Aetiology of shame and its association with adolescent depression and anxiety – CAMHS around the Campfire

Matt Kempen
Marketing Manager for ACAMH

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For this session we welcomed Professor Thalia Eley, Professor of Developmental Behavioural Genetics, KCL, to discuss her JCPP paper First published: 16 June 2021 doi.org/10.1111/jcpp.13465

Authors; Milica Nikolić, Laurie J. Hannigan, Georgina Krebs, Abram Sterne, Alice M. Gregory, Thalia C. Eley.

Slides from the session

To get the most from the session we suggest reading/watching the following resources;

About the session

A panel, comprising paper author Professor Thalia Eley, independent expert Dr. Maria Loades, Tara from The McPin Foundation with lived experience, and Douglas Badenoch, will discuss the research and its implications with Douglas Badenoch. This discussion was facilitated by Andre Tomlin (@Mental_Elf).

Transcript

Andre Tomlin – Hello, everyone. Welcome to The Woodland. It’s a pleasure, as always, to be here for another CAMHs campfire. We’ve got a really good one for you this month, and it’s lovely to see so many people introducing themselves in the chat. Do carry on saying that. Tell us who you are. Tell us where you’re from. We’ve got a really interesting conversation this evening about shame and depression and anxiety in young people and do contribute to that discussion. Tell us what you think as we go along.

Tweet your thoughts if you are that way inclined. The Twitter hashtag this evening, as always, is CAMHs campfire, we’re putting that into the chat. So share what you think of this evening’s webinar with your followers on social media and everything that we do this evening will be saved on the ACAMH website afterwards. So this video of the webinar, the slides that are being presented, the papers that are being discussed and the links that will be discussed as well later on, they’ll all be brought together on the page, on the ACAMH website.

So don’t worry about any of that. You’ll get an email afterwards and it will give you a link to all of those things. So let’s start off by having a poll and just finding out who we’ve got here in the room. So, Matt, if you could please start the first poll. So just tell us which of these groups best fits you. Are you a psychologist or a social worker or a student or none of the above? Just tell us quickly which of these is closest to your particular role?

Just to get a sense of who we’ve got here in the webinar. We know that we’ve got a really international audience. As always, people joining from all over the world. So that’s great to see, but let’s just get a sense of what type of people we’ve got here as well. That will really help us with the conversation. So, as always, really mixed. I think the biggest group there is psychotherapist’s at 19%, but we’ve got lots of other different types of health practitioners.

We’ve got some researchers. We’ve got lots of students, and we’ve got lots of others as well. So thank you very much for telling us which of these groups best fits you. First of all, I’ll introduce our panel. We’ve got a great panel of experts here today. We’ve got three people who’ve joined us for the conversation over the next 55 minutes, and our first panel member is Talia. That’s Professor Talia Eley, Professor of Developmental Behavioural Genetics at King’s College, London.

And it is Talia’s paper that we can be discussing this evening. We’ve also got Maria. That’s Dr Maria Loades. She’s a senior lecturer, a clinical tutor for the doctorate in clinical psychology at the University of Bath. We’ve also got Tara with us this evening, who is a student with experience from the McPin Young People’s Network. So thank you very much all of you for joining us. They’re all joining us virtually, of course, as always at the moment with this Zoom way of living.

We’ve also got somebody who’s joining us doubly virtually this evening. That’s my colleague Douglas, who can’t even make it to the webinar this month. He’s got a very good excuse. He’s been to see the eye elf today. He’s got a little bit of something that needs sorting out. So we hope that’s gone well Douglas and that you’re recovering. Douglas is the co-founder and director of the National Elf Service. My colleague. He’s an information scientist. He’s got a black belt in critical appraisal, and he’s done a little video today that he’s going to talk through the paper and tell us what he thinks of this paper that we’re going to discuss today.

So we’ll be playing that in a few minutes. As always, the campfire is in three acts. The first act, we’ll talk about the background to the subject. The second act is Douglas’s critical appraisal of the paper, and then the third act is, so what? What are we going to do now, now that we’ve got this new research?

What impact should it have on our lives, on practice, on future research? So do chime in with your questions as we go along. We’ll try and get as many of those to the speakers as we can. So we’re going to start off talking about the background, and my first question to Talia is, well we know depression is common in young people and we know that anxiety is also common and evidence that we’ve had over the last few years suggests that it’s actually going up in young people.

What do we know about the genetics of depression and anxiety? Do we inherit these conditions from people in our family?

Prof. Talia Eley – Sorry, I’ll silence my phone. Thank you, and thank you so much Andre for the lovely welcome and introduction. I’m just so excited to be here. And I am at heart a psychologist that uses genetics and I’m just so excited to see how many clinicians there are in the audience, because one of the things I’m always really passionate about is trying to make sure that genetic findings are written in a way that people who don’t normally think about genetics can understand them.

So hopefully that’s something that people can take away from this session of us talking about it. So the bottom line answer to Andre’s question is, yes, genetics are important for both anxiety and depression, but they’re not by any means the most important thing. So if we think about the proportion of the variation in the population in anxiety and depression it’s about 30 of that that comes from variation in genetics. So about a third of it and then the rest comes from environmental experiences.

So different things that happen to us and particularly the sorts of things that are very specific to you. So not things that are shared by the family to the same extent. So that doesn’t mean the family experiences aren’t important. It’s more that the evidence seems to suggest that you’re sort of individual take on what’s happening in your family and your individual response to is the important part from the environmental point of view. So both of them influenced by both genetics and the environment and actually, interestingly, it’s very similar genetics for both anxiety and depression.

So the genetic vulnerabilities to these two conditions or types of symptoms are largely overlapping, but in contrast the environmental experiences associated with them tend to be quite distinct. So it’s almost like what you inherit is a sort of general, sort of emotional tendency, which might be low, it might be medium, it might be high, and then depending on what happens to you, you might express some symptoms and feelings and whether those anxiety or depression might depend on what you’ve experienced.

