Why self-help is not always helpful

 “Self-love is the balance between accepting yourself as you are while knowing you deserve better, and then working towards it.”

― Vex King, Good Vibes, Good Life: How Self-Love Is the Key to Unlocking Your Greatness

‘Self-help’ is a movement and an industry. The rhetoric of self-help includes self-knowledge, self-change, self-improvement, self-understanding, self-mastery, self- motivation and self-love. It all sounds positive, yet there is a darker side to the self-help movement, particularly surrounding illness.  

Self-help literature prioritises self-knowledge and honesty, with self-assessment scales and questionnaires designed to increase knowledge of our own strengths and weaknesses, giving us the ‘truth’ about ourselves (Rimke 2000: 67-68).  The emphasis on self suggests that power is being given to the individual. But the rhetoric of self-help can be used to perpetuate existing power relations under the guise of voluntary ‘self-improvement’. 

Self-love

According to Rimke, we defer to experts in psychology, because we assume that all problems are psychological ones and that psychology can make us happy and ‘normal’. ‘Self-help is the logical extension of a psychologistically oriented culture in which psychology enjoys cultural authority as a form of expert knowledge’ (Rimke 2000: 63). Power operates through self-help with cunning sleight of hand. We are told to love ourselves, to be responsible for our own psychological states but also improve and conform to social psychological benchmarks. 

Self-help rhetoric is full of neoliberal ideals. In brief, neoliberalism is a political and economic ideology favouring capitalism, free market competition and minimal government interference. Neoliberalism can lead to a hyper-individualist, meritocratic outlook where individuals are the authors of their own success and failure (Franssen 2020: 102). The emphasis on self in self-care literature reinforces this. 

However neoliberalism is also accused of exacerbating social inequalities due to excessive individualism and a failure to recognise that individual vulnerabilities are often the result of social and economic disadvantages. There is evidence that for people with mental illness such as bipolar disorder, the internalisation of meritocratic world views, in which individual success or failure is perceived as the result of their own efforts (or lack thereof), results in self-stigmatisation and increased feelings of guilt or shame (Rüsch, Todd et al. 2010). 

If we are being told that ‘individuals possess the ability to choose happiness over unhappiness, success over failure, and even health over illness’ (Rimke 2000: 73) then the implication is that those who fail to recover simply made bad choices or failed to master their own psychology, diverting attention from the forces of power that can actually make structural changes. This is victim-blaming of the most vulnerable.

This dark side of self-help is a type of hermeneutical injustice that is not simply an absence of the appropriate hermeneutical resources needed to make sense of a social experience (Fricker 2007). It is not that we lack the concepts of inequality or neglect in healthcare. Rather, it is a case of what Falbo describes as a species of hermeneutical injustice where there is an ‘overabundance of distorting and oppressive concepts’ which crowd out, defeat or pre-empt the application of a more accurate concept (Falbo 2022: 353). 

In many cases of illness, a failure to recover would be appropriately understood in terms of inequality, disadvantage or neglect. But these concepts are replaced by a hyper-individualised, neoliberal meritocratic ideology, perpetuated by self-help literature. The very movement that is meant to increase self-knowledge becomes hijacked in a way that diverts attention from the structural inequalities that those in power should be addressing, instead blaming the victims of those inequalities. When this happens, self-help rhetoric is not only unhelpful, it is harmful. 

Sally Latham is a PhD student with the Open University and recipient of the Royal Institute of Philosophy Jacobson Studentship. She is soon to submit her thesis arguing for a non-narrative approach to mental health.

"Trauma is not being seen or heard"

 epistemology 

noun, epis·te·mol·o·gy i-ˌpi-stə-ˈmä-lə-jē

the study or a theory of the nature and grounds of knowledge especially with reference to its limits and validity

Two weeks ago I went to dinner and drinks with members of the London ACEs (Adverse Childhood Experiences) Hub, it was a small group in which everyone came from very different backgrounds and professions including some with lived experience. You can see some of us here.

It struck me that the diversity of our group was evidence that expertise in Adverse Childhood Experiences and developmental trauma cannot be held by any specialty. Nobody can claim epistemic dominance. Like the blind men feeling an elephant and each being certain that the whole creature resembles the part they are feeling, in matters of trauma nobody can claim to be able to see the whole picture. Modern medicine is structured with specialists at the top and generalists (like GPs) at the bottom.

