encouraging their self-absorption and quest for affirmation even further. Christopher Bellitto’s book, Humility: The Secret History of a Lost Virtue (2023) speaks volumes alone with his title.

The American psychologist Jean Twenge is a leading thinker on generational differences, and her research (published in two editions of her book Generation Me) asserts that millennial Americans are more narcissistic than previous cohorts – as Storr suggests. However, the picture is more nuanced when it comes to Gen Z and some studies have suggested that narcissism has been declining among young people since the 1990s. Psychotherapists are critically aware of how much our young struggle with anxiety and depression, and how some of this distress is fuelled by concerns for the future of our planet rather than individual ones.

While therapists think about cultural and generational influences on our narcissism, we are also guided by clinical thinking as to what other influences help make a narcissist. The psychiatrist Paul Näcke is often credited as being the first to write about it in 1899, as a problem of ‘narcismus’ to describe someone who is sexually turned on by their own body as much as anothers’. Sigmund Freud, a thinker many therapists begin with, broadened these ideas in his 1914 paper On Narcissism: An Introduction. He distinguished between a healthy ‘primary’ and unhealthy ‘secondary’ narcissism, the former referring to the early infant phase of his theory of sexual development.

Freud’s ‘primary narcissism’ refers to the developmental stage when we have yet to realise our separateness from another, and we all tend to accept this as normal. None of us expect a baby to worry about bothering a parent when she needs a nappy change, nor do we think a three year-old is ‘full of herself’ when she proudly dresses up as Elsa and declares ‘I’m a princess!’. Similarly, in adulthood, it is healthy to be able to prioritise our needs at times – without a desire for positive attention or praise (and looked at this idea with ‘boundaries’ in the previous chapter). We put the oxygen mask on first before helping another less able than us, otherwise we could pass out cold and be no use to anyone.

Freud’s notion of unhealthy narcissism wasn’t examined in any great depth in the therapy literature until the 1960s and 1970s when the psychoanalysts Heinz Kohut and Otto Kernberg outlined the ‘mask model’ of narcissism stating that ‘grandiose’ traits, such as arrogance and entitlement, mask feelings of insecurity and low self-worth. Kernberg focused more on the malignant side of narcissism than his colleague, and some suggest this may be because as a teenager he had had to flee the Nazis occupying his home of Vienna.

By 1980 narcissism made it into the DSM in its extreme version, as a personality disorder (Narcissistic Personality Disorder or NPD), blending ideas from Kernberg and Kohut. Around the same time, the Narcissistic Personality Inventory (NPI) was published to measure narcissistic traits that don’t meet NPD criteria, and this quickly became a gold standard of assessment for psychologists and researchers. This has been revised over the years and replaced by other scales – the Grandiose Narcissism Scale, Pathological Narcissism Inventory, Narcissistic Grandiosity Scale to name a few.

Research into narcissism has blossomed alongside our cultural growing fascination, and results have remained clear about the two distinguishable dimensions that Kernberg and Kohut both wrote about: the grandiose (associated with arrogance, entitlement, high self-esteem and aggression) and the vulnerable (low self-esteem, distrust of others, isolation and unhealthy egocentrism).

There are many ways to describe how narcissism plays out in us, but I like the work of Dr. Craig Malkin. He is a psychologist and lecturer at Harvard Medical School and author of the 2016 book Rethinking Narcissism which intends to rehabilitate the concept of narcissism as one of a spectrum of traits as opposed to a wholly negative personality. He dislikes the NPI for including many healthy traits of a personality, and worries it runs the risk of labelling people as narcissistic inappropriately. He wants to make more room for healthy narcissism, assuring us that it’s ok to ‘dream big but not at the expense of relationships’.

Malkin developed an alternative to the NPI, that can be completed online: the Narcissistic Spectrum Scale which captures ‘healthy’ narcissism in the middle of its 0-10 rating (at the lower rating, he describes ‘echoism’ which describes people who focus too much on others and rarely feel special – perhaps a codependent person as described in chapter 1. Echo fell in love with Narcissus and could only repeat what others said). He discerns three main types of ‘trait narcissism’ at the higher rating of his scale, and at the very highest, people might tip into pathological narcissism – ie diagnosable as having NPD.

The ‘grandiose extravert’ type Malkin describes is the one we all tend to ‘know and loathe’. In self-reporting questionnaires, they tend to agree with statements such as ‘everyone laughs at my jokes’ or ‘I like looking in the mirror’. Hallmarks include grandiosity, pride, self-involvement, entitlement, arrogance, omnipotence and an over reliance on achievement to feel a sense of self-worth. They are driven, sometimes relentlessly, to feel better than the rest and might only show up in therapy to find an ally in their cause of ‘me’.

While grandiose types can dole out criticism, they tend to be very sensitive to receiving it because their sense of self is so fragile, and maybe even unformed to start with. They might even deny mistakes or failures in the face of easy corroboration - a ‘narcissistic amnesia’ illustrated by one client of mine who kept contemporaneous notes of her husband’s self-obsessed rants, only to be told she had been hallucinating while writing them. This fragility of a narcissist’s personality means they can easily spiral into feeling shamed and humiliated, although they wouldn’t be able to, or even want to, describe their feelings in such vulnerable terms.

The ‘covert introverted type’ may be less obvious to you or me and are more likely to show up in therapy than their grandiose siblings - their grandiosity hides inside, rather than brashly advertised externally. They tend to agree with self-report statements such as ‘I’m more sensitive than others’, and avoiding the spotlight, they control others through passive-aggressive acts such as blaming others. Essentially, their pain is worse than others and they may also want others to assure them of the same. A client of mine was so consumed by her hatred toward her neglectful mother that she became stuck in her story of her own tragedy. She was a journalist and had colleagues involved in the reporting of a child trafficking ring but seemed unable to accept that the traumatised children they wrote about had suffered worse than her.

