Head To Head Maudsley Debate

Is emotional restraint a healthy response to adversity?

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6607 (Published 05 November 2014) Cite this as: BMJ 2014;349:g6607
  1. Kathryn Ecclestone, professor of education, University of Sheffield, Sheffield S10 2TN, UK ,
  2. Ben L Robinson, core trainee CT3 in psychiatry, National Psychosis Unit Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, Beckenham BR3 3BX, UK,
  3. Sarah Wheeler, founder of Mental Fight Club, Dragon Café, London, UK
  1. Correspondence to: K Ecclestone, k.ecclestone{at}sheffield.ac.uk, B L Robinson benjamin.robinson{at}slam.nhs.uk

Kathryn Ecclestone worries about inappropriate educational interventions that promote emotional openness and pathologise normal responses, but Ben Robinson and Sarah Wheeler point to evidence showing better outcomes in patients who have been encouraged to express what they are feeling

Yes— Kathryn Ecclestone

An unchallenged consensus exists across health and education professions and among many parents and policy makers of all persuasions that the mental health of young people is in crisis. A growing preoccupation with “vulnerability” has turned emotional expression and management into a non-negotiable foundation for educational and life success.1 2

Many in the mental health and medical professions seem unaware of the extent to which this view has shifted from specialist psychological interventions for a minority of young people with mental health conditions or special educational needs into classroom based programmes for everyone, administered by teachers and other non-specialists. These include circle time (where children are encouraged to share and express emotions about diverse experiences), mindfulness lessons, nurture groups, resilience training, and “mental toughness” training.3

Evidence is missing or flawed

Drawing randomly on cognitive behaviour therapy, rogerian counselling, positive psychology, self help, and psychodynamic therapy, a powerful orthodoxy that emotional restraint is dysfunctional now pervades the education systems of the United Kingdom, the United States, and growing numbers of European countries, including Sweden and Finland.

Interventions based on cognitive behaviour therapy are especially popular. Based on the notion that individuals can develop skills in cognition driven emotional restraint, cognitive behaviour therapy has proved effective for many mental health problems. Yet it is being co-opted increasingly by non-specialists in interventions for which it was never intended and for those with no identified mental health problems.

For example, Birmingham local authority has introduced Promoting Alternative Thinking Strategies (PAThS), a widely used US programme derived from cognitive behaviour therapy and positive psychology, to all its primary schools. PAThS encourages children to become aware of their own emotional arousal, using an explicit vocabulary and prescribed activities to create a calm, stepwise response to regulate emotions and reason better about problem solving. Proponents claim that repeated practising of “empathy and openness in dealing with emotional needs” are transferable skills integral to “character development.”4

Similar claims permeate the Social and Emotional Aspects of Learning strategy (SEAL), used widely across UK primary and secondary schools.5 Yet evidence for such claims is highly flawed. Only one of the two published randomised trials of PAThS was independent of the creators of the approach, and in both trials assessors knew whether children had received the intervention. Just as worrying, the control condition was not a comparable intervention but no intervention. There is therefore no evidence that PAThS offers anything that simply spending more time with children (or parents) would not provide equally well or better.6 In general, evaluations of classroom based programmes, including SEAL, offer poor methodology and highly partial, inconclusive evidence of short term, let alone long term, benefits.7 8

Harms of disclosure

Such schemes are dangerous for several reasons. Firstly, their understanding of adversity includes everything from serious trauma and individual and social crises to everyday stress and anxiety, relationships, and “uncomfortable feelings.” Without judgment about which of these stressors warrant emotional openness, there is a danger of creating hypersensitivity to common difficulties integral to learning and development, and an assumption that these require therapeutic strategies. Studies of the effects on adults of compulsory psychological briefing after trauma are pertinent here, suggesting that unnecessary disclosures raise awareness of problems that do not exist.9 There is therefore a risk that encouraging emotional openness in children could create problems in adulthood.

Further, studies of therapeutic interventions in schools reveal ritualistic, normative training of vocabulary and ways of being and acting that are privileged over other responses: children refusing the “voluntary” disclosures of circle time, rejecting “anger management strategies,” or choosing their own approaches to serious and trivial adversity have been labelled as having “esteem issues,” repressing emotions, or being disruptive.10 11 It seems that emotional restraint itself has become an indicator of mental ill health.

The unfettered promotion of emotional openness creates infinite demand for intervention and arguments between proponents of different approaches. This diverts specialist resources from real need. Instead, we should regard everyday life as sometimes trying and difficult; see restraint as a normal response; and curb interventions that soothe fears of crisis but pathologise people’s own emotional coping strategies.