 

The Telegraph newspaper has had a series of headlines recently pointing out that GPs don’t know enough about cancer or antidepressants or anything else. According to The Telegraph if people are sick, they ought to a specialist. These are easy accusations to make and have been news headlines for my entire career and will continue until journalists understand and value the fact that generalist knowledge about the ways different illness interact is not the same as the accumulation of number of different specialisms. There were two GPs at the LAH dinner and drinks, evidence perhaps that GPs more than any other specialty see the ways that biography and biology are constantly affecting each other leading to familiar pattens of physical, psychological, and social disruption. Nevertheless, our medical perspective only captures part of the picture which is why our group includes people working in criminal justice, racial justice, education, community activism, parenting support, and more. We depend on one another to see the whole picture.

A few days after the dinner, I attended an interdisciplinary workshop about trauma with philosopher Havi Carel and a range of speakers including philosophers, literary scholars, educators, and a music therapist. Once again, none of us could claim epistemic dominance. Professor Havi Carel is perhaps best known for her work on Epistemic justice in healthcare. Epistemic injustice in healthcare happens when a professional assumes that because of certain characteristics their patient is an unreliable narrator and interpreter of their own experiences. Consequently they fail to listen to or take seriously what their patient has to say. The only story that counts is the medical history and the only interpretation that matters is the diagnostic formulation. Patients experience not being seen or heard, i.e. invalidation.

People who are suffering the consequences of trauma, living with what I describe as the trauma world of hypervigilance, shut-down, toxic shame, dissociation and harmful coping strategies, are especially likely to have characteristics that professionals assume render them unreliable witnesses. These include being a child or female or trans, being black or other ethnic minority, being neuro-divergent or having a mental illness, having any kind of physical or mental disability, having an addiction past or present, being homeless, having low levels of literacy or educational attainment and so on. Intersectionality matters, so a Black woman with a mental illness and an addiction is subject to multiple assumptions and is especially vulnerable to Epistemic Injustice. One of many valid definitions of trauma that I’ve heard from researchers including Bessel van de Kolk and Jacob Ham as well as survivors is,

“Trauma is not being seen or heard.”

Trauma happens under conditions of overwhelming stress where those affected are unable to talk about what’s happening because it is too dangerous or there is nobody who will listen. They learn to bottle it up and in so doing, increase the risk of the kinds of inflammatory and autoimmune disease that are hugely over-represented in people with traumatic life histories. A healthcare professional represents someone with power who may cause the patient to re-experience feelings of powerlessness, but also has the potential to provide a safe environment and attuned presence. If they feel safe enough, patients may want to talk about what has happened to them. If we refuse to listen or don’t listen carefully enough, then they may experience the traumatic invalidation that they have suffered before, and the potential harm is enormous. Patients with trauma are at greater risk of Epistemic Injustice and suffer greater harm from it.

My own Achilles heel as a doctor is explaining too much. I recently discovered a quote from Donald Winnacott, a child psychotherapist and paediatrician who worked near my practice over 50 years ago and it was reassuring to know that we have at least this in common:

“It appals me to think how much deep change I have prevented or delayed in patients in a certain classification category by my personal need to interpret. If only we can wait, the patient arrives at understanding creatively and with immense joy, and now I enjoy this joy more than I used to enjoy the sense of having been clever. I think I interpret mainly to let the patient know the limits of my understanding. The principle is that it is the patient and only the patient who has the answers. We may or may not enable him or her to encompass what is known or become aware of it with acceptance.” Playing and Reality

In my teaching about trauma, I use a quote from Leslie Jamieson, The Empathy Exams:

“Empathy is asking the questions whose answers need listening to.”

I hope to persuade the doctors and students that I teach, as well as constantly reminding myself that you can demonstrate your expertise by the questions you ask. In so doing we can enable patients to tell their stories and come up with interpretations that help them make sense of their experiences. It’s important to remember that figuring why you are like you are doesn’t necessarily make things better, and may even make things worse, but it is a necessary part of a healing process. Making sense of painful lives through stories is not a radical departure from clinical medicine, but an essential and inseparable part of it. Stories are how medical knowledge is transmitted and ‘how doctors think’ even if we’re unaware of it.

