Not Everyone Needs to Go to Therapy

Everyone should be in therapy.

This phrase becoming embedded in our lexicon is a mark of how much American culture has shifted.

The destigmatization of mental-health problems—and the normalization that many people do struggle with severe mental illnesses—has been one of the great cultural transformations of the 21st century. And with this shift have come concerns about unintended consequences.

After all, what if therapy is less like exercise—something everyone should do to be healthy—and more like prescription medication—something you should only really use if you need it? On today’s episode of Good on Paper, I’m joined by Dr. Lucy Foulkes, a researcher at the University of Oxford who has become increasingly concerned that raising awareness is not unambiguously good. Rather, she worries, it could encourage people to pathologize mild forms of distress.

Foulkes’s questions about inadvertent harms are focused on untailored mental-health awareness campaigns, particularly ones targeted to school-age children and by schools themselves, a practice that has become commonplace in the U.K.

“How on earth do we ask this question without undermining, firstly, the people who are most unwell, who are still not getting help, but also the people who might not have a mental disorder, but they have distress and difficulty that needs to be taken seriously?” Foulkes asked. “But I think, actually, the more we allow the conversation publicly to proliferate and go unchecked, a risk of all of that is this en masse skepticism that you’re now seeing towards almost anyone who stands up and says, I have a mental-health problem.”

Listen to the conversation here:

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The following is a transcript of the episode:

[Music]

Jerusalem Demsas: Just go to therapy. It’s the kind of thing that’s become very common to say, regardless of the circumstances. For many, therapy—or mental-health treatment—has become less like health care and more like exercise or eating healthy foods: prescribed to everyone broadly, regardless of their individual circumstances.

In my opinion, destigmatizing mental illnesses and making people comfortable with asking for help is one of the great cultural innovations of the 21st century.

But there have been increasing worries that this cultural shift and the policy and behavioral changes that have accompanied it, particularly in schools, are having some unintended consequences.

In a provocatively titled psychology article, our guest today, Dr. Lucy Foulkes, asked the academic community, “Are mental health awareness efforts contributing to the rise in reported mental health problems?”

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

This is Good on Paper. It’s a policy show that questions what we really know about popular narratives. I’m your host, Jerusalem Demsas. And today’s show is about whether the effort to destigmatize mental health and encourage people to get therapy when they need it has not been tailored enough. Not everyone needs to be in therapy. For some people it may even be harmful.

[Music]

Lucy Foulkes is a really thoughtful guest, and I wanted to have her on the show because, unlike many people in this space, she doesn’t see this issue as black and white but rather as a variety of tradeoffs we need to weigh against one another.

Questioning the growing orthodoxy that therapy is always good or asking if frequent discussions of mental health may have some serious drawbacks doesn’t mean dismissing mental illness as a serious concern. But it does open us up to many difficult questions—ones I explore with Lucy in today’s episode.

Demsas: Dr. Lucy Foulkes, welcome to the show.

Lucy Foulkes: Hi. Thanks for having me.

Demsas: I want to start with a paper you published last year that I feel like set off a real firestorm, and it was called, “Are Mental Health Awareness Efforts Contributing to the Rise in Reported Mental Health Problems?” Tell me about this paper. Why was it so controversial?

Foulkes: Well, I’ve been interested for a long time in the possibility that some really well-intended efforts to get people to talk more about mental-health problems—and to label them and to seek help for them—might have had some unintended consequences. And that paper was the culmination at that point of my thinking about it, along with my colleague Jack Andrews.

And really in that paper, we posed it as a question that needs to be investigated and tested and explored. And the question was: Is it the case that the more we encourage people to think and notice and talk about mental health, the more they end up reporting mental-health problems?

And we posed two potential routes, one of which is: If you raise awareness about mental-health problems and destigmatize them and help people understand what they are, then you’re probably going to have more people reporting problems who otherwise would have kept it hidden. So maybe in previous generations, they weren’t admitting these problems and now they are. So the actual base rates aren’t getting worse, but it looks like they are.

