The Looking Glass: Issue Seven by The Looking Glass

THE LOOKING GLASS February 2015 Issue Seven

WW1 Centenary 2014-2018 War and psychiatry special focus Phantom Limbs: Ghosts in the System

Apps for PTSD: The Virtual Therapist in your Pocket The Invisible Scars of War

Contents

February 2015

features 05

Phantom limbs

Ghosts in the system

The scars of war

The psychological impact of conflict

Apps for PTSD

The virtual therapist in your pocket

15th Maudsley debate

Does the trauma industry medicalise normal suffering?

Being a reservist for the UK military

The inside scoop

Thinking outside the box

Business, technology, and psychology

regulars

03 Editorial

The First World War centenary

Missing in action

The Inspiring Women talk, Nov 2014

25 Reviews

Deerhunter

Two Days, One Night

On the couch

Dr Tamara Russell

Welcome from your editor Welcome to your latest issue of The Looking Glass. With our editors busy taking exams and studying, it’s been a little longer in the making than expected – but we hope it’s worth the wait. We have all the regular news, reviews, and debate. What’s more, to coincide with the First World War centenary (2014 – 2018) we have a special War and Psychiatry focus. Our articles explore themes as diverse as apps for those suffering from PTSD, to the neuroscience behind phantom limbs. We also have two interviews in this issue. On the Couch is back featuring an interview with Dr Tamara Russell, whose mindfulness research explores an alternative psychological therapy to support those with psychiatric illness. We also hear from Dr Patapia Tzotzoli, a clinical psychologist who is turning her skills to business and web-based support services. If there’s not something amongst all this to spark your interest, then why not write for us yourself? If you have a topic you’re burning to see between our covers, then put pen to paper (or more likely fingers to keyboard), and send your submissions to our usual address.

War AND Psychiatry Phantom Limbs: Ghosts in the system The Scars of War: The psychological impact of conflict Apps for PTSD: The virtual therapist in your pocket Debate: Does the trauma industry medicalise normal suffering? Being a reservist for the UK military: The inside scoop

First World War Centenary 2014-2018

Editorial

by Steffen Nestler

merican Sniper, currently in cinemas across the UK, showcases the might of modern military forces, with armoured vehicles, fully automatic machine guns, and wireless telecommunications. A lot of these technologies hark back to inventions and their mass application in the First World War, the centenary of which we would like to commemorate in this issue. World War 1 was triggered by the assassination of Archduke Franz Ferdinand of Austria in 1914 by a Yugoslav nationalist. However, there were a variety of underlying causes for the conflict, such as belligerent national interests fortified by political and strategic alliances among the fighting factions, an arms race with accelerated military spending, and persistent conflicts in the Balkans. At the end of the war in 1918, 9 million soldiers and 7 million civilians had lost their lives. In addition, countries in Europe and around the world were marked by economic depression, unabated nationalism, weakened governments, and a sense of humiliation in Germany, as well as the former Russian, Austro-Hungarian, and Ottoman empires. On an individual level, psychological upheaval spread throughout the globe. Shell shock engulfed many of those involved in

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battle and became a household term. While today it is more commonly known as posttraumatic stress disorder (PTSD), the signs and symptoms, as exhibited by the American sniper Chris Kyle, were probably very similar to the soldiers of WWI. As shown in the film, he would often be as vigilant as in the field with an immensely high blood pressure when returning from a tour in Iraq. At the same time, he avoided addressing the decisions he made on foreign ground, perhaps for a lack of direct connection with his emotions, preventing him from fully re-engaging with his family at home. What also stood out was Chrisâ&#x20AC;&#x2122; lack of admission to any kind of impairment and his continued drive to serve. Although we as researchers can probably not contribute immediately to the care for veterans or solve the ethical dilemmas which have haunted Europe since the beginning of the last century, the similarly important task of finding out about mental health difficulties in those affected by trauma may fall to some of us. Public engagement remains equally vital in communicating that the majority of the population are resilient in the face of adversity and that not every soldierâ&#x20AC;&#x2122;s experience is the same. For now, let us honour the memory of those that have fallen.

The First World War centenary is a global commemoration, taking place across the world during 2014 â&#x20AC;&#x201C; 2018. A number of events will take place to allow people to come together and remember those who lost their lives in the conflict. If you would like to know more, visit http://www.1914.org/ The Looking Glass

Phantom Limbs Ghosts in the System By Malvika Katarya Following the 2014 centenary of the Great War, this article focuses on a syndrome common among veterans and war victims. Phantom limb syndrome is a neurological disorder in which one has the feeling of having an arm or leg, despite it being previously amputated or lost in an accident. Patients with phantom limbs can have continued, vivid experiences and sensations in the missing limb, even years after it has been lost.1 Almost 90% of amputees will experience the sensation of a phantom limb at some point, and it can vanish and reappear on its own.2 The sensation of the limb’s presence is so real, that people might automatically reach out to grab something with their phantom hand, wave goodbye, or gesticulate, before they remember that the limb is no longer there. Although, not everyone can voluntarily ‘move’ their phantom limb. Whilst they feel it is present it is completely paralyzed.1

feel their arm contort into unnatural and painful positions for days on end. The sensation of pain varies in patients: it can be very intense and has been described as “stabbing with a knife or hot poker”, but it can also feel like muscles that are cramped after prolonged exercise. It is important to note that these patients are not suffering delusions. They are fully aware that the pain is not real, yet they cannot rid themselves of the sensation. The pain itself can last anywhere from minutes