In summary, understanding epistemic (in)justice is essential for trauma-informed care because patients affected by trauma are more likely to not be listened to or taken seriously and are more likely to be harmed by invalidation. Because no specialty within medicine can claim epistemic dominance, they experience what Psychoanalyst Michael Balint described as the ‘collusion of anonymity,’ where “the patient is passed from one specialist to another with nobody taking responsibility for the whole person.”

The answer for me lies in creating a safe environment and continuity of care with well cared-for and respected generalist professionals who can truly listen.


Thanks to Flo, who has been helping me teach this and has inspired me to try to figure this out.

This post is authored by Jonathon Tomlinson who has been a GP and educator in Hoxton, East London for over 20 years.

Jonathon is especially interested in the intractable problems that characterise 'deep end' general practice like complex-trauma, chronic pain and the intersections between biography and biology.

Fred Cooper joins EPIC

More good news for project EPIC! Fred Cooper, currently a Research Fellow at the University of Exeter, will join EPIC as a Senior Research Fellow based in the Law School at the University of Bristol. We asked Fred a few questions about current interests and future plans.

Fred Cooper

Hi Fred! What is your main research interest?

Most of my work to date has been about attempting to understand the historical, political, and experiential dimensions of loneliness, although this has led me to spend substantial amounts of time with other problems, particularly shame, which share a porous border. As a historian of medicine, I’m interested in how the idea of loneliness that we work from today has been assembled over time, in different processes and contexts and by individuals and groups with different claims to expertise. 

I have an upcoming article, for example, on loneliness, shame, and personality, which uses historical methodologies to unpick some of the ways that loneliness has been (and continues to be) framed as a matter of personal failure. Maybe predictably given my disciplinary training, I’m also interested in temporal representations of loneliness (i.e., as a crisis or epidemic linked to the present or the very recent past); I’ve written recently on the history of this strain of thinking and why I think it constrains the kinds of questions we need to ask.

Threaded through this work has been a series of important questions over how knowledge is built and by who. Focusing primarily on loneliness, my case study at EPIC will tack between historical, philosophical, and engaged research methods to think critically about how epistemic injustices are produced and perpetuated over (relatively) long periods of time, and the impact this has on opportunities for epistemic, experiential, and structural redress.

Why do you think it is important to study epistemic injustice in healthcare?

I strongly suspect that a significant number of people working in the medical humanities, social sciences, and other kinds of health research – particularly where that work involves co-production, engaged research, or other kinds of participatory methods – are fundamentally concerned with epistemic injustice, even when they don’t use that precise framing. 

Just the other day, I spoke at a knowledge exchange symposium between the University of Exeter’s Wellcome Centre for Cultures and Environments of Health (my workplace for the past six years), and the Copenhagen Centre for Health Research in the Humanities; in almost every talk or discussion, problems of service user testimony being discarded or derided were addressed, or of complex systems of knowledge being created around – but not necessarily with or for – the people concerned. 

As well as opening up new lines of research and new ways of identifying and ameliorating harm, epistemic injustice is a vastly useful conceptual tool for better articulating and understanding many of the phenomena that researchers are already substantively engaged with. In the ethical imperative to work on epistemic injustice in ways that don’t unwittingly reproduce hierarchical or extractive epistemic processes, it can also inform and improve our engagements with different partners and publics.

What are you working on right now?

I’m currently working on a resource which draws out insights from historical research on loneliness for a wider, non-humanities audience. Co-authored with 15 other scholars, it’s an overture to other disciplines - and health policymakers too - to work in closer dialogue with historical questions, findings, methods, and researchers. One of many reasons I’m excited about joining EPIC is the chance to show what historical practice can do in this kind of outward-looking interdisciplinary space, particularly as historical contributions to the existing literature on epistemic injustice have been relatively few. 

I’m also working on several talks: my first Keynote, for a symposium on loneliness and shame at the University of Bristol, and a paper on loneliness and culture for a seminar with the European Commission’s Joint Research Centre. Ahead of starting work at EPIC in the new year, I’m beginning to sketch out how my case study will work in practice, thinking about sources and archives, and putting together thoughts on possible collaborations with the rest of the team.