So, for example, if you’re someone who is quite high on this sort of emotional, genetic risk that I was talking about, the experience is a major loss event. Then you might find that you experience stronger depression reaction to that. Stronger depression symptoms after that than somebody with maybe a lower genetic level. Whereas if you experience perhaps something that’s more of an ongoing chronic stressor or something that might be happening in the future then inevitably that’s more associated with anxiety than depression.

So it’s really interesting that those genetic findings, largely from the literature, kind of reinforce what we know about how depression and anxiety operate in terms of how they function, in terms of our responses to the kind of things that we experience. So I find that very interesting from ta psychological point of view. It makes sense that the environmental sort of influences or triggers for anxiety and depression tend not to be the same. Whereas the sort of genetic underlying vulnerability is the same.

Andre Tomlin – How robust is that evidence that we have about mental health and genetics? If you compare it to, I don’t know, cancer or diabetes or other illnesses that we know have a hereditary component. How robust are those findings linking genetics to depression and anxiety in people?

Prof. Talia Eley – That are really robust and I would say the main reason that they’re robust is because we’ve seen evidence for them from a number of different types of study designs. So what we’ve got here in the paper today is the twin design.

That’s one of the oldest longstanding designs for disentangling genetic and environmental influences, and there’s absolutely enormous literature now showing that anxiety and depression are heritable. Interestingly, not so much in pre-adolescent children, so particularly for depression. So depression in pre-adolescent children is almost exclusively a response to traumatic and highly stressful experiences. Whereas from adolescence onwards it’s where the genetic influences kick in and they seem to have quite considerable stability across the lifespan. So it’s like what someone inherits is a sort of general, lifelong predisposition to tend to respond to things either more or less emotionally.

And now the evidence from these more contemporary genetic approaches using data from the genome is really confirming these findings. So we now see that when we look at genome wide data we see the same thing. So we are now identifying individual genetic variants that are associated with anxiety and depression and it tends to be the same ones. So again we see this big genetic overlap between them and it tends to be the same across the lifespan in general. There are some specific, some influence of specific time points or age ranges, but in general, there’s quite a lot of genetic stability for these traits.

Andre Tomlin – Brilliant. Thank you. That’s a great summary to introduce us to the topic. Let’s talk a bit about shame then, and I’m going to come to Maria first of all. I want to ask you, Maria, as a clinical psychologist does this make sense? This link between shame and depression and anxiety in young people?

Dr. Maria Loades – Massively, yes. So for me I was absolutely fascinated to read Talia’s paper and it really got me thinking actually, you know, we see young people presenting with a whole range of different difficulties, which might be underpinned by shame. So I was thinking about, you know, eating disorders presentation, social anxiety, certainly depression, where we see the sense of worthlessness and kind of badness and unacceptability, and I think it’s such an issue for teenagers, isn’t it?

Because it’s when we’re teenagers that other people’s opinions of us and particularly our peers’ opinions of us matter so much. So I think it’s rare to work with a teenager who’s not at least to some degree, pre-occupied by what other people think of us, and shame is all about what other people think of us, but in a very global sense. So, you know, the difference for me between shame and guilt is guilt is feeling bad because you did something bad.

Shame is much more about feeling bad and worthless as a person, much more global, and of course we know that in depression and anxiety our thinking patterns tend to be much more global. Much more general, much more negative. So we see shame an awful lot, Andre, and I think it’s a really exciting avenue for us to think more about.

Andre Tomlin – Brilliant. Thank you. That’s great. Well it’s not great, is it? It’s horrendous. We’re talking about the topic and it’s a great introduction. Tara, what’s your reflections on what you’ve heard so far? You were nodding a lot there when Maria was talking.

Tara – Yeah, I think what she said is really, really profound and very important. I think she mentioned the part about how as a young person you’re very preoccupied about what your friends think of you, and obviously in adolescence we see the shift in the attachment hierarchy where your friend’s opinions become so much more important than your parents’ opinions or family’s opinion. So it makes a lot of sense and I think obviously, speaking from someone with lived experience, every time I had anxiety or depression when I was younger, it had a lot to do with what was happening outside of me, but also people’s opinions of me as a person or the way that I looked or the way that I behaved.

It was very rarely about I mean, yes, it was about internal circumstances but I would say that it was really, you know, the depression was perpetuated and maintained because of the way that I felt about myself and more importantly, how I felt others perceived me. So I think you walk around the world thinking you just feel really small and you think, oh, everyone hates me. Everyone thinks this, everyone thinks that and then that just created that in a dialogue that maintains that depression and anxiety.

So it’s really true, and I think teenagers, adolescents, they’re very vulnerable. You might not have had the emotional maturity that you cultivate when you’re 21 years old or whatever. So there’s no kind of line of reasoning where you can kind of talk yourself out of that mental group or say to yourself, well, no, other people’s opinions don’t matter. So I think that’s why it’s especially sensitive, because they haven’t cultivated that emotional maturity to be able to reason the way a 25 year old would be able to reason and pull themselves out of that difficult position.

But I think it is a very exciting thing to explore. I think there’s so many areas that really can go into it. I think when we start speaking up, I mean, she’s brought the topic of eating disorders, which I think is really important and I think the thing that comes to mind when we’re talking about all of this is shame, as the different levels of shame that different people experience. So, for example, I’m thinking of people of ethnic minority background and the shame that they experience in the way that we see depression levels and even levels of psychological disorders.

We know that some psychological disorders are elevated in ethnic minority groups. So now I’m thinking, how is that linked to the shame they experience that is also obviously linked to social exclusion, social isolation, racism, all these things. So I have a lot of thoughts, but yes, that’s mainly it.