Malkin’s third category refers to the ‘communal’ type which describes those who feel special by being indispensable to humanity. They may leap to help at any opportunity, or ostentatiously give money or time to charities, tingeing their actions with a martyrish tone. They are also prone to making mountains out of molehills to remain firmly at the centre of the helping stage.

Studies suggest that genes play a role in narcissism, but the influence that therapists tend to consider the most is the link to a childhood of emotional deprivation of a particular kind. So, we often see narcissism to be a full-blown expression of someone who was used by a parent (or caregiver) to fulfil their own ambitions, desires, or ideals. This means that the narcissist’s idiosyncratic and authentic nature, including all their vulnerabilities and desires and needs and quirks, were ignored or overruled because their parent’s own needs were always far more important.

Typically, this child was idealised (which doesn’t mean the child is truly understood), or denigrated or maybe both, to make a parent feel better about themselves (and these parents may well be narcissists too as narcissism can breed narcissism). It’s easy to think that a narcissist must have been lavished with praise growing up, and this may be true but it’s likely that it was hollow or conditional: an ‘A’ in a test was a cause for celebration, but a ‘B’ was dismissed or a reason to humiliate. Essentially, a narcissist’s true self was ignored and another ‘false self’ emerged to compensate (a term coined by the psychoanalyst Winnicott).

Ariel Leve wrote a stunning memoir, An Abbreviated Life (2016), about growing up with a narcissistic mother who saw Ariel as an extension of herself, and present to serve every (wildly changeable) emotional need she had. Her extraordinary self-obsession was typified by her chilling habit of demanding that Ariel help her re-enact the moment of her birth, under the covers of her bed. Her mother could then re-live the glorious, powerful feeling of magnificence at giving Ariel life - rather than marvel at her daughter’s essence of being that hits most new mothers I talk too.

If we aren’t seen or understood by a parent in these ways, we can learn to inflate parts of ourselves that were reliably valued (such as looks, intelligence or athletic prowess) and to discount parts that were ignored or even subject to humiliation (such as a struggle to learn quickly or emotional sensitivity). This false self is essentially, a very fragile one, seeped in a tension between these poles of grandiosity and worthlessness. The tension varies in its tightness, making narcissism vary in its expression from healthy, to unhealthy to utterly maladaptive – as all the scales measuring narcissism suggest.

As a psychotherapist with an understanding of narcissism, it is easier for me to respond to a narcissist with the educated guess that they are, deep down, feeling stranded and deeply lonely. Part of my job is to help my clients take appropriate responsibility for their role in creating bumps in their road – such as repeated relationships going south or getting fired from job after job. But a narcissist can only see themselves as a victim of other people’s wrongs, leaving the only role of therapy – if at all – as a place to validate their wonky worldview.

My memorable client P wanted me to do this. I remember him well because he treated me with such disdain. I was a rookie and not experienced enough to know what was going on between us in the short time we spent together. He turned up late for each of the (only) three sessions we had, and then expected it to overrun, to make up the 50 minutes he paid for. It didn’t occur to him that I might have had another client after him, nor that he was in any way responsible for a shortened session – it was the fault of a colleague or bus or traffic.

P didn’t acknowledge his lateness, would then look around my room, nose in the air, peeling off his expensive coat and jacket, ensuring I’d see a flash of their tell-tale designer linings. He’d also take time making himself comfortable in the chair opposite mine, making it obvious by his adjustments that he was unhappy with its dimensions and upholstery. He also made me know early on that he would have preferred to be somewhere more salubrious than my humble north London room, and to be paying far more to a psychotherapist with a better reputation (His parting shot being, ‘Are you thinking of putting your fee up soon, as it’s much lower than others I’ve seen?’).

For a reason that I wouldn’t find out, he had made his compromise with my paltry services, and in the less than three hours we had together, I consistently felt that I wasn’t good enough. I later worked out, with the help of my supervisor, that a good measure of this feeling of inadequacy was not mine, but his feeling, projected into me – this ‘transference’ often happens in the orbit of a narcissist. It’s so unbearable for them to feel their own sense of low self-worth, that they unconsciously project it into others close by who are receptive to it (which, as a new therapist keen to please, I was).

P would stretch out his legs, tip his head back to swerve my gaze, and often cupped the back of his head with his hands, as if catching the sun. A fly on the wall might assume he was chatting to a mate at home on his sofa. He ignored most of my questions that dug beneath the surface of his anecdotes (of ‘irritating’ colleagues and dates that were ‘boring’), preferring to throw a few verbal darts in my direction – ‘I’ve read that book on your shelf there, or rather the newer edition’.... ‘Do you mind not having double glazing with this noisy street outside?’... My repeated efforts to learn about his inner world always failed, as P had to keep me far away from his core vulnerable self, which meant eye contact was unbearable too.

P was unwilling to reflect on his possible contribution, conscious or unconscious, to his distress, as he was stuck in the view that the world was inadequate and unfairly set against him. I doggedly kept persisting with other interpretations of his story, but he didn’t want to consider them. We muddled through these painful sessions, but his growing frustration at me became palpable and as our third session eventually got going, he announced that he was after a therapist who would ‘crack him like a chiropractor’ and that he’d be moving on.