And then the second route is the possibility that raising awareness about mental health might make people misinterpret milder, more transient levels of mental distress as symptomatic of mental disorder—and whether that then, in turn, might make those problems become exacerbated or exaggerated in a self-fulfilling manner.

Demsas: Tell us a little bit more about that. Why did you decide to look into this? Was there something you saw in the literature or something you saw when you were working in schools that made you concerned about this problem?

Foulkes: I was working in schools as a researcher, so I was observing what teenagers were being taught in schools about mental health, and I was interested in that. You know, if you go to the bathroom when you visit a school, there are signs in the bathroom, telling you to think about your mental health. For example, there’s information on school websites. There’s information they receive via assemblies and lessons. So quite early on, I was interested in the fact that young people are learning about mental health now in a way that my generation never learned about in school.

And I was also then working as an academic, as a lecturer at the University of York. And I was noticing that the undergraduate students were also receiving an awful lot of messages, encouraging them to notice and talk about their mental health. And there was one particular incident where I remember becoming a bit more skeptical. My colleague, underneath her email signature, she had in big letters: In crisis? Get help here.

And I thought, That probably is helpful for a student who is in crisis and doesn’t otherwise know where to go. But I realized that every student that she emails will see that message, and they’ll see that message in the context of everywhere else being told that they are at risk of experiencing mental-health problems and that there’s certain language that they should use. And I think that was a bit of a turning point of starting to think, Hang on. Are there some side effects to this that might be a problem? Even if there are benefits for other students or other young people.

Demsas: So I’m interested in digging into a little bit of what we actually know right now. I know this is a space that when you wrote this paper, you were setting out towards trying to get a lot more research done. But there’s also a lot of research that’s already done on mental-health interventions.

And something you said in a video you did struck me, which was that all this awareness isn’t reducing rates of mental-health problems. Do we have causal evidence that the increased awareness is leading to an increased rate of mental-health problems?

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

But in terms of causal evidence, there are various bits and pieces that have come out since we wrote that paper, and there’s groups trying to collect more evidence, and we’re trying to collect more ourselves. But there are some little clues so far, experimental studies, showing that the way you encourage people to talk and think about their mental health does influence how they interpret and report it, which actually shouldn’t be surprising at all. There’s a big evidence base about expectancy effects and how what you tell people influences what they experience and what they report. So it’s new, but there are several studies now supporting this idea.

Demsas: So there’s two kinds of interpretations that you’ve laid out, right? Because one is that you’ve given people this language, this awareness, and thus you’re able to find individuals who previously would not have known what they were experiencing. Maybe they had depression. They were experiencing severe anxiety. And, as a result of the awareness campaigns, now a lot more people might be coming out and identifying themselves to doctors, or to their teachers, or to their parents.

And the other is that there’s this group of people who are not actually experiencing strong—what a clinician would describe as severe depression or anxiety—but are pathologizing themselves instead.

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

Foulkes: That’s part of the difficulty of all this, that it’s very difficult to tease those two apart. And certainly there are some people that would argue that it’s all the former phenomenon. Or it’s that more people are reporting problems because, in various ways, life is more difficult now, so that’s absolutely a possibility, as well.

So the question is: How do you distinguish between the two groups that I describe? And it’s incredibly difficult, especially considering that the way we measure mental-health problems is to ask people to self-report symptoms. It’s harder to tease those two apart.

Demsas: And so when you say things are much harder now, what do you mean?

Foulkes: Oh, in terms of what? On a population level?

Demsas: Mm-hmm.

Foulkes: Well, there’s an awful lot of interest in the idea that social media has caused the problem. There’s a camp of academics arguing for that, and then there’s another camp of academics arguing back and saying no, that that’s not the problem, or it’s not the entirety of the problem.

Then, obviously, there’s the pandemic. COVID-19 undeniably had an impact while it was going on and possibly in its aftermath. I’m never ever saying it’s the case that this explains everything, but I think it’s enough of a possibility that we need to take it seriously and not just look at an increase in reported rates and take it at face value.

Demsas: What was the reaction when you released this paper? Did you get feedback from folks who were in schools?