Andre Tomlin – That is very interesting. This kind of compounds discrimination and inequality that you experienced. Absolutely. I think that’s so important and so complex. What do you think about the relationship between shame and depression or anxiety? I mean, I know what you mean? I myself, I have lots of experience of depression and anxiety, either on their own or together at the same time, but I’m interested in what you think about how shame impacts on those two separate conditions, if there is a difference?

Tara – Yeah, I think for starters, depression and anxiety, I experienced differently. They look different. So I think when I think of anxiety and shame, I think of I’m not leaving the house today because what will people think of how I look, whether that’s to do with weight or to do with your status as a certain person, whatever it is. So that’s what I think, and then when I think of depression, obviously we know that depression, anxiety really interrelate and they’re very connected, but when I think of depression I think of, it’s your emotional state and how the shame kind of like needs to be maintained in that emotional state. So you stay. So you might be like, I don’t want to leave the house because I’m anxious. You might feel that anxiety but then you also might start to feel extremely emotionally withdrawn and really sad and despondent because of this internal dialogue of I cannot leave the house because of how I look or whatever it is.

So I really think that they really affect each other. I would say that in different ways, of course but I think yeah, I hope that makes sense what I’m saying.

Andre Tomlin – Yeah, it very much does. It’s obviously a very personal experience, but I think there’s certainly some truth about the interlinking between the various conditions that a lot of people identify with. I want to come back to you Talia and ask you to kind of give us a bit of an introduction then to your mind-set as you started to do this research, as you started to have your kind of initial questions around this? You already decided to focus on shame as the important emotion to study. Why?

Prof. Talia Eley – Well, it’s really interesting what Maria was saying about her role as a clinical psychologist, because actually this measure was included in the study by Deakin Psych trainee for their research project, and he was somebody who had worked in the department for a few years and developed an interest in the genetic side of depression, anxiety, but from a clinical point of view he was really fascinated by shame. So he wanted to answer, it’s Ed Stern who is one of the authors.

He wanted to answer the question, is it the same genetic influences that impact on shame, that impact on anxiety and depression? That’s what his Deakin thesis was about and I was fascinated by that myself because a lot of my work has been not just to look at depression, the genetics of depression, anxiety, but to think about how those genetics happened. Like how do they influence it? So I’ve spent a lot of time looking at different aspects of cognitive processing and cognitive style and cognitive biases. Some of the sort of things Maria was talking about the way people think, who experiences conditions, and looking at the extent to which those might capture or reflect this genetic risk.

So shame felt like it fitted in really well with that, because I think a big part of how our genetics functions is it influences how we see the world around us and how we respond to it and interpret it and shame is going to have that same impact. It’s going to influence how you engage with those around you.

And so it was really that kind of background that led to us, including the measure in the study, and then Ed went off and did his clinical career and the data never got published. Then I was always really interested in looking back at it and Melika, who is the first author I saw presenting about shame, just a purely psychological presentation at AEBCT a few years back, and I was very impressed by her. I thought she had some really interesting ideas and went and chatter to her and said, look, I have this measure of shame in our twin study and we’ve done very little with it, and I’d love to chat about that some time.

Anyway, she was in the middle of having children and things. So it all took a bit longer than we expected, but the final result was this this paper. So it started with Ed and then Melika kind of picked up the wheel further along and we managed to get back in touch with Ed as well and bring him back in and introduce this sort of longitudinal element of looking at the extent to which shame was associated with changes in symptoms over time, which I thought was an even more interesting thing to look at really, and to me, in a way, the most interesting finding from the paper is not the genetics. It’s about the fact that the shame is associated with a change in depression across adolescence, and I think that really gives us a sense of something that maybe we can do something with.

Andre Tomlin – Thank you. It’s a nice window into the world of academic mental health. It delays the experiences people have lives and they go off and have children and they get jobs.

Prof. Talia Eley – They do. They do.

Andre Tomlin – I am interested in how it kind of fits in to all the other priorities. So, Maria, maybe you can kind of put it into context for us. I guess, you know, young people these days, young people these days they face all sorts of challenges, don’t they? You know, I won’t list them. We all know what they are. It’s really huge. Is shame important priority, do you think, alongside all those other things? Would you put it up there as something that’s a really key topic for us to discuss?

Dr. Maria Loades – I think what we need to get better at Andre is spotting these things that we can change at an early stage. So working off of what Talia was just mentioning, which is so exciting about this is seeing something that we could actually, you know, malleably make changes with at an early stage that could potentially and, of course we would need to test this out in practice, but could potentially help us to build up resilience and decrease vulnerability to developing anxiety or depression.

But I think also going back to what Talia was talking about, you know, one of the really big issues at the moment is, of course, for marginalised groups like youth of colour, for instance, for whom shame and collective shame is a huge issue. So I do think that yes there are so many priorities, but more than anything the priority must be about preventing and intervening as early as possible with youth mental health, because we know that developing mental health problems in young people has an ongoing impact well into adulthood.

So really we need to prioritise what we can do here and I think shame makes a great target.

Andre Tomlin – Thank you. Tara, what’s your experience? What’s your reflection on what Maria has just said there and also the inspiration for this from Talia’s perspective?

Tara – Yeah, I think obviously intervening at an early stage  is definitely key, but I think what I’m also thinking is I think young people often don’t have the language to actually understand or express what they actually are feeling and experiencing. So I’m trying to think of when I was younger and I was experiencing all these things, I couldn’t put to words and say, what I’m feeling is shame. Instead, it was, oh, my friends think this and this and this.

So I think, first of all, giving young people that language is really important because we can’t fix what we cannot identify and we can’t fix what we don’t label. So I think that’s such a key thing for us, and I think we were talking about marginalised groups, you know, inequality to access. That’s such a huge thing. We know that the access is… There’s disparities in access. We know that people of ethnic minority background are underrepresented in mental health services, and now I think we need to start thinking about why.