Medically, phantom limbs are not newly observed phenomenon. Evidence for this disorder is even seen in medieval literature, although the sensations were attributed to demonic or immoral spiritual causes2. The first medical record of such occurrences was in 1552, from the French surgeon Ambroise Pare. However, the term ‘phantom limb’ was coined in 1871 by Silas Weir Mitchell, an American doctor working at a ‘stump hospital’ in Philadelphia during the American Civil War.4

Almost 90% of amputees will experience the sensation of a phantom limb at some point, and it can vanish and reappear on its own. Sadly, as many as up to 70% of people suffer with extreme pain in their phantom limb3. For example, arm amputees might feel their fist clench tightly and their nails digging agonizingly into their palms. They might feel intense burning sensations like scalding hot oil on the skin. Some 5

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to days, and thus significantly hinders an amputee’s quality of life. This can be a truly devastating experience, leaving patients feeling hopeless and wondering how any doctor could possibly treat a limb that does not exist.

In his fictional work “Autobiography of Quack”, Mitchell details the life of one extremely unfortunate Dr. George Dedlow. As a surgeon in the civil war, Dedlow first lost an arm in an attack, and then awakens in a war zone to find both of his legs amputated as well. Here, Mitchell

describes phantom limb pain: “I got hold of my own identity in a moment or two, and was suddenly aware of a sharp cramp in my left leg. I tried to get at it to rub it with my single arm, but, finding myself too weak, hailed an attendant. “Just rub my left calf,” said I, “if you please.” “Calf?” said he. “You ain’t none. It’s took off.” “I know better,” said I. “I have pain in both legs.” “Well, I never!” said he. “You ain’t got nary leg.” As I did not believe him, he threw off the covers, and, to my horror, showed me that I had suffered amputation of both thighs, very high up. “That will do,” said I, faintly.”5 Today, our understanding of phantom limbs is less spiritual and more neurological. We know that the brain receives somatosensory information, such as pressure, temperature, and pain, from each part of the body (soma being the Greek word for body). This information is organized in a precise map that is projected onto the somatosensory cortex, and larger areas of this “map” correspond to greater sensory input from a part of the body. This map is commonly known as the somatotopic map, or more casually as the sensory ‘homonculous’, as the mapped regions represent the sensory blueprint of the human body. The incoming sensory information is further used by another part of the brain – the parietal cortex. Here, sensory signals are analysed along with visual information from the eyes, to create an intuitive sense of the body in space, or a body image. Lastly, any motor activity, such as reaching out for a cup, causes a signal to be sent to the cerebellum (a part of the brain responsible for coordination and movement). This helps to fine tune the motor action, by comparing your intended movement with the actual outcome. In the example of reaching for a cup, it prevents you from extending your arm past the cup, or stopping before you reach it. This also contributes to your body image, helping you orientate your movements in space. When all limbs are intact, the sensory inputs function as they should. However, once a limb has been amputated, the sensory signals that would have reached the somatosensory cortex are lost, but the neurons in the brain that would have received this information still exist. These residual neural connections are thought to be the basis for the onset of the phantom limb phenomenon. Although the aetiology for phantom limb pain is not well understood, one theory suggests the loss of an inhibitory feedback signal from limb muscles to

the cerebellum could cause the pain. Without any information coming from the skin and muscles, the cerebellum cannot appropriately fine-tune the commands being sent to the limb. Thus, the unchecked cortex might make the limb muscles tighten unnaturally. This could explain why patients experience sensations of muscles tensing beyond tolerable limits, leading to a cramping pain where the limb once was. Phantom limbs may therefore emerge as a maladaptive response of the brain to the loss of sensory input from the limb. Although we have a better understanding of the basis for the phenomena, there is no permanent cure available, and treatment at this time is focused on managing the chronic pain. The Looking Glass

The American neurologist, Dr. V. S. Ramachandran, pioneered an innovative therapy that has sparked excitement in this field. This technique, called ‘Mirror Visualisation Therapy (MVT)’ helps patients suffering from phantom limb pain to visualize their missing arm or leg by constructing an illusion that tricks the brain into seeing the phantom limb. Remarkably little is required to perform MVT. First, the top and a side of a cardboard box are cut away, and a mirror is placed in the middle of the box. Next, the patient sits with the open side of the box perpendicular to their chest, placing their normal and amputated (phantom) arms on either side of the mirror, with the normal arm facing the mirror’s reflective surface (see image). Once arms are in place, the reflected image of the normal arm should be superimposed on the felt position of the phantom arm (this might require some shifting on the patient’s part). When the patient feels the illusion is compelling, they are asked to make symmetrical movements with both hands – opening and closing fists and moving the palms sideways. The reflection of the normal hand falls over where the missing hand should be, making it seem as though the missing hand is moving as well. It is not clear exactly how the therapy works. It may have something to do with the mismatch of signals from neurons controlling vision and those controlling proprioception. The parietal lobe, unable to make sense of the discrepancies concludes over time that there is in fact no arm present anymore. This is associated