Foulkes: Yes. Interestingly, I was expecting a lot of criticism. I have got some criticism but, actually, I’ve received more support than I had anticipated.

And what surprised me and interested me is that people want to tell me in private. So they say, I’m saying this in confidence. I’m saying this off the record. And I quite often get people telling me I’m brave or that they wouldn’t want to be the one saying this, which I think is interesting.

Demsas: And why is that? What’s the fear there?

Foulkes: Well, it’s a legitimate one, which is: How on earth do we ask this question without undermining, firstly, the people who are most unwell, who are still not getting help, but also the people who might not have a mental disorder, but they have distress and difficulty that needs to be taken seriously? So the worry is that if you ask this question, you undermine the suffering of people who need to be heard.

But I think, actually, the more we allow the conversation publicly to proliferate and go unchecked, actually, a risk of all of that is this en masse skepticism that you’re now seeing towards almost anyone who stands up and says, I have a mental-health problem. There’s a collective shrug like, Oh, well you and everyone else—

Demsas: Like, Who doesn’t?

Foulkes: Yeah.

Demsas: I want to get into some of the research here. So there’s a big trial in the U.K.—the Myriad trial. Essentially what happens is the researchers randomize 85 schools to either get teaching as usual or to get something they call school-based mindfulness training. And school-based mindfulness training has already been found, by at least one systemic literature review of RCTs [or randomized controlled trials], to have significant positive effects for things like mindfulness, executive functioning, attention, depression, anxiety, and stress.

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

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

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

Foulkes: Firstly, those three studies that you describe are large-scale, good-quality trials, so we should pay attention to their findings, and they have made an important impact on the field. But it is still the case that some other studies have found generally small, positive, average effects, or null effects. So it’s definitely not the case that all school interventions are finding these negative effects. But because of their quality and size, people have paid attention to these three.

I think what’s important about all of them is that they’re universal interventions. So that means that they were taught to all young people in a class, regardless of need, with the very reasonable idea: Why not try and help everyone? Why not try and give everyone the tools and knowledge that they might need, either because they’re struggling now or because, at some point in the future, they might benefit from this information? But the trouble is what that does is you’re taking principles that were originally designed to be taught one-to-one, and then you’re teaching them to a group of 25 or 30 teenagers or young people, all in one class.

So if you learn these techniques in one-to-one therapy, you can adapt them to your specific issues. You can troubleshoot with your therapist when you’re having difficulty. You can ask for explanations and clarifications when you don’t understand. That mindfulness is a difficult skill to learn. So part of the issue for why these interventions don’t work well, or sometimes have negative effects, is because you have diluted the practices too much.

And then, in addition to that, you are, by definition, teaching it to a whole class with a variety of needs. But that means within that class, you will have a lot of young people who are actually fine. It’s become a bit unfashionable to talk about this, but there are a lot of teenagers who don’t have mental-health problems. So potentially you’re asking them to learn skills that aren’t relevant to them. And a lot of young people, if you ask them, they say they find these lessons boring and not relevant to their lives.

Or, at the other end of things, you have people who are having such significant difficulties that this kind of intervention doesn’t really touch the sides. They need something to change in their life, or they need a lot of one-to-one support. So potentially it’s difficult for them to be made aware of a problem that can’t then be fixed with the solutions that they’re given. Or they try, and they fail, and then how will that make them feel?

So I think that the field is starting to move very gradually—early days—but possibly toward becoming more skeptical of this idea of universal interventions, whether there’s actually useful stuff we can teach everyone en masse that will meaningfully make a good difference to enough of them.

Demsas: Part of what I started wondering about these large, universal interventions in schools—or just largely in society, how we’re changing, how we’re talking about this—is that it’s just an implementation issue, maybe. Is it the case that if people were better at implementing, whether it’s CBT or mindfulness training, if you actually had the investments to make teachers experts on this as well as doing their jobs educating students?

I mean, I guess I’m trying to get at here: Would you think that there is a problem in a world where you had that level of investment? Or are you just saying, We’re never going to get there, so we should stop doing this? Because I feel like that’s two very different conversations.