I think what it is also where shame comes in is shame of actually not being okay. So I feel depressed and I feel depressed because I’m ashamed but now I’m ashamed because I’m depressed and I won’t go to services because I’m ashamed. It’s just kind of snowballed into an entire thing. So this is why I say I think, first of all, giving people the language and giving people to be able to say to them this isn’t necessarily your fault. That there are other mechanisms at play, like genetics, like emotional vulnerability. So I think that’s what comes to mind, is that I think it would be difficult to help people if they themselves cannot label what they are experiencing and what they’re feeling.

Andre Tomlin – Go on. Come in Maria.

Dr. Maria Loades – Yeah, I think that’s such a great point, Tara, because of course, also shame by its definition is something that we might well want to keep hidden and that we might not want to bring to the fore, even if we’ve got the language. So giving them the language, but also the permission which is I think what you’re getting at is so important. I so much agree.

Andre Tomlin – So if language is important let’s ask this question that Helen is putting in the chat, which is around what’s the difference between shame and embarrassment? Can you address that Maria?

Dr. Maria Loades – I can try. Talia might have a better answer than I do, but for me this is aligned. So like I’ve mentioned, you know, full of guilt, humiliation, shame, embarrassment. I think there’s probably a spectrum, isn’t there, and guilt is quite kind of situation specific, living through embarrassment and humiliation into shame, but I guess for me what’s different about embarrassment is it tends to arise where you have actually committed a kind of violation of a social norm, as it were. Whereas shame is this much more global.

I am generally bad irrespective of what I’m doing right now. Shame continues there. Whereas embarrassment tends to be kind of quite linked to right now I’m embarrassed because, for instance, my phone rings during a Zoom call arguably.

Andre Tomlin – Don’t be, that happens all the time and we expect it, so that’s absolutely fine. Do you want to add anything, Talia to that?

Prof. Talia Eley – Just to say, I have a similar perspective on it to Maria, but I have to admit I haven’t drilled into the theoretical underpinnings of these different sort of social emotions in a huge amount of detail, but that’s certainly the ordering that she presented there is very similar to how I think about it.

Andre Tomlin – Okay, that’s great. Alright. So it’s time to pause for ten minutes or so and to listen to Douglas’s video presentation.

Douglas Badenoch – Hello, I’m Douglas. I’m sorry I can’t be with you today for the club around the campfire, but I’ve done a quick critical appraisal of the paper. So bear with me and I’ll run through a few slides about this longitudinal cohort study of twins and sibling pairs. So just a few bits of terminology for those who may not be familiar aetiology means that this study is looking at the causative links between one thing and another, and this case between shame and depression and anxiety.

Another important term from, just that we get from the title here is that this was a prospective study, which means that they started rolling the study and they followed people forward in time, and that’s a good study designed to get good quality data because you have less bias than if you’re looking backwards at a set of data that’s previously been gathered. And finally, it is an observational study. So it’s not an interventional study. We’re not doing something and then seeing what happens.

We’re measuring shame and we’re seeing what happens after that. So we’re not actually doing an active intervention and that limits some of the things we can say. So why do we critically appraise evidence? Well, this quote from Ben Jovanovich is quite a useful Orwellian take. Not all studies, unfortunately, are created equal. So the process of critical appraisal is to kind of rule out the possibility that bias might have caused the results we’re seeing. Get a sense of how much they could be accounted for by the play of chance, because if you can rule these two things out then we know what we’ve got is the truth or getting close to the truth.

And that’s a very powerful process once you can get through it but sometimes it’s a bit of a rocky ride. Why does this matter? Well, the short answer is because there are many instances that people have been harmed over the years by treatments, care, other behaviours that are based on biased claims about various things we do. We also know from studies done by people who keep an eye on these things that there’s still a problem with a very large proportion of research being affected by bias, either in the conduct or in how it’s reported.

Things can be taken out of context and so on. So that’s why we do this, and just because something happened in a certain way in study is this what we would expect to see in real life? It’s always an important thing to keep in mind. So with this particular type of study, observational studies, we need to be careful not to overstep the mark in terms of saying that correlation necessarily implies causation. So we’re just going to be able to identify correlations here.

That’s important first thing and the other thing to bear in mind is that if you do lots of correlations, lots of data analysis, the way statistics work mean that you’re going to come up with false positives from time to time. So patterns of data make coincide when they don’t actually have a causal link or some other third party link between them. I always like to pull out one of these examples. Fortunately, there’s a website linked in the slides.

You can explore them. So here we’ve got a very strong correlation between the consumption of cheese, mozzarella cheese specifically, and civil engineering doctorates awarded. So it’s obviously just to illustrate the point that if we just dive into lots of data looking for correlations we’re going to find false positives, if we’re not careful. So we’ve talked about the importance of critical appraisal, they talked about the kind of things that people need to be aware of for this type of study.

Now, let’s look at it in a bit more detail itself. What did they actually do and what were they looking at? So we’ve summarised the research question. As we said, this is an aetiology question, so it’s about cause. So there’s a checklist of questions we can run through, which we’ll look at in a little bit of detail and any time you’re reading this type of study these sorts of questions will be useful to keep in the back of your mind.

So do we have a clearly defined set of participants? Did they measure them consistently? Did they follow up for a long enough and do the claims satisfy what they call some diagnostic tests for causation? So our research question, we looked at children and young people aged 12 to 19 minutes, main age of participants at stage one was 15, I think. We recruited twins and siblings from an office for National Statistics database and other children, young people were recruited from the Genesis cohort.

So we’ve got two different sources and not a lot of detail about the breakdown, the demographic breakdown of those folks. So that might be an interesting thing for the authors to expand on in the discussion are these findings. Would they expect to be similar in different ethnic groups, for example? In terms of aetiology, the exposure we’re looking at here is shame and shame was measured with a questionnaire based instrument to measure the extent to which people had sort of globalised, negative self-blame, self-attribution thoughts, and the tool that was used here was a kind of shortened version of a kind of validated tool.