I did not persuade P to stay, as his declaration was such a relief it warmed me up. I now wonder if I had been more patient, and skilled to tune into the synthetic nature of his arrogance, this would have led me to his buried shame. P may have built up enough trust in me to allow us to think together about dismantling his grandiosity, but this would have taken great courage on his part to face that fear. I’ll never know of course, but I do know that I feel fonder of him now than I did then.

My client Alex came to see me for help after the breakdown of her relationship with her aunt, Ella. They’d never been firm friends, but things between them had deteriorated greatly since Ella had married a ‘pompous, arrogant, misogynist idiot’. One week Alex arrived at her session still steaming after a recent family gathering. The ‘idiot’ (I never learned his name) had made a lewd comment to Alex’s teen daughter. Her fury was largely directed toward Ella. ‘She just looked at him adoringly. She didn’t seem to care! Her niece was obviously so uncomfortable, and she did nothing. It was staggering!’ Alex paused, looked me in the eye and announced, ‘She’s a psychopath.’

I will never know Ella well enough to know if she could be a psychopath, bearing in mind this is a clinical judgement I can’t make, and even if I could, I shouldn’t from afar. The little I did know about Ella led me to wonder if she was being emotionally abused by the ‘idiot’ and was acting from fear. Although I understood Alex’s passion, it was a harsh word to use and one that I am not so sure Alex would have used if we’d met five years ago. Our accounts of each other have become more categorical, and extreme at times, and, as Alex showed (and anyone with access to TikTok could do too), we are also more prone to using terms that pathologise. In other words, those that determine that we are psychologically ‘abnormal’ or mentally unwell.

Daniel Siegel, a US psychiatrist and author notes this new habit of ours of ‘nounifying’ or ‘nominalisation’, which he sees as a tendency to turn dynamic processes into something static or fixed. It encourages us to latch onto an aspect of ourselves or another and let that define us, rather than connecting us with the ever-changing nature of our experiences. So, rather than saying ‘I feel anxious’, we might say ‘I’m an anxious person’, and rather than Alex saying something like, ‘Ella seems to like her niece being humiliated’, she says ‘She’s a psychopath.’ It’s tempting to define ourselves when it helps us feel more certain about things but cynically, it can also be a way to close down conversations or even win an argument.

Siegel rightfully laments how reducing each other to labels – mental health ones or otherwise – is ultimately socially destructive, because in doing so, we forge distances between us. If you are an X and I am a Y, without also labelling the bridge or bridges between us, we run a higher risk of black and white thinking too. But if we take a bit more time to use more words, and describe ourselves more, this tilts us toward more fruitful conversations and, maybe more compassion for each other too.

When Alex was talking about Ella, I expected her to use the term ‘narcissist’ as it has become a go-to term to describe anyone who is selfish or seeks attention or seems arrogant. Many of my clients these days also worry about being a narcissist for coming to therapy in the first place. I will, in my next post, go on to de-bunk this much-used term, before looking at the tricky notion of personality disorders and bipolar disorder which are both examples of labelling in mental health that are controversial. I then look at the antithesis of the nasties amongst us: ‘empaths’ who feel too much and are often keenly aware of their emotional overload (unless they are a ‘dark empath’).

I will be looking at more terms that have crept into our language from therapy consulting rooms and other sources (I’ve peeped at ‘codependence’ which launched into the mainstream after a best-selling book, and ‘gaslighting’ which first became a verb in response to a chilling British play and film, while ‘narcissism’, ‘empath’ and many others have gained their traction online). However, I also look at some terms that differ from the rest, because they are ones used by mental health professionals to diagnose – such as OCD, PTSD, narcissistic personality disorder or ADHD.

A mental health diagnosis is made after assessing symptoms against written descriptions and criterion that are set out in diagnostic manuals (the two most important ones I’ll come onto describe), and other clinical guides. A clinician’s experience and personal understanding of their patient comes into play in diagnosing too, as much of the assessments made will be subjective, and there will always be room for interpreting things differently. Ultimately, diagnosis needs to be done very carefully, and to be left to the professionals – and I’ll come onto explain that most of us, including me, aren’t in that camp.

In my posts I refer to the manuals but also return to the idea of how diagnosis – even when done by a qualified practitioner – is a double-edged sword. While it means you may be able to access treatment (if available), and have a useful meaning-making to distress, many feel that many diagnoses reduce the complex nature of a human distress to a simple label (perhaps better stuck on a jar). For example, I have had a client diagnosed with ‘major depressive disorder’ to find this de-humanising and critical, while another found it relieving to know they aren’t at fault for their struggle to function.

Diagnoses made in mental health settings tend to be made for two main reasons, firstly, as just mentioned, to identify an appropriate treatment pathway, such as, say for depression, a referral for Cognitive Behavioural Therapy or for a prescription for an anti-depressant SSRI drug. They also make communication between clinicians, and within research communities, easier as they can compare like for like. In other words, a GP may refer her patient to a psychiatrist for an assessment for OCD, and both doctors have a ballpark idea of what the concern is.

Our whole system of diagnosing in mental health care has become a battleground of late, and you may be familiar with the split between those who think we are diagnosing mental health conditions too much (in particular, ADHD and anxiety), and those who point to the swell of waiting lists for assessments, and think we aren’t diagnosing enough. You may well also be confused about who can or can’t make a diagnosis too.

In my posts to follow, I show how diagnostic categories have drawn lines where smudges may be better – or at least there could be different lines that capture our suffering better than they currently do. Their demarcation is also bound up with the profound question as to what makes a psychiatric ‘disorder’ or ‘condition’ in the first place, which has been the focus of much debate amongst anti-psychiatry advocates since the 60s (when both the Scottish psychiatrist RD Laing and the French historian Michel Foucault challenged received ideas of who, or what, decides if we are ‘sane’ or not). Many feel that the current tilt toward our concentration on mental health symptoms ignores the relevance of the many causes of anguish, the contexts in which they arise, nuanced subjective experiences, and our individual dignity.