Foulkes: The implementation thing is really interesting because there can be therapy designed in a certain way or an intervention designed in a certain way, and it’s not necessarily how it ends up being delivered.

And certainly there’s variation from school to school within a trial about how well things are delivered for all sorts of practical reasons. It’s also relevant with Myriad because they taught existing schoolteachers to deliver the mindfulness intervention. And that’s really important because really what Myriad was showing was not necessarily that mindfulness doesn’t work, but that you can’t teach existing schoolteachers in a short period of time to deliver mindfulness en masse that works.

So that’s important, but the resources question is still there. We do not have the resources to train people to become mindfulness teachers, which can take a long period of time at that level of expertise, and then deliver it one-to-one. If you could, I’m sure we might have different results, but I think that still rests on the assumption that what everyone needs to solve their mental-health problems is one-to-one therapeutic intervention. And I think that’s potentially ignoring all the other external factors that cause mental-health issues.

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

And so is this issue just that it’s too early to be introducing this language? Or that the societal wide shift needs to be different just for young people and how we talk to very young preteens and teens? Or is it something that’s actually a problem for all age groups?

Foulkes: My prediction would be that older adults haven’t had the same transformation in language, but I actually don’t know. And I think it’s a good question. I’d say when you hit certain demographics, like middle-aged men, that the problem is still that they don’t talk about it enough. There’s still massive amount of stigma talking about mental health. So I don’t know. The concern and the conversation is certainly about what’s happening in young people.

Demsas: And the thing that’s worrying to me is, first of all, the reason why these universal interventions are done is because they’re much more cost-effective than the one-on-one interventions that you’re talking about. But secondly, you can choose not to implement school-based mindfulness training, but when we’re talking about this larger societal shift in how we talk about mental health, there’s no policy lever that undoes that, right?

So is part of your concern here not just these large-scale changes in schools towards investing in universal mental-health treatments, but also this larger societal discussion of how mental health is talked about in public?

Foulkes: Yeah. And I’ve been asked before, Do you not think it’s too late now? Is the cat not out of the bag? If we were to make a societal shift, it would be a big one. Because it’s not just what’s happening in schools. It’s even the psychiatric language. The language of therapy is in pop songs. It’s in sitcoms, reality-TV shows. It’s everywhere online. So culture has become saturated in the language of psychiatry and mental health. I don’t think that means we don’t ask questions. And if you look back across time, society has changed gradually in how it frames psychological distress and talks about mental health, so I don’t think it’s fixed.

I actually gave a talk in a school a couple of months ago. And a teenager who’s maybe 17 asked me, what did I think was the long-term prediction for what would happen? She said, Do you think we’re going to talk more and more and more about it? Or do you think there might be a peak and then things will start to fall again? And I thought it was such a good question. I wonder if we will reach such a saturation point, and the skepticism will become sufficiently high that this language doesn’t have the same currency as it once did, and maybe we’ll start using it less.

Demsas: When you say the currency that mental-health language has, can you talk a little bit more about that? What are the ways in which this is seen as beneficial?

Foulkes: I think it’s, in lots of settings, the language that you need to use to be taken seriously. Partly because so many people are using this language, everyone else needs to use it to kind of be taken seriously. It’s not enough to just say that you’re sad or you’re worried when everyone else is saying that they’re depressed. You have to match that level and possibly go above it in order to be heard.

Certainly in a society that has limited resources for helping you—you know, the threshold for getting mental-health treatment in the NHS [or National Health Service], it’s extremely high in some cases, so—people are incentivized to use this language because it’s the language that they hope will get them heard. But it’s difficult, because the more everyone else uses it, the more it becomes inflated to kind of keep your head above the water.