And the outcomes we were interested in depression and anxiety, these were measured at the start of the trial. At the study at time one and then on average two years later a second data capture around. So what do the results say? Well, the first thing that really stands out is that we’ve got a fairly substantial drop off between the numbers of participants at the start and the numbers of participants at the end. So that’s something we need to bear in mind.

We’ve got 60% of the data at the second stage of the analysis, but we can still identify some quite important patterns in the data. There was a moderate strength correlation between shame score and depression and anxiety score. So at the start of the study people who had experienced more shame type thinking were also experiencing more depression and anxiety, and that correlation was similarly found at the follow up stage. So certainly was depression to a lesser extent with anxiety.

So it looks like there was a correlation between shame and depression and with potential for worsening depression and anxiety. The twin data gives a slightly different perspective on this. So in the twin analysis, what we’re looking at is comparing genetically identical siblings with siblings who are not genetically identical, but are in the same environment. So from looking at that comparison what the researchers concluded was that there was evidence that here’s what they call moderately heritable.

So there’s a bit of genetic influence in people, how people scored on the shame questionnaire that couldn’t be accounted for by other factors, but I think the really telling finding then is that over time environmental influences seem to predominate. So while there might be a pre-disposition towards experiencing a certain amount of shame and then depression or anxiety, actually it’s the environment that are the interaction with the environment that takes over. So complicated picture as we might expect. I’ve put up here my sort of completed checklist. I suppose I’ve already spoken about my main concern was that with a 60% follow up, there’s quite a lot of people who aren’t accounted for, and it’s possible that that might tip the balance if those people were different from the ones that complete the follow up.

While I think the results are consistent with other evidence in this area and the patterns makes sense, I feel that there’s a little bit more that needs to be done to be sure that it’s the shame, does the shame drive the depression and anxiety or do they drive each other or are there other factors or actually do we actually need to understand a bit more about the details of all these processes? So while I feel this is an important signpost, I think it’s a signpost towards where we need to look in more detail at how these things interact with one another. So if you want a bit more information about all of this, there’s a link here to critical appraisal checklist for aetiology and harm studies, and there’s a nice set of blogs about genetics and mental health on the King’s College website.

So there’s a link there, and as I may have said at the start, the slides will be uploaded to the event page, hopefully by the time you’re watching this. So just summing up, I think we’ve got a study here with some important strengths around the sample size under prospective design. They had lots of data points. They were able to sort of cross validate with each other, but again, because of the study design we can’t really rule in or rule out causation here.

Some issues potentially with the drop-out rate and potentially it would be interesting to get some clinical commentary on particularly the shame instrument. How they measured that outcome and maybe there’s better ways of measuring shame that we need to think about. So having run through the critical appraisal process, here is my broad conclusions, which are not too different from what the authors have put in their discussion. I think we will recognise the limits of what we can say about correlation versus causation, but acknowledging that there is important data here that’s consistent with other data that we’ve found and it underlines the complexity of how these different things interact.

How perhaps these different measures might work in different ways. So perhaps the evidence is kind of not honing in on shame as a potentially useful treatment target for preventing mental illness or treating it, for that matter. So it’ll be very interesting to get the other perspectives from the panel on this, and I’ll just leave all my questions that I had for the authors, but there may be other perspectives on this.

So please feel free to comment in the comments box. We’ll do our best to answer everything, and hopefully I’ll be here to see everyone in the flesh, as it were, next month for the next campfire. Hope you enjoyed that session and thanks for paying attention.

Andre Tomlin – Wonderful. Thanks Douglas. Always lovely to hear the dulcet tones of Mr Badenoch, and we hope that you can see us even more clearly next month when you come along, hopefully with a much more functioning eye. So, yes, what do you think, Talia? There’s some fairly sort of direct follow up questions that I need to put you on Douglas’s behalf. What about the drop-out rate? Were worried about 40% drop-out.

Prof. Talia Eley – Yeah, that obviously wasn’t ideal. I mean, it’s another opportunity to understand the research process because the earlier waves of assessment were funded by a fellowship to myself as part of my early career research training. Then because it’s such a valuable sample experience and it had been such hard work putting that sample of twins and siblings together, I went on trying to follow up, collecting data from them, but completely unfunded. So just with help of whoever wanted to help me in exchange to getting to analyse the data it led to.

So obviously with the big funded twin cohorts, we would usually work hard and have the funding for voucher payments and follow up phone calls and all these sorts of things that would lead to a higher response rate, which unfortunately we didn’t have in that instance. It’s clearly not ideal to have that kind of response rate, but a couple of things make me less worried about it than I might be. So the first is we did do quite a lot of research to understand who it was that was dropping out and there are modest associations with expected variables, like measures of depression, anxiety. Like measures and demographic status, for example, but actually when you control for those in analysis it didn’t seem to make a great deal of difference to understanding associations.

So it might mean that you misunderstood the mean levels of things that you’re seeing. So it might be that the people that you’re seeing at the second time point have a little bit lower depression, a little bit lower shame than they would if you’ve managed to get everybody, but the association between the depression and the shame wasn’t really influenced by it and the rationale for that association. I use that as the example. We did this quite widely across a number of different variables to check it out. So some of the papers we explicitly include that test as part of what we did in this when we chose not to, but in general I feel quite persuaded that as long as we don’t use, this as a data set where we’re trying to say how common something is or what the average of something is that we can’t do with a data set like this.

But if we’re looking at associations amongst variables then they’re less affected by this kind of drop-out. So I guess those are the two main points really.

Andre Tomlin – Yes, a strong answer. Thank you. What do you think about this idea of the instrument itself? Tell us a bit more about how the adjusted instrument came about and do you think we can measure shame reliably? How would you like to see it developed to get even better?