In the UK, a loud dissent against our ‘medical model’ of symptom-led diagnostics that we currently have is reflected in the growing alliance behind ‘The Power Threat Meaning Framework’, launched in 2018 by senior psychologists such as Lucy Johnstone and Mary Boyle, and other mental health advocates. They want to shift the fundamental premise of diagnosing from one of ‘What is wrong with you?’ to a broader enquiry of: ‘What has happened to you?’ This more compassionate approach seeks to re-frame observed symptoms – such as those of anxiety - as understandable, and appropriate, human responses to adversities, as opposed to being problems to fix per se.

So, for example, anxiety can be understood to result from a constellation of factors - such as our evolutionary biology (our brain is wired toward negative thinking), our politics and culture (with a media feeding us negatives stories, as well as truly negative stories), family and social influences (such as experiences of deprivation or abuse). This new way of diagnosing asks us to consider the whole story of someone’s distress so that we can respond with more appropriate treatments than the ones we have now – such as offering help with housing or family relationships, rather than just a prescription for drugs.

As a psychotherapist, I am freed of diagnostic categories to fit, or bend, my clients into, and I have been trained to respond to my clients in ways like this. For me, and my colleagues, the ‘what has happened to you?’ question sparks the most of my early conversations in the consulting room. I can’t diagnose a client, even after a five-year training (including a lengthy placement in a psychiatric unit), and over twenty years’ experience of full-time work in the field. In the UK, psychotherapists, counsellors, mental health support workers, and social workers may share their view on the matter with someone who can diagnose, but we can’t act alone.

It’s worth bearing in mind that typically, mental health diagnoses are made by psychiatrists (who have completed medical school and further training in mental health), who can also prescribe medication, such as anti-depressants and anti-psychotics. Clinical Psychologists with doctoral-level qualifications (usually a DClinPsy or PhD in Clinical Psychology) can make some diagnoses too, but they cannot prescribe medication. General Practitioners can also make initial diagnoses for common mental health conditions, like depression or anxiety, as well as prescribing some commonly prescribed drugs, but they tend to refer patients to psychiatry for more complex or severe conditions.

In the US though, things are a little different and given lots of us read US literature online and watch US shows and films, it’s useful to know that they work differently. Psychotherapists there can diagnose, typically using the diagnostic manual of the Diagnostic Statistic Manual (I’ll come onto shortly and mention a few times in this book). This is partly because insurance companies that cover therapy bills need DSM diagnoses with specific codes to process claims and determine coverage. (I have met US therapists who dislike having to ‘reduce’ their clients into diagnostic boxes so much that they work privately, outside the insurance system. However, the unhappy trade-off means having to charge private fees, which many can’t afford.)

US psychotherapists can’t prescribe medication just as I can’t, unless they are medically trained as well. So, they also refer clients onto a psychiatrist for this, which means many US ‘patients’ or ‘clients’ (depending on who is saying this – I’ll come onto explain!), see two professionals for their mental health as mental health prescriptions are at a far higher rate in the US. In some states, clinical psychologists can also prescribe if they have been trained and licensed to do so.

Just to complicate things a little further, psychoanalysts, who practise the Freudian form of psychotherapy (or those of his affiliated schools), can also use their own diagnostic language amongst themselves and to their ‘patients’ (they use the language of medical doctors here, while most psychotherapists, like me, refer to their ‘clients’. Few refer to the older term of ‘analysand’ instead). Early psychiatric diagnoses, in the 40s, 50s and 60s were heavily influenced by Freudian thinking, and while they have since drifted away from this, some terms linger. For example, you might have heard the terms ‘schizoid personality’ or ‘Oedipus complex’ or ‘anally retentive’ which aren’t diagnoses, but complex descriptions that are best left to discussions between analysts.

So, to re-cap, diagnostic terms should be used by those with specialist training, and they rest upon classifications that have evolved since medical authorship began in the late 17^th century. We’ve had some sort of psychiatric ‘nosology’, or classification of disease since then, but this only really began to take off in the way that we are familiar with after the Second World War when in 1948, the World Health Organisation published the sixth revision of its International Classification of Diseases, ‘ICD’, with a dedicated section for mental disorders for the first time. The American Psychiatric Association (APA) responded with their own Diagnostic Statistic Manual, the ‘DSM’ in 1952, then a far slimmer volume than today’s more weighty iteration (and as I mentioned above, heavily influenced by Freudian thinking).

I will refer to editions of both the DSM and ICD and although the DSM doesn’t govern UK diagnostics, it does govern international research literature and is often referred to in US journalism and other first-person accounts. You’ll see how each edition responds to growing research and even the politics of the time, which means diagnostics evolve over time too – including the creation and deletion of conditions. I show how this happened, for example, in the context of anxiety, depression, PTSD and autism in this book. You’ll also see how every diagnosis has room for interpretation, subjective assessment and, in some cases confusion and controversy.

It’s worth adding that in England, that mental health diagnostics are also heavily influenced by guidelines from the National Institute for Health and Care Excellence (NICE) which provide evidence-based recommendations for the prevention, diagnosis, treatment, and management of health conditions. They often reference ICD classifications and use its language, rather than material from the DSM. GPs also use various assessment tools to screen for depression, anxiety and other commonly presenting conditions, and research continues to amend and improve on these too. However, I have spoken with GPs who have so much experience in mental health – sometimes more than other health problems – that they don’t need to refer to guidance (which is why you might have had a diagnosis without completing a form).