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with a significant reduction in phantom limb pain, often allowing people to live pain free lives. For some, regular MVT treatment has even caused their phantom limb to disappear completely. For MVT to work properly, the illusion must be convincing. Patients must remove any jewellery or watches, and practice with the mirror three times per day for weeks on end.6 What’s more, it doesn’t work for everyone. However, for some it has been remarkably successful. Those who have benefitted from it reported significant reduction in pain: one patient even felt his Mirror Visualisation Therapy (MVT) phantom fist unclench immediately allows patients to see their amputated ‘phantom’ limb as a reflection of their in the first session of MVT7. normal hand. The patient’s brain is The advantages of MVT make it tricked into seeing the phantom hand, a very good therapeutic option and can thus “see” and “feel” the phantom for sufferers of phantom limbs. hand performing simple motor tasks.4 It is inexpensive, easy to set up, completely non-invasive, and has quality of life for amputees is looking no known side effects. It is already more positive. As our understanding being used in military hospitals of the brain increases with time, so for American soldiers who have too will the availability of treatments. lost limbs in combat in Iraq and 1.Ramachandran, V.S. & Blakeslee, S. Phantoms in Afghanistan.8 Due to its low cost, the Brain. (Harper Perennial, 1998). MVT is also ideal for use in low- 2. Nicolelis, M. Living with Ghostly Limbs. Sci. Am. 18, 52–59 (2007). income and low-resource areas. Mind 3. Sherman, R.A., Sherman, C.J. & Parker, I. Chronic Steven Sumner, a Canadian whose phantom and stump pain among American veterans: phantom leg pain was cured with Results of a survey. Pain 18, 83–95 (1984). 4. Ramachandran, V. S. & Rogers-Ramachandran, D. MVT, recently made the news as Touching Illusions. Sci. Am. Mind 18, 14–16 (2007). he cycled around rural Cambodia 5. Mitchell, S.W. The Case of George Deadlow. Lippincott’s Magazine of Popular Literature and with a stack of mirrors, searching Science 563–569 (1871). for amputees in a country ravaged 6. Ramachandran, V.S. & Rogers-Ramachandran, Synaesthesia in phantom limbs induced with by decades of civil war, ready to D. mirrors. Proceedings. Biological sciences / The Royal Society 263, 377–386 (1996). empower them with MVT.9 The effects of battle and traumatic experiences can be long lasting, leaving physical and psychological reminders of difficult experiences. Because of successes like MVT, the future medical treatment and

7. Ramachandran, V. S., Rogers-Ramachandran, D. & Cobb, S. Touching the phantom limb. Nature 377, 489–490 (1995). 8. Trevelyan, L. “Mirror therapy” aids US amputees. BBC News (2009). at <http://news.bbc.co.uk/1/hi/ health/8179429.stm> 9. Perur, S. The mirror man. Mosaic: The Science of Life - Wellcome Trust (2014). at <http://mosaicscience.com/story/mirror-man>

Invisible Scars of War the effects of war on mental health

By Hannah Deen

e see images of conflict every day. The media provides us daily with graphic reminders of physical destruction – burning ruins of buildings, bleeding children, and starving families displaced from their homes. We are familiar with the brute, unsympathetic force that comes with conflict, and the visible damage it causes. However, what do we learn of the psychological damage? When war tears through a region, it incites a silent crisis, one not depicted on our television screens. Often, an epidemic of mental illness spreads, leaving large proportions of populations burdened with anxiety, depression, and PTSD: conditions that take time and sensitivity to treat. Whilst the link between traumatic events and mental illness is still not clearly defined, evidence (as I shall outline in this article) supports this image of significantly increasing mental health disorders, both during and after conflict. The ongoing conflict in the Occupied Palestinian Territories is one of the few places that can provide us with data on the mental health changes as a result of conflict. With severe restrictions on resources and movement imposed on Palestinians, it is not surprising that systems put in place for mental health patients by the government are inadequate for the number of affected people in the territories. There are currently two government run facilities that can provide psychiatric services to patients. The first, Gaza Hospital, has 40 beds allocated to psychiatric patients. The second,

the Bethlehem Psychiatric Hospital in the West Bank, has 320 beds - 30% of which are dedicated to chronic epilepsy patients. These serve populations of 1,330,000 and 1,450,000, respectively (data from Humanitarian Practice Network). In the absence of adequate government provision, international aid organisations and local civil service organisations have attempted to pick up the slack. There are around ten community-based mental health help centres in each district in the West Bank. However, the implemented restrictions on movement within and between these areas make it exceedingly difficult for Palestinians to access treatment. Gaza Community Mental Health Programme estimates that 9.8% of the Palestinian population has severe PTSD and say that “depression and anxiety have become rampant, resulting in a dramatic change of lifestyle”. (Discussion of these and other statistics can be found at http:// www.theguardian.com/world/2009/dec/17/gaza-israelinvasion-children-traumatised). Médicins Sans Frontières (MSF) has collected a significant amount of data on the Palestinian population. The resulting estimates of the mental health burden, paints a distressing picture. Estimates suggest many adults in the Palestinian population are seeking treatment for mental health problems, including anxiety, PTSD, and depression. Children may be particularly affected by PTSD, whereas in adults depression is the most commonly diagnosed disorder1. The mental health issues present in these children suggest that there is the potential for the conflict to produce a generation of adults who are low-functioning and possibly disabled by the psychological effects of conflict, making recovery or redevelopment of the territories an even more onerous task. Worryingly, it seems that experiencing the conflict first-hand not only increases one’s risk of developing mental illness, but more distressingly, trauma experienced by a parent can cause changes in gene expression, which are subsequently passed on to their children. The passing of trauma from parent to child is a concept that has been present for decades. In Children of the Holocaust, Helen Epstein refers to the trauma of her parents that she herself felt burdened with throughout her own life:

“I felt it coiled up inside of me, so bottled up that sometimes it caused aches and pains in my legs. I let it out in running and talking, in pounding on the piano, in making things, in school. But there was so much of it. At times, my life seemed to be not my own.” She is by no means alone in this. The phenomenon has been accepted and often explained through the upbringing of the children in a ‘traumatised environment’, in which the trauma of the parents is felt by the children or results in neglectful parenting. However, evidence now suggests that it could also be a vulnerability that makes children of parents who became

traumatized more susceptible from birth. Experiencing trauma may increase sensitivity to future trauma as a result of epigenetic changes that make an individual more sensitive to stress. These epigenetic changes may be passed on to one’s children, and the evidence supports a genetic role in the transmission of trauma across generations. This is particularly pertinent in the context of war, in which traumatic experiences are imposed upon entire populations in the shape of ambient stress, imminent danger, breakdown of social structure, lack of food, water and shelter, and displacement. All of these may cause epigenetic changes that permanently alter the sensitivity of entire populations, and their children, to future trauma. The implications of such changes are baffling. A traumatised population could lead to generations of people who are highly susceptible to mental health disorders, making the recovery of a country an ever more crippling task. Given such potentially damaging consequences, quantifying the strength of the association between war exposure and the development of mental disorders, whilst complex, is an extremely important endeavour. The identification of unique risks associated with unique exposures is virtually impossible in war zones, due to the complexity of the exposure. Countless confounding variables mean that association studies provide a fuzzy picture of what is really going on. As a solution, the effects of isolated traumatic events can be extrapolated after thorough research and used to formulate effective responses to ease the impact of mental disorders resulting from war. Dr Rachel Yehuda is at the forefront of this research, examining epigenetic changes in response to traumatic events such as the Holocaust, and also more contained traumatic events like the World Trade Centre collapse2,3. Yehuda has shown that reductions in cortisol levels observed in women who were pregnant when the World Trade Centre collapsed can also be measured in their children. Of course, it could be argued that this is because of genetic variation determining expression levels of cortisol. Critically though, the trimester during which the traumatic event occurred dictates the strength of the correlation and the level of reduction of cortisol levels. This suggests an epigenetic component. Despite the gravity of the potential (and actual) damage that can occur as a result of conflict, there is a disparate lack of engagement from the international community when it comes to mental health in war zones. One important issue is that mental illness is still fraught with stigma and prejudice in many parts of the world. These prejudices make it difficult for mental healthcare to gain precedence as part of international aid systems during and after conflicts, and can also prevent effective action from being taken within the affected country. Many regions are still not in a position to accept mental illness as a disease worthy of attention and treatment.

The social stigma attached to mental illness can be strong, and provides serious obstacles in obtaining or providing treatment. As an example, a 2008 study examining prevalence of DSM-IV mental health disorders in the Lebanese population found that over 25% of the population met the criteria for a DSM-IV mental health disorder4. On average, there was a delay of 6 to 28 years between onset of the disorder and treatment, compared to about 1 to 10 years in most of Western Europe and North America. Lebanon has 3.7 physicians per capita which is extremely high when you consider Canada has 2.1, the US has 2.4 and the UK has 2.7. This indicates that perhaps in Lebanon other factors play a stronger role in preventing treatment, such as social stigma, cultural taboos, and lack of public awareness or physician vigilance. Another obstacle is that mental health problems are less visible. They don’t present an immediate threat to life and are more difficult to diagnose. The most visible measurements of a conflict’s impact are structural and physical, for example the number of wounded and killed. Naturally, these are hugely important things to consider as they are acute crises requiring urgent action. Mental illness, however, is a relatively unquantifiable problem, as mental health severity in individuals is only indirectly apparent. Not surprisingly, it is the immediate and most obvious effects of war that are of the highest priority, both during and after conflict. Nevertheless, sitting as it does at the root of the human experience of war, mental health must be taken seriously within the context of conflict. There is an urgent need for controlled steps to be taken in order to assess and administer the appropriate treatments to those who are suffering within extant war zones, and in post-conflict zones. At what point, does the mental and psychological damage of conflict become a sufficiently important metric that it should be dealt with? The scars of war can be carried in the minds of civilians and combatants alike for entire lifetimes and it seems that these scars reverberate in successive generations almost as loudly. Perhaps that is a convincing enough plea. References 1. Espié E. et al. (2009) Trauma-related psychological disorders among Palestinian children and adults in Gaza and West Bank, 2005–2008 Int J Ment Health 3: 21 2. Yehuda R. et al. (2005) Transgenerational Effects of Posttraumatic Stress Disorder in Babies of Mothers Exposed to the World Trade Center Attacks during Pregnancy JCEM 90(7): 4115–4118 3. Yehuda R. et al. (2007) Parental Posttraumatic Stress Disorder as a Vulnerability Factor for Low Cortisol Trait in Offspring of Holocaust Survivors Arch Gen Psychiatry 64(9): 1040-1048 4. Karam E. et al. (2008) Lifetime prevalence of Mental Disorders in Lebanon: First Onset, Treatment, and Exposure to War. PLOS Med 5(4): e61

Mobile phones: everyone has one, and thereâ&#x20AC;&#x2122;s an app for everything