Video abstract

No—Ben L Robinson, Sarah Wheeler

Last year, one of us (SW) had treatment for breast cancer. For 30 years before this she had had a severe mental disorder, variously diagnosed during inpatient stays as bipolar disorder, psychosis, or major depression. After much emotional work in psychotherapy, SW now feels in good health all round. She now views this disorder as generated by a paradoxical mix of having a highly sensitive nature with a learnt tendency to repress emotions.

SW is clear about the emotional cause of her recovery, but emotions have had a bad press in medicine. “Expressed emotion” is a poorly named variable used in psychiatry, not to measure how good people are at expressing themselves but to record a toxic combination of hostility, criticism, and overinvolvement within families.12

Higher expressed emotion carries a worse prognosis in schizophrenia.12 Expressed emotion and other pejorative terms such as “emotionally unstable personality disorder” (a misnomer for one type of inflexible mode of relating to self and others) only add to the sense that emotions are somehow distasteful, as does the concept of the heartsink patient, who is usually associated with being overly emotional.13

Moreover, the preferred model of psychotherapy in the NHS has become cognitive behaviour therapy, which considers difficult feelings to be the undesired products of imperfect belief processes. For many professionals, however, cognitive behaviour therapy represents a grossly simplified and market driven view of the psyche.14

Despite much early enthusiasm and ongoing use, literature reviews and meta-analyses suggest that cognitive behaviour therapy may have unexpectedly poor outcomes, particularly over the long term and in some disorders, such as post-traumatic stress disorder and psychosis, for which it has been promoted.15 16 Anecdotal experience is that cognitive behaviour therapy groups are not well attended or liked on acute psychiatric wards, where the need for effective treatments is greatest; groups that focuses on relationships and feelings may prove more feasible.17 Clinicians must therefore question medicine’s stance towards the emotions and examine evidence for other, overlooked interventions and modes of relating to patients.

Longer survival

Many group interventions in patients with breast cancer emphasise emotional expression.18 Those who attended one particular group weekly for a year survived, on average, 18 months longer than non-attendees.19 Though this claim was questioned over subsequent decades, a recent Cochrane meta-analysis of six studies of cognitive behaviour and emotionally expressive therapies found that women who attended such groups survived longer in general (856 women; odds ratio 1.46).20 Subgroup analysis found that the emotionally expressive groups drove this effect, with no contribution from the cognitive behaviour therapy groups. Significantly reduced depressive disorders, hopelessness, and trauma symptoms among attendees were also noted.21

If emotional expressivity can improve health, can a “stiff upper lip” impair wellbeing? A prospective examination of 532 patients in Japan with rheumatoid arthritis found that “rational and anti-emotional behaviour,” measured using patients’ responses to a questionnaire, was linked with poorer functional outcome two years later.22 Another Japanese study found that mood disturbances after mastectomy were greater in women who scored more highly in assessments of emotional suppression before surgery.23 This recalls Carl Rogers’s idea that expressing emotion, far from reflecting more serious mental health concerns, may help to alleviate them.24

What happens when doctors fail to encourage emotional expression? A friend of SW also developed breast cancer. She was terrified of surgery, elected not to have a mastectomy, and died three years after diagnosis. Might she still be alive had she been more able to express and accept her fear?

A recent study suggests that patients feel burdened by their family and clinicians to be excessively positive, denying them expression of their true feelings.25 Our experience suggests that doctors’ awareness and acceptance of emotion in the clinical relationship can be key to the effectiveness of treatment.26

Access to services

Finally, we think it is dangerous to advocate a “stiff upper lip” given current problems with access to services. A staggering two thirds of people in the UK with depression are reportedly not getting any treatment.27 And councils are failing almost completely in their duty to fund preventive mental health programmes.28 In this context, doctors must refer without fail where services exist, and advocate for more elsewhere.

Calls for less mental health intervention for schoolchildren are therefore incomprehensible, particularly as a recent observational study has shown that the burgeoning use of school counsellors is accompanied by measurable benefits, including better test scores and fewer behavioural problems.29

Increasing clinical evidence and experiences from both sides of the consulting room call for a sea change. In place of an out of date disdain for emotional expression, doctors must recognise the value in encouraging patients to speak about their experience—in all its joys and its adversities. Such expression improves the health of patients and the trust between patient and professional that is so crucial to effective care. We should not fear anger, sadness, despair, hope, pleasure, shame, love, desire, and loss. Emotional expression is authentic, valid, and vital for health.


Cite this as: BMJ 2014;349:g6607


  • Competing interests: All authors have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • The authors are taking part in the 51st Maudsley debate, “Whatever happened to the stiff upper lip? This house believes that emotional restraint is a healthy response to adversity” to be held in London on 10 November 2014. A podcast of the debate will be available at www.kcl.ac.uk/ioppn/news/maudsleydebates/index.aspx.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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