Demsas: I want to dig into what the actual harm is here because you’re focused a lot on young people, adolescents, especially in the school context. So if there’s a kid in a class, and he starts exhibiting lethargy, or he seems really sad, and his teacher is worried about him, and he or she decides to report to the guidance counselor, to the parents, Hey, I think your kid might be depressed. And let’s say he gets therapy. And he goes to a clinician, and they talk about his problems, and he either gets medication, or he gets just someone to talk to. And then he goes to therapy. Even if he doesn’t have clinical depression, what is the harm that you’re seeing in that series of events?

Foulkes: Yeah. It’s a good question because the issue is that the series of events that you describe doesn’t necessarily happen. And at each of those steps, something might go wrong. So, certainly in the U.K., it’s very difficult to access good-quality one-to-one therapy. One possibility is that you identify a supposed problem in a young person, and then there’s nothing you can offer them to help. So you’re encouraged to go to the GP—that’s what the campaigns tell you to do—and then you get there, and you see, well, actually, it’s an 18-month waiting list. So that’s a potential problem that if that person isn’t clinically unwell—or even if they are—there’s a potential harm involved in telling someone that they have a problem and they need help, and then telling them that the help isn’t there.

But then there’s also the assumption in that sequence that having therapy will be helpful. Therapy doesn’t work for everyone and makes a small but not irrelevant proportion of people worse. So it’s not necessarily the case that—I’ve been asked before, Should we just give all teenagers therapy? Would that solve the problem? Well, no, because therapy doesn’t work for everyone. And also, it may be a problem that therapy can’t help this. It’s quite individualized. These messages that we get, you know, to go and get help and get therapy implies that the problem is situated within the individual.

And that could potentially mean you’re not getting them help in other aspects of their life that would actually be helpful, in terms of bullying, or maybe they’re living in poverty. I think to frame it as a mental-health problem and send them down that pathway might be unhelpful, because it means ignoring other sources of solutions.

So yeah, the ideal is if someone has a mental-health problem, you identify, you get them the right help quickly, and the help works. But it doesn’t necessarily work like that.

Demsas: I feel like a lot of this is just the network impacts on broader populations. A kid—maybe the best case happens, and he’s able to go to a therapist and finds out that he’s not experiencing some clinical depression, but he’s able to get some help. But he goes back to school, and he tells his classmates about it, and they’re influenced by that. Or, you know, it’s clearly a situation where a lot of—you know, this is a concept that you talk about, this idea of co-rumination—young people are talking to each other about their mental-health issues, and even if this kid gets therapy, he’s not an expert himself, and so he’s advising now a bunch of other people that they also have a problem.

So is a big part of the issue that you’re also worried about, that you are targeting a lot of people who are currently sick, but you’re getting a bunch of people who are less sick now really pathologizing themselves and then demanding resources that may otherwise be better used targeted at the really ill populations?

Foulkes: Yeah, so there’s a lot that’s interesting there, firstly, about social influence. And I think that’s really, really interesting. I certainly get told anecdotally about it a lot. So I had a parent after a talk say to me that her teenage daughter felt left out because she was the only one in her peer group who didn’t report having anxiety or depression. You can get all kinds of interesting merchandise on Etsy. I saw there are badges that can say, you know, I have anxiety, and a little heart. Or you can get—the latest I saw was a hoodie that says, Hot girls take antidepressants.

Demsas: (Laughs.)

Foulkes: Which is funny but also a sign of a big problem, I think, in terms of, in some cases—absolutely not for everyone, but in some cases—that we might have so far overshot moving away from stigma that we’ve moved into some of these things being possibly socially desirable. And then what impact does that have among peer groups?

Last week it came out in a paper about how disorders might spread within peer groups. So I think it’s a really, really relevant point. You know, adolescence is a period of heightened susceptibility to peer influence. And I don’t think we should ignore that context when we think about telling them to talk and think about their mental health.

Demsas: Okay. We’re going to take a quick break. More with Lucy when we get back.

[Break]

Demsas: When we’re talking about the problems with mental-health education efforts in schools, how much of this is a concern about resource allocation?