APPS FOR

PTSD The virtual therapist in your pocket By Rachel Potterton

lexander Graham Bell would be hard pushed to recognise his original telephone in the smart phones we use today. Super-charged and loaded up with software, they are ready to entertain us, inform us, and solve our every dilemma. Constant Whatsapping, Snapchatting, Tindering, and cat video-watching has become an intrinsic part of many of our lives. With this in mind, it is not surprising that the potential role of such technology in the management of physical and mental health conditions is now being explored. Apps produced for post-traumatic stress disorder (PTSD) are a case in point. Searching for â&#x20AC;&#x2DC;PTSDâ&#x20AC;&#x2122; on the Google Play Store produces one hundred and forty results - sixteen of which mention PTSD explicitly in their optimistic-sounding names. Examples include apps such as PTSD Free, Bust PTSD, Reclaim your life from PTSD, and Fighting PTSD, to name just a few.

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PTSD Coach is by far the most popular of these products, with over 130,000 downloads in 78 countries worldwide1. This app was developed by the National Center for Telehealth and Technology (a faculty within the US Department for Defence) for ex-military personnel experiencing PTSD. Such technology, however, may also provide support to those outside of military professions, and is available to download free from both the Google Play Store and iTunes. The app content is informed by principles from cognitive-behaviour therapy (CBT), and encourages sufferers to learn more about their condition, develop adaptive coping strategies, and monitor their progress over time. Upon opening the app, you are faced with a main menu, which presents four options: ‘Learn’, ‘Self-assessment’, ‘Manage symptoms’, and ‘Find support’. The ‘Learn’ section is psychoeducational in orientation, allowing clients to learn more about PTSD and its management. Responses to questions such as ‘What is PTSD?’, ‘What treatments are there for PTSD?’, ‘Do I need professional help?’, and ‘What if I am embarrassed about seeking help?’ are provided via audio feedback. The content of this latter section attempts to refer users to professional services. This may be particularly helpful for sufferers who are ex-army personnel, as they may find it difficult to seek help for mental health problems2. It has been reported, for instance, that only between 23 and 40% of veterans experiencing mental health difficulties have tried to access services1. Given the internet’s increasing use as a source of health information, it is plausible that going online and downloading an app may be easier, and less intimidating, than approaching professional healthcare providers. Thus, PTSD Coach appears to maximise its potential to reach an audience who suffer with PTSD, but do not ordinarily come to the attention of health services. Further, it may encourage users to contact support services or health professionals and therefore act as

a stepping-stone to seeking formal help. In addition, the ‘Find support’ function attempts to link users with outside help by providing them with helpline numbers to contact when they feel ready, or when feeling overwhelmed. Such measures aid in reducing maladaptive selfreliance, and let users know help is there if they need it. The ‘Self-assessment’ function allows users to receive feedback on the severity of their symptoms after answering several questions, and plots their trajectory over time on a graph. Such feedback is consistent with the self-monitoring techniques integral to CBT practice, which helps to track client progress, and guide future therapy. In the ‘Manage symptoms’ section, the user is presented with a range of scenarios they might be experiencing (e.g. being reminded of trauma, avoiding triggers, anxiety, or inability to sleep). Having selected one, the user is presented with a simple tool designed to alleviate symptoms. Examples of such tools include progressive relaxation and deep breathing exercises, through which the user is guided visually. A device that could provide accessible, in-themoment symptom management and coping tools is particularly useful, as the symptoms of PTSD are not always continuously present but tend to wax and wane, as well as being triggered by reminders of trauma. Rather than waiting for the next appointment with your psychologist or psychiatrist, there is the potential to have your own virtual therapist in your pocket. Although the idea is certainly promising, the execution could perhaps be improved upon in some respects. For example, tools such as those titled ‘Pleasant events’, ‘Distract yourself’, and ‘Change perspective’ appear to be just prompts without any useful content. In addition, the variety of tools appears to be limited, and it is easy to see a user becoming bored and frustrated with them if using the app for longer than a couple of days. Overall, the app seems functional, easy to use, and consistent with CBT principles. But

Post-traumatic stress disorder (PTSD): A debilitating psychological condition caused by the long-term inability to cope with a previously witnessed or experienced terrifying event. Symptoms may include uncontrollable thoughts or flashbacks to the event, often accompanied by severe anxiety and nightmares. People often experience both hyper-arousal and, paradoxically, emotional numbing, as well as avoidance behaviours. For more information: http://www.nimh.nih.gov/health/ topics/post-traumatic-stress-disorder-ptsd/index.shtml

“going online and downloading an app may be easier, and less intimidating, than approaching professional healthcare providers” to address the elephant in the room, does it actually work? Unfortunately, the answer is that we don’t know the effectiveness of the app in reducing PTSD symptoms. A feasibility and acceptability study of PTSD Coach has been conducted and published, but there are currently no randomised controlled trials of effectiveness on clinical outcomes. Results of the published feasibility and acceptability study were positive, with 89% of the sample (limited to only 45 veterans) indicating they were ‘moderately’ to ‘very’ satisfied with the app. While still lacking the research base to back it up, PTSD Coach does seem at least to be built on honourable intentions and not motivated by commercial interests. This is a refreshing comparison to the majority of products out there that require your credit card details before they are willing to commence working their magic. One such product is Bust PTSD, available through the Google Play Store for the princely sum of £6.48. It’s a product not shy of blowing its own trumpet, claiming in the product description that it “lays down the foundation for a healthy, normal and happy life by reprogramming neurological activity patterns in the brain”. Such pseudo-scientific jargon is a common theme among the products surveyed. PTSD Free, for instance, makes the bizarre claim that through “brainwave entrainment” the app “quickly shuts down the flight or fight reaction and activates the relaxation response”. Bust PTSD lags significantly behind PTSD Coach in terms of circulation, racking up a meagre ten to fifty downloads on the Google Play Store. The app was developed by a company called CCEI Psychotherapy and Research Inc. Based in British Columbia, Canada, information about this organisation is scarce. The app content claims to be informed by “cognitive-behaviour therapy, imagery, the behaviourist approach, the somatic/