Prof. Talia Eley – Yeah, so it’s really common in longitudinal cohort studies that you don’t get to use the full published measure. So I’m also Director of the Twins Early Development Study. Our twins are now in their mid-20s and we almost never use a whole published measure because there’s so much we want to ask our twins about, and they are so generous with their time year after year after year, but we do have to be careful how much we expect. So it’s really common to try and think of sort of sensible, statistically supported ways of reducing a measure, which is what we did in this instance.

So Ed would come to me and said, I want to do shame and this is the best measure of shame and can we please include this, and I’d looked and gone, oh God. He’s got 26 items or something. There’s only like a third of a page left to fit more items in. So we can’t do that many. So there were published factor analysis where the measure had broken into, I think it was three scales. So what we then looked at was what the factor loadings are. So basically how important each item is as a measure of each of the factors.

So what we picked were the four items. I think we ended up with 12, but correct me if I’m wrong. The four items on each of those sort of scales did the best job of capturing information that would have been there if we’d had all of them, and that is a, kind of, fairly well used and well regarded way of reducing the length of a measure. Clearly, in an ideal world, we’d have had 100% response rate and a full detail measure with most reporters and everything but actually sometimes you just have to make pragmatic decisions. So that was a big part of why both of those things were the way they were.

Andre Tomlin – Yeah, okay, that’s great.

Prof. Talia Eley – I guess in terms of your question about whether we can. Sorry, I was just thinking about the other part of your question, Andre, about when we can measure it, and I just think all these sort of social emotions are going to be partly responses to experiences people have had. That’s the whole point. They are about engaging with the world, with other people. We’re very social creatures as humans. So these social emotions are very, very powerful and for some people, the way the questions are worded won’t quite tap into their take on what it is that makes them feel shame, and again that would be best captured by a longer measure.

It would also potentially be captured better by having an hour long conversation with somebody like Maria who can really get into the detail of it, and certainly for anxiety and depression, you know, the gold standard is a clinician interview, which you might spend an hour over, but again it’s the same old thing really, that you have to be realistic about how you’re going to capture your data. So it’s not a perfect measure, but it’s probably good enough to learn something from it.

Andre Tomlin – It really brings me back to the point, Tara, that you were making earlier, where you were saying when you were younger you didn’t have the language to describe these feelings of shame that you felt, and it’s that disconnect, isn’t it, between the kind of clinical instrument or the kind of approach that a health professional has to try and work out what’s going on and our inability as teenagers to actually express ourselves. How do you kind of reflect on Talia is saying there?

Tara – Yeah, I think also what comes to mind when Talia is speaking of what you just said as well, Andre, it is self-awareness. I think that also comes to mind and I think that comes to mind when we’re talking about questionnaires and instruments and filling them out is in order to actually, I think that’s why self-report and report bias is really such a thing, but I think that in order to actually say what you’re feeling you have to understand it. You have to be able, to be able to sit with yourself enough to go, oh, this is actually what I’m feeling.

I think also what shame does is that it disallows you from being able to express yourself properly or being able to even develop the self-compassion to understand what you’re feeling and to actually listen to yourself, because I think it silences you above all else. I think it makes you kind of turn on yourself and that’s why I think that the self-awareness thing is such a huge thing because how can you accurately communicate that what you’re feeling is shame if shame suppresses you from even developing the empathy and compassion to understand that what you’re feeling is shame?

That might sound a bit wordy and might not make sense, but I think based on my experience and also just working with young people myself that’s what I’ve seen, is that they are so enamoured by that feeling of shame that they can’t even say that what they’re feeling is shame.

Andre Tomlin – What do you think we can do, Maria? What do you think we can do to help young people alleviate these feelings?

Dr. Maria Loades – Well, I think Tara said beautifully into the answer to that question, Andre.  You know the therapy that has been developed over many years now is compassion focussed therapy. Developed particularly by Paul Gilberton colleagues where, you know, building on evolutionary psychology principles and neuroscience and biology and actually the Buddhist school of thought, he’s looked at how we can build up that self-serving system. You know, recognising that we have a drive system and a threat system, but a self-serving system, too.

And actually, for those people who really struggle with compassion they tend to not be very able to engage with that self-soothing system. So he’s developed this therapy that’s all about how we can build up compassion and particularly self-compassion, but really what that involves is nurturing that kind of warmth and understanding and acceptance and forgiveness for yourself in just the way that Tara was so beautifully describing it. So to be able to get in tune with your feelings and to sit with that distress and to develop that sense of kindness for yourself in the same way you would be kind to other people being non-judgemental to yourselves.

And there are lots of ways in which we can do that therapeutically and compassion psychotherapy uses lots of different activities to really help people to build that compassion and compassionate spirit towards themselves. For example, a kind of compassionate imagery exercises and ideas for mindfulness and so forth, and what’s absolutely fascinating is thinking actually, how much do we know about this in young people and how much do we know about how effective this is in young people?

And the research evidence is just emerging. There was some really interesting work last year as part of one of the Wellcome Trust active ingredients calls of looking at self-compassion in young people, and Tracey Egan and her colleagues in Australia reviewed what we already know and we really need to do more research in this area, but so far what the research is indicating is that longer courses of therapy that involve building self-compassion really does seem to help young people to reduce anxiety and depression symptoms.

So at least four sessions of a therapy that builds up self-compassion can really help us to reduce anxiety and depression. So I do think Tara you’re really on something that and that’s certainly the way I would be thinking to go if I was working with a young person with difficulties with change.

Andre Tomlin – I’ve got 100 follow-on questions. It’s one of those areas, isn’t it? It’s just so fascinating and it sparks all sorts of different. We’re going to have a series of campfires over the next six years just on shame. Thanks, Talia. I wonder, in the eight minutes we’ve got left if we can think about maybe shame as a kind of therapeutic target. If we have got a really… we’ve got an established link here, haven’t we, with this research?