Foulkes: Definitely it’s a problem, and it’s a difficult argument to make. But, if certainly in the U.K., this huge drive to tell people to notice mental-health problems and label them and go and seek professional help for them has not been matched with help at the other end, you’re now funneling more people into a system that doesn’t have the resources to help them. And then what happens is people try to find alternatives, particularly in schools, in terms of teaching children en masse about mental health because that’s, you know, cheaper and fairer than one-to-one therapy. But I think that has its own difficulties. I don’t think that’s necessarily the solution.

Demsas: In a world where there aren’t enough mental-health resources being provided, whether it’s because there’s actual scarcity or it’s because of government policy or whatever reason, is it better, in your view, not to know whether or not you’re depressed?

Foulkes: As in, is it better off to have never known and then—

Demsas: Like, you have the same symptoms, the same kind of issues going on. And there’s not going to be therapy. There’s not going to be antidepressants available to you. Is it just better not to know you’re depressed?

Foulkes: I think it depends on whether there’s other useful change that can happen as a result of knowing that information. It’s very possible that learning that you have depression is still helpful, if it means you can understand yourself better, communicate that to other people in a way that leads to better social support. And it might be helpful if it means you can implement certain forms of self-help, which is useful.

So the idea of self-understanding, communicating it with other people, being able to implement change—all those things might mean it’s useful to learn that you have depression, be told you should go and get professional help, turn up, and it’s not there. It might still be useful information, but I think it’s a reasonable question to wonder whether that sequence of events ends up being harmful for some people.

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

Foulkes: So that’s the question that I’m trying to understand and that I want to understand over the next few years: What happens when you self-label with some of these disorders and these terms? How does that change the way you understand yourself, and how does that change what you do?

So there’s some evidence that identifying yourself as having depression over and above the levels of symptoms that you actually have is associated with more problematic coping, so less-useful coping strategies. So that means even when they control for the actual level of depressive symptoms, there’s something about considering yourself to have depression that might be unhelpful.

But, having said that, it’s a correlational study, so we don’t really know the direction of the effect. So there’s more work that needs to be done that was led by a Ph.D. student called Isaac Ahuvia, and he’s doing lots more interesting work in this area. So I suspect for some people, and we need to identify who they are, taking on these labels ends up being actively unhelpful.

Demsas: So if I have sad feelings, and saying, Oh, these are depressive feelings, that has a different impact on my own experience of the world than saying, I’m a depressed person, and taking that on as a label?

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

Demsas: A lot of this conversation is also difficult because these are not, like, discrete categories. As you’ve said, it’s not a situation where you can take a blood test and someone can tell you you have depression or you have anxiety. These are conditions that are difficult even for clinicians to diagnose accurately and require, often, a battery of tests to be reasonably certain about someone’s condition.

And you’ve referenced the work of a Canadian philosopher, Ian Hacking, and he talks about these problems of classification and how classification happens and how social, medical, and biological sciences—they create new classifications, and they often interact with the populations themselves. Can you tell us about his work and how it’s influenced your thinking?

Foulkes: Yeah. I think perhaps even more important or, in parallel, equally important to the fact that these things exist on continua is the fact that psychiatric disorders aren’t biological entities that exist in the real world, that exist in nature. They are constructs that have been created around symptoms as a useful framework for understanding some incredibly difficult, disruptive, dysfunctional thoughts, behaviors, and feelings.

But there are some people who argue that it’s never useful to frame these symptoms and human distress as disorders. So there’s a lot of arguing about what psychiatric disorders even are and where we put the boundaries around them. But what kind of linked to that, what Hacking was saying, is that in that act of labeling something as a disorder—when professionals, scientists, doctors, academics put a boundary around a set of symptoms, a level of symptoms, and call it a disorder—you bring that disorder into being in a way that it didn’t exist before.

And the looping effect that he’s talking about is that what happens when you diagnose or label someone as having a problem or difficulty, like, for example, binge-eating disorder, which is a relatively newly diagnostic category, they then go up and read about it. They learn about it. They view themselves as someone who has that disorder. And then they turn up again at the doctor’s office or the research study, holding in mind that diagnosis, that self-concept, that changed behavior, and then the professional observes them and themselves starts to learn more about the disorder.