body-oriented therapeutic approach and yoga/ meditation’s grounding techniques”. The content is therefore largely focused on symptom management, and lacks the psychoeducational and self-assessment components of PTSD Coach. Research examining the effectiveness of Bust PTSD appears to be non-existent. Unable to find any published studies, I contacted CCEI Psychotherapy and Research Inc. asking them if they had any effectiveness research, and if so, what the results indicated. According to CCEI, veterans’ data was classified information, and the National Security Act prohibited them from sharing it. They went on to claim that the app “reduces 70% of PTSD symptoms in less than three applications”, although individual needs may vary. They suggested I download the app myself and test it out in my “local PTSD population”, although this did not seem to adequately answer my question. The resounding impression given by this (albeit cursory) exploration of the world of PTSD apps is the striking disjunction between the sheer quantity of apps available and the total dearth of evidence regarding their effectiveness. Indeed, a systematic review of apps for mental health conditions conducted in 2013 noted that whilst there are more than 3000 mental health apps freely available to download, they could only identify eight evidence-based apps, none of which targeted PTSD3. These remarkable findings highlight the fact that regulation of mental health apps is virtually non-existent. The FDA in the US did release Mobile Medical Applications Guidance in 2013, but mental health apps were contained within the list of excluded devices, as they were deemed to pose a low risk to the health of the public. Admittedly, the apps examined here did seem fairly innocuous and unlikely to do any serious harm, and certainly not widespread harm considering the tiny number of downloads. It still seems bizarre, however, that anyone can, should they be so able and inclined, develop an app, slap a catchy name on it, and attempt to flog it to groups of vulnerable people. It is apparent that if smartphone apps are to become a useful and valued resource in the provision of treatment to those experiencing PTSD there must be evidence to back them up. With this in mind, regulation may be necessary in order to provide tech companies with the impetus to develop products with science, not commercial gain, at their core.

References 1. Kuhn, E, et al. (2014) Preliminary evaluation of PTSD Coach, a smartphone app for post-traumatic stress symptoms. Mil Med 179:1 2. Hoge, C, et al. (2004) Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriers to Care. NEJM. 351: 13-22 3. Donker, T, et al. (2013) Smartphones for smarter delivery of mental health programs: a systematic review. JMIR 15:11

The trauma industry inappropriately medicalises normal suffering

DE DE

The field of post-traumatic stress disorder (PTSD) remains a controversial area. Do the symptoms seen following adversity constitute a disorder? When is a diagnosis of PTSD appropriate? Can professionals contribute to recovery, or are traditional non-medical treatments more effective? What is the role of the media and the law in the modern day trauma industry? These were just some of the issues debated in the 15th Maudsley debate: “This house believes that the trauma industry inappropriately medicalises normal suffering.”

FOR

Ben Shephard Journalist and Author

This motion requires you to do two things. Firstly, to see things in historical perspective, and secondly, to consider the nation’s mental health in the broadest sense: the health of the nation as a whole. In the first half of the 20th century there were a number of World Wars. Whole societies had to live through traumatic events; combat, bombing, being prisoners of war, losing their loved ones. Out of this experience, a broad consensus was forged. Doctors and psychiatrists found it was best not to medicalise this process. That was the lesson of shell shock in WW1, where it was found that medicalisation undermined the patient’s sense of responsibility. You should leave people as much as possible to cope on their own. You should respect the culture and the defences such as humour, singing, alcohol, sex, etc. This was not a culture of denial. It was a culture that assumed most people are healthy, robust, and resilient, and can come through horrible experiences with appropriate social support. In the 1970s, this was thrown aside by a group of American psychiatrists. In order to prove that America’s Vietnam veterans were uniquely screwed up, these psychiatrists seized on the rhetorical weapon of trauma. They moved trauma to centre-stage; they took what was previously pathological and made it the norm. They announced that a new insight of the human condition had been achieved, and then, largely by emotional blackmail, they got the American Psychiatric Association to give it a name, and thus PTSD was born. Nearly all the traditional wisdoms were stood on their head. Now it was thought you must not leave the traumatic victim alone. It was not previous personality that mattered and intelligence was no longer an important factor. Thanks to America’s guilt of sending thousands of young men into a dirty, unwinnable war millions of dollars were thrown at research to establish the biological cause of trauma. Most of these PTSD doctors had little clinical experience of their own and very few of them made any serious attempt to understand the overall clinical record of the past. However, by the late 1990s, they had acquired some experience, and what do you think they then started to reveal? That previous personality, NOT the magnitude of the stressor, determined outcome. By this stage, it was clear that America’s Vietnam veterans had not benefitted from “the intervention of PTSD”, and that 20 years of passionate rhetoric about trauma had produced no therapeutic gains. By then, however, trauma had been vectored into the society by the media and seized on by the law. PTSD represented some great breakthrough in medical understanding. In public culture as a whole, this idea is still propagated. Trauma is one of the staples of daytime TV and magazines, it is the cheapest form of drama. Psychiatrists, journalists, and lawyers have created a culture of trauma and they pretend that all that they’ve done is to rediscover something that has always been there. Lawyers took post-traumatic stress disorder and stretched it to include bullying at work. We could ask whether a medical category that now takes in everyone from the inmate in Auschwitz, to a policeman in apartheid South Africa, to a personnel officer in the NHS, can any longer mean anything?