And it might be that we do more research that really cements that relationship in our understanding. What would we do about it? How would we actually target shame? Talia what’s your thoughts.

Prof. Talia Eley – Well, I’m not the clinician in the room. So I think we’ll have to pass this back to Maria in a moment, but I was also reflecting it as well as making shame a therapeutic target. I think some of what Tara was speaking about earlier about particular groups being stigmatised or abused and treated negatively is going to be associated with shame at a more population level as well, and I was reflecting that mental health conditions themselves are still so associated with stigma and can be associated with shame, and I think we haven’t really come back to the bi-directionality that Douglas was raising, and it is very definitely a possibility that there’s bi-directionality which we couldn’t look at because we only assessed the shame once, but I do think there are so many good efforts happening at the moment to try and reduce stigma around all sorts of protective characteristics as well as around mental health, but it seems like progress is maybe slow and it perhaps just motivates us all to just try harder, but also maybe try new things.

But I would definitely look to the clinicians for that guidance about that kind of intervention is not so much my area of expertise.

Andre Tomlin – What do you think, Tara? Kind of building on that? Do you think the stuff we’re doing already to reduce stigma and discrimination do you think that’s going to just do the job with shame, or do you think there’s something specifically we need to do to target shame?

Tara – I think to answer your first question, I think that the way that the world is moving, obviously we see such a huge shift right now in the way that things are in terms of reducing stigma and discrimination, but I also think that then we need to kind of go a bit deeper and then address the trauma that exists in these groups. I think things are shifting now. Thank goodness for that, but we all know that just because someone apologises doesn’t mean you no longer feel that pain that you felt when they first hurt you.

So I think we need to, first of all, really get to the core of that and really address that collective and generational trauma that exists in these groups. I think once we do that then we can start to, kind of, unpick at how do we then help them kind of get rid of this shame that they’re experiencing, because although things are changing, I think it’s been years. It’s been so many years. So I think we need to sort of talk about that. What was your second question, sorry?

Andre Tomlin – If we do target shame specifically, any kind of intervention way. If we say to the health system, you know, this is how you can train your therapists to be better at dealing with it, how do you think that would work?

Tara – I think the thing that I’d like to say is that I think that when it comes to therapy and when we’re talking about interventions and access, I think it’s also important and crucial to understand that some people might not be able to kind of reap the benefits because, like I said before, they don’t have that language. They don’t have that self-awareness, and I think the clinicians also sometimes don’t have the language to then communicate with these people who are experiencing extreme shame.

I think therapy really and interventions really work for people who not only want the help, but are also willing to meet the clinician halfway, but how does that happen if neither the clinician nor the person have that language and the person doesn’t have the language because they experiencing such debilitating shame and the clinician might not have the language because maybe this is someone from a group that they are not familiar with working with. So I think that there’s a lot of things that we need to address before we can say let’s develop an intervention.

I think we need to kind of figure out how do we make sure these people can reap the benefits. Yeah, if that makes sense.

Andre Tomlin – Yeah, absolutely. It’s a much bigger problem than developing an intervention, isn’t it? It’s making sure that the services that we have, the system, the broad system, is actually accessible for people, and if the people that are feeling this kind of intergenerational trauma that you’re talking about and the shame associated with, you know, centuries of racism, don’t feel that going to see a therapist is culturally a thing that’s okay to do. Then that’s a massive barrier.

Thank you. Maria, do you want to say something more about how you think we can target this.

Dr. Maria Loades – Well absolutely. You know, one of the things that I was thinking about too is thinking about the role of parents and wider communities around young people in this. So I think that links to what Tara said, you know, stigma we need to work at multiple levels. Again, linking also to what Talia was talking about. We need to think about how we influence this at all sorts of different levels. You know, I do think like with any emotion shame is an emotion which is part of our emotional repertoire and is going to be something that is there.

But they are likely to be a group of young people who get stuck with shame being very debilitating and disabling and gets in the way of them doing the things they want to do and succeeding in life. Those are the young people for whom I think we need to actually target interventions. Now marginalised groups might be a particular risk of being in that group, but what we need to be careful to do is not to then end up kind of labelling and medicalising something that is actually part of our wider experience.

So I think it’s important that we think about this at all levels, but I think also we need to think about what those environmental factors are that might contribute to shame developing as a problem for young people and how we can start to remediate some of those, and again just one example that we know from the literature that actually some parenting styles, particularly, you know, overly hostile parenting, for instance, might particularly be a vulnerability factor, a risk factor for developing shame.

So I think there’s lots of different directions we can go in with this, and one is to think about what we can do and change develop, but also what can we do before that to help young people who we know are vulnerable to what they perceive to be the social norms and the social views of other people. How can we help them at an even earlier stage not to end up in a place where they’re feeling so much shame?

Andre Tomlin – I’m going to have to draw it to a close because we’re running out of time and there’s a couple of quick things I want to do before we finish, but thank you very much for all your very insightful comments. Matt, could you please put up the second poll for us? I’m interested in finding out from the people in the audience whether this paper has changed your perspective. So whether Talia’s paper on shame and depression and anxiety in young people has changed your perspective?

So ten is firmly agree and one is from is not at all, and Talia is sitting watching you all filling in this survey. So it’s extraordinarily unbiased. She won’t be at all offended if you said no, definitely not. This is getting your evaluation for [inaudible 00:57:04], Talia. This is an incredibly meaningful analytic. We can compare it to all the other campfires. That’s actually pretty good. So I think we’ve got what’s that, 13, 22, 32. Almost 50% say seven to 10 I think.

So that’s very good, very strong, but actually a real range of people as well. So some people said not at all. So interesting. Very interesting. Thank you, and then one more survey we’ve got. Finally, just ask me what you thought of this session? Would you recommend this kind of session to a colleague? And again, one is definitely not and ten is definitely yes. So tell us what you thought of coming along to the webinar today.