Diagnosing a mental health condition must also be done after a thorough, and confidential, assessment of the person concerned. As tempting as it is to define someone as having a ‘narcissistic personality disorder’ or as a ‘psychopath’ - especially with the words and behaviours of many male politicians baffling our minds on the world stage – none of us should be diagnosing from afar, including the experts. This so-called ‘Goldwater Rule’ should really apply to us all.

Barry Goldwater was a Republican US senator in 1964 and his extreme views became associated with his saying ‘Extremism in the defense of liberty is no vice!’ in his acceptance speech for the Republican nomination for President. During his campaign, Fact magazine published an article, ‘The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater’ having canvassed 12,356 psychiatrists for their view on whether Goldwater was psychologically fit to be president. Of the 2,417 psychiatrists who responded, 1,189 declared Goldwater not to be, with some offering specific diagnoses, although none had met him. (One wrote, ‘A megalomaniacal, grandiose omnipotence appears to pervade Mr. Goldwater’s personality giving further evidence of his denial and lack of recognition of his own feelings of insecurity and ineffectiveness’).

Goldwater successfully sued the magazine for libel, and since 1973, his nominal rule has been embedded as an ethical guideline in the APA’s Principles of Medical Ethics and has since been extended to other mental health professionals in the US and endorsed by the UK’s Royal College of Psychiatry. This makes it unethical to offer professional opinions about the psychology of any public figures who have not been properly assessed, unless they have given their explicit permission for such opinions to be made.

The Goldwater Rule reminds all of us to take care when we use clinical diagnostic terms. Even if you have listened to many podcasts or TikTok posts about social anxiety disorder and think you, or your friend has it, it’s best to hold this idea lightly and consider finding an expert opinion, and further support for your distress. You may be right of course, but if you aren’t, you could run the risk of ‘boxing yourself in’ and underestimating your built-in resilience. I come back to these ideas more in my posts that follow.

For the non-therapists reading this, I’d be surprised if you haven’t come across ideas of attachment theory. They now scaffold the advice in many dating, parenting and self-help guides as well as conversations about intimate relationships. My client X, who I will come onto, met me for the first time wearing a T-shirt with a bright red logo emblazoned across it: ‘My Attachment Style Is Velcro’, which told me how far into the mainstream this developmental theory has percolated. X isn’t alone either, as more and more of my clients meet me with their own ideas about their own ‘attachment style’ - and maybe you do too. An idea of what style you are can be a useful place to start therapy, but I’ll come onto explain how it can adapt and change and is far from a definitive ‘diagnosis’ (my next post will be all about diagnosis…).

Our fascination with how we ‘attach’ to other human beings mirrors a whopping growth of research into the field in the past thirty years in psychology, psychiatry, child development, education and neuroscience. It is the biggest theory of human development to date, and its dominant paradigm, which is why you have probably heard about it. Some psychotherapists even specialise as ‘attachment-based psychotherapists’ or, more of a mouthful, ‘attachment-based psychoanalytic psychotherapists’, although I like to think that all therapists would have had some training in it.

Put simply (and I realise that over-simplification is a problem that I will warn against), this theory pivots around the idea that the quality of our early relationships with our caregivers shapes a range of developmental, relational, and even clinical outcomes. If we have a good enough start in life, we have a ‘secure attachment’ blueprint which will protect us against struggles in relationships later down the line, and associated with this, mental ill-health. However, if we have a less than good enough start, we may have an ‘insecure attachment’ blueprint which could mean we find relationships difficult, and that we suffer with our mental health as a result (and we fall into three versions of this blueprint that I’ll come onto). An extreme illustration of this is the high prevalence of insecurely attached men and women in our prisons.

If you are ‘securely attached’, this doesn’t mean you are immune from distress or the need for therapy though, and you may well need support for a life event that has inevitably thrown you off course – such as a major bereavement, or illness or redundancy. I also talk to many pregnant women who may be of the secure camp yet worry (sometimes unnecessarily) about their baby’s future insecure attachment – in other words, that their short temper or need to get back to work quickly will create one. I meet many more clients (individually or in couples) who are ‘insecurely attached’ though, as they may well have struggled with their relationships, and life’s hurdles, along the way.

Attachment theory began with the observations and research of John Bowlby, an English psychiatrist and psychoanalyst working after the Second World War. His less well-cited collaborator, Mary Ainsworth promoted their groundbreaking research to American psychologists in the 1960s and 70s. Interestingly, in a letter to Bowlby in 1968 Ainsworth fearing her work might become distorted, lamented how ‘attachment has become a bandwagon’. Over half a century later, it has certainly become far more crowded and risks separating us all into four teams.

Bowlby’s theory emerged from his work with troubled boys – or, as was then described more pejoratively, ‘delinquents’ – in the 1940s. He noted how many of them had experienced loss and separations as infants and he linked their problematic behaviours to the inevitable distress of these early ruptures. So rather than writing these boys off as simply ‘badly behaved’, he understood how they were, unconsciously, acting out from past frustrations and hurts. Another way of describing their problems was as ‘solutions’.

Influenced by the two great theorists of his day, Charles Darwin and Sigmund Freud, Bowlby suggested that we are born with an innate, and immediate, need for connection to a caregiver, which, at his time, meant mothers. This idea is undeniable now, although it wasn’t back then, and the sophistication of our newborn brains is now well accepted, as is the sophistication of our unborn brains too - my friend’s baby would repeatedly kick her mother’s womb when she played her ABBA’s Waterloo.