The Looking Glass

BA T E Transcribed and arranged by Zara Goozée

“One client works so hard that they literally break down on the way to work in their car, they have to drive off the road and they burst into tears and they cannot bring themselves to drive to work, and that is their breakdown.” Andrew Buchan, PTSD barrister speaking against the motion

AGAINST

Professor Simon Wesseley Institute of Psychiatry

This side of the house agrees that people should be, and are presumed to be, resilient; we agree that people can, should, and do cope with adversity. We agree, however, that when terrible things do happen people become distressed, they grieve, they mourn. And we agree that this is not a disorder, and nor should it be. We also agree that when bad things happen, most people recover. We know that most, given time, will come back to psychological health. And we agree that there has been a trivialisation of stress, in recent years. Those whose lives have been ruined by exposure to terrible adversity see their own suffering marginalised by people suing because their coffee was hot or someone made a bad joke in the office. But we’re talking about our role, as professionals, in the trauma industry. We have the best trauma services in the country. However, it takes ages to get a potential patient seen. And in the real world beyond the Maudsley, most will not be seen for love nor money. Where is the trauma industry when you need it? We need more of it; we need more psychologists, more of the well-trained and the proper professionals who can offer assistance when it is needed. Are we right to professionalise a problem when we think it is necessary? Our argument is that there are times when this is necessary, appropriate, right, and beneficial. If we look at people who have been in war (for example, the amazing studies of George Vaillant of the Harvard class of 1942) we see that in a class where 70% of them have combat exposure, 30-40 years later all of them continued to have memories of their experience, to have nightmares about it. None of them had forgotten. These were not traumatised people. But among that group there were a small number who were. Three killed themselves, two had long term psychiatric disorders, and one had simply disappeared, possibly murdered. A minority deserving of care and compassion. When we look at what we mean by a psychiatric disorder, PTSD scores on all the relevant points – sufferers have recognisable, reproducible, well-described, wellmeasured disturbances of mood and affect. Their sense of self can be so injured that suicide can be contemplated. Their fears can so paralyse them they are unable to carry on with their occupation, earn a living, and enjoy a family. They are at risk for other mental disorders, they are at risk of drinking, and so on. Their memories of trauma are actively and repeatedly interfering with the process of getting on with their lives. It is a disorder in statistical terms – the best studies find it to be about as common as schizophrenia (1-3%), which we have no problem in accepting as a psychiatric disorder. It is a disorder in symptomatic terms, and in functional terms. And we can now say that there are things we can do to assist. The evidence shows that the new psychotherapies can make a difference if properly applied to the right people and by the right people. So, our argument is this: we oppose the medicalisation of distress. We deplore the devaluation of psychiatric injury by the trivial and the fashionable. We accept that most people can and do recover from adversity without our help. But we also say there are people who develop psychiatric disorders after trauma. These disorders fulfil all the criteria that we use for defining psychiatric disorders. And for those people we argue services, far from being abundant, are rare, often struggling, and dramatically under resourced. So for them, please, we think we should have more of the trauma industry and not less.

“PTSD to me is the diagnosis in an age of privatised disenchantment... Once there is an advantage in presenting yourself as a medicalised victim rather than a feisty survivor – you are in a position to construct your distress in psychological language.” Dr Derek Summerfield, IoP, speaking for the motion

You can access podcasts of all past Maudsley Debates on the KCL webpages: http://www.kcl.ac.uk/ioppn/news/ the-maudsley-debates/index.aspx You will also find details about the next Maudsley Debate, which will take place on 13th May 2015.

The Looking Glass

the inside

scoop

Being a reservist for the UK military By Anup Mathew

Anup is currently working as a Higher General Adult Psychiatry Trainee within South London and Maudsley NHS Foundation Trust, based at a community outpatientâ&#x20AC;&#x2122;s team. He recently completed an MSc in War & Psychiatry at Kings, and subsequently started an MA in Clinical Education. Having been involved in the Combined Cadet Force during school, he always had an interest in the military and so joined the Royal Marines Reserve (RMR) in 2007. Joining the reserves is voluntary and recruits undergo the same training as regular personnel, just over a longer period. Training at the unit consists of weekly evening sessions, during which there is an inspection, lectures, and a physical training (PT) session. Recruits also complete one weekend exercise every month and a two-week exercise every year. Here, Anup tells us what itâ&#x20AC;&#x2122;s like being a reservist in the UK military.