Was it useful? Was it relevant? And again, I’m going to close my eyes, I won’t see any specific. This is anonymised. So say what you want, and while you’re doing that. Oh, here we go. Wow, that’s hugely positive. Thank you very much. That’s great to see. Very encouraging for us. I think that’s probably the best yet, Matt.

Matt – It is.

Andre Tomlin – Clearly we chose the right paper and the right panel for this one. So, yeah, it just remains to say thank you very much again to Talia and to Maria and to Tara for joining us. For taking the time in this sweltering heat we’ve got here in the UK. We’re all looking redder and redder. So it’s time to go and stick our feet in a bucket of water somewhere, and yes, thank you all for joining us. Thanking ACAMH. Thanking also the McPin young people’s group who work with us on these events and always bring along great people like, Tara, to participate.

About #CAMHScampfire

ACAMH’s vision is to be ‘Sharing best evidence, improving practice’, to this end in December 2020 we launched ‘CAMHS around the Campfire’, a free monthly virtual journal club, run in conjunction with André Tomlin. We use #CAMHScampfire on Twitter to amplify the discussion.

Each 1-hour meeting features a new piece of research, which we discuss in an informal journal club session. The focus is on critical appraisal of the research and implications for practice. Primarily targeted at CAMHS practitioners, and researchers, ‘CAMHS around the Campfire’ will be publicly accessible, free to attend, and relevant to a wider audience.

Previous sessions are listed in our Talks & Lectures section.

About the panel

Professor Thalia Eley
Professor Thalia Eley

I am Professor of Developmental Behavioural Genetics at the Institute of Psychiatry, Psychology & Neuroscience, King’s College London. I direct the Emotional Development, Intervention and Treatment (EDIT) lab, and my work focuses on the interplay between genetic and environmental factors in the development and treatment of anxiety and depression.

My work is highly interdisciplinary using both the twin design and molecular genetic approaches, and drawing on cognitive, clinical and developmental psychology. I have written over 140 empirical papers and received numerous awards including the Spearman Medal from the British Psychological Society, the Lilly-Molecular Psychiatry Award, and most recently the James Shields Lifetime Achievement Award from the International Society for Twin Studies. I am one of the Chairs of the Psychiatric Genomics Consortium Anxiety Group.

I am really passionate about enabling early career researchers and was Chair of the Research and Innovation Committee for over 5 years, developing and leading numerous initiatives aimed at supporting this group. I am very keen to see greater diversity in those conducting, and taking part, in scientific research.

I am particularly interested in finding ways in which genetic approaches can inform psychological practise as well as theory. Using molecular genetics, I am exploring the role of specific genetic markers in the development of anxiety and depression, and as predictors of psychological therapies response for these conditions. With my close colleague Prof Gerome Breen, head of the NIHR Maudsley BioResource centre, I am leading the new Genetics Links to Anxiety and Depression (GLAD) Study. You can watch us describing the purpose of this study here, and can watch an animation about the study here. I am particularly excited about this area of work as it has the potential to be useful in making clinical decisions.

I am also really interested in why anxiety and depression tend to run in families, and whether this is due to sharing home life or whether it is due to sharing genes. I am Deputy Director and Director Elect of the Twins Early Development Study (TEDS), which is the largest longitudinal twin birth cohort in the UK. As our twins reach their mid-twenties we are particularly excited about recruiting the next generation into the Children of TEDS (CoTEDS) Study.

Twitter @thaliaeley
Bio and image via KCL

Dr. Maria Loades
Dr. Maria Loades

Dr. Maria Loades is a Senior Lecturer/Clinical Tutor for the Doctorate in Clinical Psychology programme at the University of Bath. She is a qualified Clinical Psychologist, working in a variety of mental health settings, including adult mental health, a children’s inpatient unit, and various community CAMHS. She has a post-graduate diploma in CBT for children, young people and families from the Anna Freud Centre/University College London, and a Postgraduate Certificate in the Supervision of Applied Psychology Practice at the University of Oxford. She secured an NIHR doctoral research fellowship in 2016 to further her research into depression in paediatric Chronic Fatigue Syndrome at the University of Bristol, and the Paediatric CFS team at the Royal United Hospital in Bath. Her research interests include: developing and delivering CBT for children and young people with depression, including those with chronic illnesses, therapist competence in delivering CBT, particularly in the field of child and adolescent mental health, and CBT supervision.

Follow on Twitter @MariaLoades

Andre Tomlin

Andre Tomlin

André Tomlin is an Information Scientist with 20 years experience working in evidence-based healthcare. He’s worked in the NHS, for Oxford University and since 2002 as Managing Director of Minervation Ltd, a consultancy company who do clever digital stuff for charities, universities and the public sector. Most recently André has been the driving force behind the Mental Elf and the National Elf Service. The Mental Elf is a blogging platform that presents expert summaries of the latest reliable research and disseminates this evidence across social media. They have published thousands of blogs over the last 10 years, written by experts and discussed by patients, practitioners and researchers. This innovative digital platform helps professionals keep up to date with simple, clear and engaging summaries of evidence-based research. André is a Trustee at the Centre for Mental Health and an Honorary Research Fellow at University College London Division of Psychiatry. He lives in Bristol, surrounded by dogs, elflings and lots of woodland! Bio via The Mental Elf

Douglas Badenoch
Douglas Badenoch

I am an information scientist with an interest in making knowledge from systematic research more accessible to people who need it. This means you. I’ve been attempting this in the area of Evidence-Based Health Care since 1995. So far the results have been mixed. For some reason we expected busy clinicians to search databases and appraise papers instead of seeing patients. We also expected publishers to make the research freely available to the people who paid for it. Ha! Hence The National Elf service.

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