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

Demsas: And what I was really interested in with his work too is also this part of the interaction between someone who becomes labeled and how that affects their demands on scientists and people who are doing the labeling, right? This interacts with what you’re talking about a lot, too. It’s not just that there is now a classification called binge-eating disorder. It’s that when they hear that framing and they learn all that stuff, maybe they’re on WebMD or whatever, they themselves are then going and sort of demanding that that classification get expanded, perhaps, to include other things.

So thinking about these other psychiatric disorders that we’re talking about, like anxiety or depression, you know, you go on TikTok or something like that, and you hear, Oh, you have high-functioning anxiety if sometimes you’re staring at a wall too long. But if you then have a population that’s saying, Okay, you have this thing called anxiety, and now we want this other thing called high-functioning anxiety. And then you go to your therapist. You go to your scientists. You go to your researchers. And you say, This is a classification, and then they feed that back to the population, as well.

Foulkes: Yeah, exactly. That was Hacking’s idea. I’ve had clinicians say to me that they have young people coming into their clinic using diagnostic language that actually doesn’t exist, as far as the clinician is aware. So it’s not grounded in, you know, academic psychiatry or clinical psychology. It’s been born on the internet.

TikTok, in particular, is a phenomenon on its own about the way it’s encouraging people to view and understand their personalities and their difficulties.

You know, high-functioning anxiety is not a clinical term. I mean, interestingly, to get an official diagnosis of an anxiety disorder, you need to have high numbers of a lot of symptoms for quite a long period of time. But you also need it to have a significant impact on your daily functioning, on your ability to navigate the world and live your life the way you would want to.

So high-functioning anxiety is removing that key diagnostic component. That doesn’t mean high-functioning anxiety is nice or easy to have, but it’s interesting that they have so explicitly removed that criteria that clinicians would recognize about impact on functioning.

Demsas: Another part of this is just that there’s not really a way to get this totally right. Because whichever system you create, you’re either bound to be overly inclusive or overly exclusive. You either tell educators and parents, Err on the side of caution. Talk to your kid about depression. Get them to the GP if you can, or to the doctor. And if you see someone in class behaving in a way that’s really concerning, get them to the guidance counselor so they can talk about whether or not they’re depressed or have anxiety, or whatever it is.

And in that kind of world, you’re going to get some false positives, and the alternative is going to be false negatives, right? It’s going to be like, Okay. Yes. We know that there are people out there, kids out there, who are really suffering and struggling, but we don’t want to inflict a bunch of costs and harm on them, their families, and society by over-diagnosing too much.

And so unless you’re pretty sure that this kid is experiencing some kind of harm, we want to err on the side of: Talk to them and check in with them, but don’t pathologize them, or don’t tell them they should go to their doctor or medicalize their experiences too much. And so you’re going to miss some of the kids who do need that help. And so, obviously, you want to get as close as possible to accuracy, but there’s no way, of course, of designing a perfect system that doesn’t err in one direction or the other.

And so given that it’s good for some people, bad for others, how do you even distinguish which pool of people is bigger, or which harm is worse, and which harm is acceptable? How do we think through those questions?

Foulkes: I think, at the moment, we’re leaning much, much, much more towards the idea of, Let’s not miss anyone, and let’s treat everyone as a risk. And I think some of the criticism I have had is that by asking the questions that I’m asking, who cares if there’s some people with milder problems who are mislabeling themselves if, actually, it means we can get to the ones who really need help? There’s not a straightforward answer, except that I think we should care about both problems equally.

Demsas: It’s one of those things where, of course, you’re a researcher. You’re a scientist, and you’re wanting to get a lot more of that information. But on a practical level right now, you’re saying that you think we’ve gone a little bit too far in talking about and pathologizing young people’s emotions and erring too far on the side of maybe them having depression.

If you’re a teacher hearing this, and you’re wanting to make sure you’re not harming your kids, and you look out in your classroom, how do you want that teacher to change how they’re interacting with their students? Or how do you want school systems to change in how they’re interacting with their population?