We communicate to another person moments from our birth, copying facial expressions, and crying to get our needs met. Some wonderful research pioneered by the late Colwyn Trevarthen, who was Professor of Child Psychology at the University of Edinburgh, shows how the back-and-forth coo-ing and burbling between a baby and mother is often organised into musical notes, grouped in bars. We are far from being a ‘sleeping, eating, excreting blob of flesh’, as one reluctant father told me in therapy, with his despairing partner sighing deeply by his side. We make music, have feelings, and, crucially, we need to be in a relationship.

In the 1970s, Ainsworth ran with Bowlby’s ideas and pioneered the close study of the quality and stability of our early formative relationships with our caregivers through a behavioural experiment clunkily known as the ‘Strange Situation Procedure’. Researchers would closely observe infants’ responses to their mothers first being with them, then leaving them alone with a stranger, and then returning. These behaviours were coded, and the results assessed as a‘secure’ attachment style or three different types of ‘insecure’ attachment.

This work extended the existing popular idea from Freud that our relationship to our parents have a profound bearing on our development. Bowlby saw how our early patterns of relating to our caregiver, studied more closely in the SSP, informs our later patterns of relating as we grow up, and into adulthood. In other words, we bring our early patterning to other people, who will, in turn, also have their own patterning. Sticking with the music making metaphor, the meeting of these different patterns – or styles - may create harmony or cacophony, or anything in between.

Before I describe our four attachment styles in more detail, please remember it’s best to hold one that seems to fit lightly rather than tightly. It is not like your eye colour and set for life, nor is it a ‘diagnosis’ to be found in Bowlby’s work. Your style can be seen as a tendency that you have, even if it feels very entrenched, that can be a point of reflection or growth. It’s also possible that your style varies according to who you are relating to - we may have secure relationships with some people, but insecure with others. You may have felt at ease with one parent, but on edge or confused with another.

Also, please remember that you can change your style, as I, and many of my clients have done. For example, having good quality relationships later in life can be opportunities to earn trust in people, and intimate relations again. As against that, a secure start in life can be corroded by later negative and destructive relationships, such as bullying or abuse (such as gaslighting as I’ve already shown) or homophobia or racism. Although Bowlby emphasised the influence of our carergivers we are also influenced by the social contexts outside of the family and home too.

The developmental psychologist Heidi Keller isn’t alone in describing attachment theory as a ‘Western middle-class philosophy’ and she points out in her book, The Myth of Attachment Theory, that in many cultures, the emotional world of a child growing up is influenced by many more than one or two parents in a nuclear family – such as the ‘alloparents’ of siblings, aunts, grandparents and cousins, or even distant relatives and elders. For most of our history, these wider connections were crucial to how we raised our young.

It’s also worth considering that some ‘un’ attached people may not be wired ‘wrongly’ or going against our human nature in a way that is problematic. I know people who are happily lonesome and have securely attached to God, or the Universe, or animals or Mother Nature instead. My friend in rural Cumbria could be described as a hermit yet is one of the sanest, and happiest people I know. She is nourished by her relationship with her two dogs, the sea, the trees and the winter storms and wouldn’t think twice about her ‘attachment style’.

Secure attachment

A secure attachment style tends to arise from us having caregivers who protect us and are consistently responsive and available for us when we need them and generally keep our needs in mind. Therapists think of this as a vital process of ‘attunement’. After our early months of total dependency as a baby we then need the freedom to explore and to play. We can do this easily if we know someone who cares for us is close by to step in if we bash our head, or get bashed, while also encouraging us to keep on enjoying the wonders of the world.

Of course, no parent can always keep up an ideal level of attentiveness all the time, and mis-attunements - or mistakes - won’t demolish a secure base. I’ve never met a parent who hasn’t lost their temper at their child unfairly, or not been distracted by a smartphone notification, or have had to leave their child because of work or illness or because another one is born. What is crucial is that mistakes or ruptures are repaired, and that a parent is consistently ‘good enough’ (in the words of the British paediatrician and psychoanalyst Donald Winnicott). It’s also useful for us to learn, when we are young, that humans aren’t always capable of meeting our needs, so that we can build up our own resilience and trust in ourselves and others. We’ll do ok with imperfection, unless and until it tips into something else.

Insecure attachment

You may well be more familiar with attachment styles that can make relationships tricky – in other words, the three ‘insecure’ styles or types. As parents, we aren’t always able to create secure environments for our families. We may be living in a war zone or extreme poverty, or with a physical or mental illness, or deep in grief. We could find the responsibility of parenting challenging, or unwanted, or just not be up for the job yet. We may also be born prematurely or unwell too, forcing us to be separated from our parents for a long time (although neonatal care in the UK has changed over the years since my son was born at 28 weeks to keep parents near their babies as much as possible).

A less-than-ideal early environment can create ‘insecure attachment’ in us in three main ways: avoidant, ambivalent or disorganised. These iterations (that may be described slightly differently between authors and researchers) can become the cause of anguish for us, as we may struggle with our own insecure style, or we struggle with another’s, or we struggle with making sense of differing styles coming together.

An avoidant attachment style tends to be forged in us when a caregiver was consistently emotionally absent much of the time. They may have been physically absent as well, but if they were physically present, they may well have been willing to do things for you, rather than tune into who you were and what made you tick. So, for example, they might have taught you to ride a bike but were uninterested when you were upset or needed encouragement with your own ideas. The author and psychiatrist Daniel Siegel describes a vital sense that we all need – to be ‘felt felt’ which sums things up so well for me.