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

And, actually, I’m running a study at the moment with a master’s student called Katie Cunningham-Rowe, and she’s interviewing clinicians about what they think about this change in language, particularly the increase of self-diagnosis. And something that quite a few of them have said is that often a young person will come in with a self-diagnosis but, across several sessions, they will gradually start to let go of it or lose their grip on it. And they say that once you pay attention to them and take seriously their distress and listen to them and what’s happening in their lives, you often find that the diagnostic language matters less. But there are plenty of people who do have mental-health problems and mental disorders, so I think you have to err on the side of caution.

Demsas: One thing that is clearly pushing people to err on the side of caution, though, is also the legal frameworks, right? There’s also this backstop of people who are worried about lawsuits or legal liability. How is that playing a role in this?

Foulkes: I think it’s playing a big role in universities but also in schools. Obviously, the biggest fear of any educational organization is that a student will take their own lives, and that questions will be asked about whether the institution sufficiently protected and supported them. And there have been specific cases asking those questions in the U.K. in the last few years.

Demsas: Which ones?

Foulkes: There was a university student suicide, and she had social-anxiety disorder, and they didn’t make reasonable adjustments for her. And her parents successfully argued that it was a disability and that they should have done. And so that has had repercussions for other universities and schools here.

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

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

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

Demsas: Do you see this applicated in other places? I know with Hacking’s work and in other places, there’s a sense that right when something is coming into being—whether it’s understandings about multiple-personality disorder or it’s binge-eating disorder, as you mentioned—there’s this transition period where people are still trying to figure out this term and who it should apply to, whether that’s from a medical perspective or from the population’s perspective.

Do you think that this is just this liminal, transitionary period we’re living through, or it’s something that you are concerned could become the status quo that we just, in perpetuity, are just constantly treating more mild symptoms as being really concerning and thus seeing these larger, broader effects that you’re worried about?

Foulkes: Presumably, there’s an upper limit when so many people identify themselves as having a mental-health problem that that loses the meaning that it once had. Part of the reason why these labels have power is because they signal that you’re experiencing something unusual in its level of difficulty and disruption. If I had to make a prediction, I would say it can’t carry on indefinitely in the direction it’s going in, because it will reach a point—if we’re carrying on in this direction—where everyone is diagnosable with something. And then I think if we reach that point, then the labels lose the power that they once had.

Demsas: So, always our last question: What is something that you thought was good on paper, but it didn’t really pan out the way you expected?

Foulkes: This is quite a literal example, but I always wanted to write fiction. And I wrote a novel, which took years, and I had a literary agent. And it didn’t work out. They didn’t want to pitch the book to publishers. So I thought I might try writing nonfiction instead, and then I could circle back to it. And it made sense to write about mental health because that’s what I was interested in, in my work at the time, but I’ve fallen in love with psychology writing. I don’t know if I will go back to fiction.

So it was a slightly weird route into writing the books that I’ve written, but I think I had in my head and my heart that I would write novels, and it was an awful lot of work for not the outcome I wanted.

Demsas: Yeah. What was the book about?

Foulkes: Oh, it was in domestic noir. There was that trend for things happening behind closed doors that you didn’t know about and domestic drama. So it’s kind of down that road. Actually, in hindsight, it would be a good example of things you really wanted, but in hindsight, you’re glad didn’t work out. I’m very glad that book’s not out in the world. (Laughs.)

Demsas: (Laughs.) Well, I feel like the process of having written it can be cathartic, anyway. But I’m glad you’re writing about this, and thank you so much for coming on the show. We’re really happy to have you.

Foulkes: Thank you for having me. Thanks.

Demsas: Good on Paper is produced by Jinae West. It was edited by Dave Shaw, fact-checked by Ena Alvarado, and engineered by Erica Huang. Our theme music is composed by Rob Smierciak. Claudine Ebeid is the executive producer of Atlantic audio, and Andrea Valdez is our managing editor.

And hey, if you like what you’re hearing, please leave us a rating and review on Apple Podcasts.

I’m Jerusalem Demsas, and we’ll see you next week.