In environments like this, we can learn early on that other people aren’t emotionally reliable, apart from oneself. Diane Poole Heller, an attachment-based therapist calls this response a ‘reactive autonomy’, or I tend to refer to it less elegantly as a ‘super self-reliance’. This type of conditioning can set up a bind for us though – at root, we want support, help and intimacy from someone, but as we are habituated to fall back on ourselves, it can feel risky, or even impossible, to pursue.

Many of my clients fall into this camp and their avoidant tendencies map out between us too. They want my help, and commit to weekly therapy, but also fear being vulnerable with me, preferring me to offer them an easy ‘fix’ with some tips and tools. My client X (with the T-shirt I described) played this dynamic out with me, and it was no surprise to me that her partner had strongly suggested therapy to her, rather than her coming on her own steam alone. She was raised by a single mother who worked long hours, and taught X to be independent, capable and ‘tough’ from an early age. X came to see me, aged 28, because she was in her first serious relationship, but her partner was frustrated by her ‘pulling up the drawbridge’ at times of emotional intimacy, or at the whiff of any conflict.

Through our weekly conversations, X realised that she had kidded herself that she was emotionally ‘clingy’, as her T-shirt conveyed. Because she liked the company of friends and being in relationships, she had assumed she was. She was also very open and honest, but she came to realise that this never concerned her vulnerabilities and fears. Because X had been taught to stand on her own two feet from such an early age, she had learnt to push away any feelings of vulnerability. Her ‘reactive autonomy’, that she had disguised for many years, had crept in between herself and her partner, who felt shut out by X’s distance.

X realised that she had been swerving the nuts and bolts of true intimacy that comes with bearing all of yourself, because, ultimately, it felt threatening for her to do so. This included my own efforts to reach beneath her stories, to the version of herself that she had learned to bury. Over a couple of years of therapy though, X gradually let her guard down, and came to trust that I, and her partner and others, could help her out when the going got tough. She earned a more secure attachment – which is something many of us can do.

When we said our goodbyes, by X’s own admission, her T-shirt that she wore when we met could have read ‘My attachment style is Teflon’ instead. She learned that her early adaptation to others was no longer needed, and she wanted her partner to know all aspects of her including her deepest vulnerabilities. She had moved from refusing to believe there was any worth in relying on another, to being nourished by the idea instead.

An ambivalent attachment style also shows up in therapy a lot. This tends to be a response – or adaptation - to a caregiver who may well have been loving but was also unpredictable or inconsistent and could veer off into less loving, or dreadful, behaviours, such as absences, or rages, or spectacular sulks. Growing up in an environment like this could mean that we may well yearn connection with another, so we may look less self-reliant than someone described as avoidant, but this is coupled with an underlying fear of rejection. When this tension arises, we may well withdraw from someone when we feel too close, as we feel the need to protect ourselves from an (often-imagined) risk of being hurt again.

Many of my ambivalent clients learned to track changes in their caregiver’s mood early on in life, to pre-empt a switch to a darker one. They could then avoid them or work hard to improve things. One such client, Y, memorably described it to me as her ‘spidey sense’, sharpened as a very young girl in the orbit of a father who blew very hot and very cold. Her skill at discerning where her father’s temper was settling (even by the way he put his keys into the front door) made her excellent at tuning into other people’s moods – including mine.

In our sessions together, Y would often interrupt her story to check out something she saw, or thought she saw, flash across my eyes, or my face, or in subtle movements of my body. Sometimes she was eerily adept at seeing something I thought I had hidden (such as a disagreement to her opinion on something), but often she imagined I was irritated or had judged her when neither were true at all. I wasn’t like her father, who had imprinted in her emotional world. Like my client X, over time, Y also shifted away from her sticky attachment style, while holding on to her skill at tuning into people well. I was unsurprised when she later emailed me to let me know she was training as a therapist.

The third style of insecure attachment - disorganised - tends to emerge from a very chaotic and emotionally unsafe background, with caregivers who could be frightening, rather than inconsistent. You may have heard about it in the context of mental health diagnoses or in psychiatric care – such as the controversial ‘borderline personality disorder’ that I look at in a later chapter. It combines an avoidant and ambivalent style to a varying degree or may show up as a clearer oscillation between the two.

While we are born wired to connect to our caregiver, as Bowlby put on the developmental map, we are also wired to avoid danger, and to keep safe, too. This means that, in frightening environments, we can grow up with a pull between these two instincts. This so-called ‘approach avoid’ response can become so overwhelming, that we may end up ‘freezing’. This is the territory of developmental trauma, that took a relatively long time to be taken seriously by psychiatry, and that I look at in a later chapter too.

So, it may well be that your attachment style has a bearing on how you position yourself as against other people, but it won’t necessarily be set in stone if you are keen to nudge it from an insecure position to a secure one. Knowing about the potential effect of our early imprints on others can also help us to think about them with more compassion too. But you may also be thinking about how you position yourself against another with a different notion of ‘boundaries’ as well, or instead. These can be hard or soft, rigid or porous, non-existent or all over the place. Like attachment styles, they are always in relation to another as I explored in an earlier post…..

Enmeshment

Taken to an extreme, ‘diffuse’ boundaries between people can be described as becoming ‘enmeshed’. The father of family psychotherapy, Minuchin (touched on in my post about Boundaries), described families who can’t differentiate from each other at all in this way and spotted how they may even become confused over their separateness from each other. The term is also used in couples therapy, where two develop ‘interlocking modes’ of being that can remain stuck and ultimately become destructive as there’s no room for individuality. Enmeshment is often confused with codependence, which is a different dynamic, that I come onto next.

If you are ‘enmeshed’ with someone, you may find it difficult to value, or even know, your own thoughts, feelings and needs because they have become lost in those of another. In therapy, I might ask someone ‘what do you want to do?’ and the answer may be ‘I haven’t got a clue. But I know what my partner/mother/brother wants.’ A tragic, and haunting, example of this confusion can be seen to play out between a mother and daughter in the award-winning documentary Grey Gardens (1974). This peeps into the daily lives of Edith Beale and her daughter Edith Beale – Big Edie and Little Edie – best known at the time for being the aunt and cousin of Jackie Onassis, wife of US President John F Kennedy.

We watch the pair’s eccentricities in their reclusive joint lives in a desperately run down property in the wealthy Hamptons, outside of New York City. Cats and rodents run wild while the women dress up, reminisce about their lost lives of grandeur, and squabble. Some find the film compassionate, others exploitative, but either way it demonstrates an enmeshment to a heart-breaking degree. This mother and adult child – significantly named the same - are entirely dependent on each other to function, often speaking at the same time and owning each other’s anecdotes. Underneath the endearing bluster and conflict, they cling fearfully to one another.

‘Enmeshment’ and ‘codependency’ may look similar from the outside and both involve ‘diffuse’ boundaries and an intense emotional entanglement, but they each carry different dynamics and have different psychological lineages – enmeshment from family therapy, codependency from addiction recovery. Big Edie and Little Edie were overly dependent on each other, and enmeshed, but not codependent.

Codependency

You may hear the term codependency as a way of describing (and usually judging dimly) an unhealthy reliance between a couple: ‘They never go out anymore, they are completely codependent!’ But while this understanding isn’t wholly off the mark, it misses some fundamental co-ordinates, although as with other terms I look at, it also has no universally established definition or set ‘diagnostic criteria’ for clinicians or researchers to follow, or for the rest of us to agree upon.

Codependence was launched into the mainstream in 1986, a little before the idea of relational ‘boundaries’ were, when the author Melody Beattie’s first edition of her book Codependent No More was published. Over eight million copies later, it is one of the four best-selling self-help books to date, and she went on to write another 17 books, sparking a further 200-300 books on the subject too. I heard Beattie talk about her work in May 2023, having revised her seminal book. She sees co-dependency everywhere. ‘Codependency traits or behaviour include having this misguided notion that we can control other people’s behaviour, as if the more we love them, the more we can do that. But it’s just not so. Difficulty setting boundaries, not knowing who we are and what we want — throw all that in as well and the issue of codependency is rampant right now.’

Beattie was originally concerned to dismantle an ‘enabling attitude’ of a family member, typically a wife or mother, toward another suffering from a chemical dependence. She drew on her personal experience with substance abuse, from the agonisingly young age of 12, and caring for someone with it too, as well as the experiences of those helped by the support of Al-Anon (a support network for anyone affected by another’s alcoholism). Her emphasis was more on the attitude of the carer as opposed to focusing on the dynamic between the carer and addict. In other words, she looks at an obsessive need to help and look after another person, and maybe even to control them in the process.

My client D was the first to suggest her mother’s codependency problem. One of D’s earliest memories, aged around 3, was of her being taken to A&E, although she’s not sure why. Her childhood was peppered with doctors’ visits, prescription and non-prescription medicines, and lots of time off school. After her mother’s breakdown in D’s late teens, she came to realise she hadn’t been a ‘sickly child’ at all, but a target of her mother’s desperate bid for attention from healthcare professionals she could recruit for the job (she may have been suffering with Munchausen Syndrome by Proxy, as it was then known, and many other mental health problems have links with the idea of codependence).

Beattie is unsure where the word ‘codependent’ was first used but notes its appearance on the ‘treatment scene’ for addiction in the late 1970s in Minnesota. She writes of how the term quickly came to mean many things to many people, as it can do now, but she has defined a codependent person in her book as one who has “let another person’s behaviour affect him or her, and who is obsessed with controlling that person’s behaviour”. So, the nub of the issue lies with the carer, rather than the other person being cared for. Her thinking is rooted in addiction work, but the ‘other’ (a parent, sibling, cousin, lover, child, friend or even therapy client) could be healthy and of no real cause for concern, like my client D.

Thanks to Beattie’s work, psychiatry and psychology have since grappled with her notion and built different theoretical approaches to work with it. Some clinicians see it as a disease, others an addiction to love, or, as the US psychiatrist Timmem Cermak asserts, it is even capable of becoming a ‘personality disorder’ deserving of diagnostic criteria (I look at personality disorders later). The Spann-Fischer Codependency Scale (devised by two researchers at Texas Tech University in 1991) attempts its own categorisation with a 16-item self-report instrument, resting on an expanded definition of Beatties’s: ‘a dysfunctional pattern of relating to others with an extreme focus outside of oneself, lack of expression of feelings, and personal meaning derived from relationships with others.’

Beattie emphasised that codependency isn’t about loving too much, but about losing oneself in the process of caring for, or loving, others. While the dynamic she describes though can clearly be problematic, it’s also worth remembering that a loving relationship should also allow us to focus ‘extremely’ on another at times. It’s not unusual to feel our boundaries evaporate into our loved one in the throes of passionate love. This sublime interrelatedness can exist deep below healthy bonds, and are often treasured as an awesome human experience. Pablo Neruda’s poem One Hundred Love Sonnets: XVII captures the idea for me: I love you like this ....so close that your hand upon my chest is mine, / so close that your eyes close with my dreams.