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he Independent Commission reviewing the Reserve Forces stated, ‘The United Kingdom’s Reserve Forces are a vital component of our Armed Forces. They have consistently made, and continue to make, a major contribution to the defence and security of the nation. A force for good in the community, that effectively represents both Defence and Society’.1 There are reservist sections in all three branches of the UK Armed Forces: the British Army, the Royal Air Force (RAF) and the Royal Navy (RN).2 There are two types of reservists in the UK, the Volunteer Reserve and the Regular Reserve, which consist of exregular personnel.2 There are 47,266 Volunteer Reserve personnel, comprising members of RN Reserve, RMR, Territorial Army (TA), Royal Auxiliary Air Force and University Officer Training Corps. In 2006-7, the volunteer reserve trained strength (personnel completed training) was 77% for the RN, 70% for the TA, and 66% for the RAF.3 Therefore, the reserves are understrength and are experiencing a personnel crisis.

lifestyle, immersing myself within the culture, both to adapt and to achieve certain tasks. Routines, such as the weekly parade, can be mentally exhausting, with their demanding inspection to search for any creases in your kit, loose bits of thread or unbuttoned pockets. Initially, I believed this pedantry to be unnecessary and futile. However, I came to understand that it reflected planning and organisation, and was a sign of preparedness. Similar routines exist on weekend exercises. For example, if your water bottle is not ‘toppers’ or topped up right to the cap, you are punished. Usually, this consists of push-ups or a short run. Far from being futile punishment to instil submissiveness, such practice aims to instil a prepared mind-set, such that you take every opportunity to fill your water bottle on operations.

Aside from organisational skills, being a reservist stretches your team working and problem solving abilities to the limits. For example, physical training (PT) sessions may involve moving benches or a vaulting box from place to place over other obstacles, such as Reservists in the UK provide support for homeland 20 foot ropes. Alternatively, you may be required to defence and civil emergencies, they are involved in lead a group of men on a night navigation exercise. peacekeeping and humanitarian missions, and they are Teamwork is the key to success within the military, as increasingly involved in military operations abroad. But you are heavily dependent on the other men in your what is it like to actually be a reservist? unit, not only for mental support, but also physical support especially when fatigued. On the numerous The military is unique in both its social environment occasions on which I have felt too physically or mentally and organizational culture. Being part of the forces, drained to attend training, the support of my team you encounter idiosyncratic beliefs, routines, language, was what kept me motivated to get through a session. and philosophies. During my time in the RMR, I have Furthermore, supporting others has taught me to be gradually had to become accustomed to a different The Looking Glass

more understanding and has improved my ability to the reserve forces in my dissertation work. After some communicate with others, which extends to my work as a research, I found that there has never been a UK study doctor within a multi-disciplinary team. investigating factors for recruitment. Kings College London is in a unique position as a leader in the field As I am part of a reserve force, there is also a lot of military psychiatry. As such, a vast wealth of data of emphasis on individual organisation and selfwas made available to me to investigate this previously management, as the training team do not have the unexplored area. I was given access to data from two time or capacity to help us with administrative and previous military operations and answers given by organisational duties. Such duties are ongoing, from military personnel regarding their reasons for joining. medical and security checks to planning leave and reI aimed to understand why civilians choose to become arranging work commitments to allow time for weekly reservists and in doing so, identify potential factors and monthly training. Being highly adaptable and or traits that could aid with the current recruitment flexible to the needs of others, is incredibly important to crisis. This was especially interesting to me as I wanted fit commitments around family, friends, and colleagues to identify my personal reasons for joining with other at work and in the unit. reservists. I concluded that a combination of reasons Serving with the RMR provided opportunities to gain including personality, thought process, and external personal achievement through contributing to the local factors all influence a person’s decision to join the community. For example, I was involved in the Armed military. Forces Day celebrations in London. This celebrated the The current government believes that it is in the nation’s contribution of the UK Armed Forces and also raised best interest to support the expansion of the Reserve public awareness of the work contributed by the Armed Forces. Their plan and vision is that by 2020, Reserve Forces, both foreign and domestic. I have also been Forces will contribute more to the overall defence trained by TA personnel, in preparation for supporting effort.1 Following my military service, I was able to them at Fire Stations in London during strikes. gain an understanding of military dynamics, its ethos Completing an MSc in War and Psychiatry provided a and discipline while also contributing to the nation’s different perspective from my experiences as a reservist. security. But more than that, I feel I gained invaluable It highlighted to me how individuals, both civilians and skills that I have been able to take back and implement those in the armed forces, respond to psychological in my personal life and in my professional career as a trauma. I was also able to investigate why civilians join psychiatrist. References [1] Future Reserves 2020, (2011). The Independent Commission to Review the United Kingdom’s Reserves-July. Published by The Stationery Office ISBN:9780108510892. [2] Dandeker C, Greenberg N, Orme G, (2001). The UK’s Reserve Forces: Retrospect and Prospect. Armed Forces & Society, 37(2), 341-360. [3] House of Commons Defence Committee, Recruiting and Retaining, par.28, table 4

WANT TO PUBLISH YOUR WRITING? The Looking Glass is taking submissions for Issue 8. Send your articles to thelookingglass.ioppn@gmail.com

News and Events

Spring 2015

Events Mental Health Awareness Week Mental Health Awareness Week is soon approaching, so start planning how you can get involved to help to raise awareness of mental health. The week is run annually by the Mental Health Foundation, and focuses on a different topic each year, with previous highlights of loneliness, anxiety, and exercise. This year the focus is on raising awareness of mindfulness. This event will take place from the 11th to 17th May. To find out more and get involved visit: http://www.mentalhealth.org.uk/ourwork/mentalhealthawarenessweek/

Head of Neuroscience at the Wellcome Trust visits the IoPPN Professor John Isaac joined the Wellcome Trust in 2014 as the Head of Neuroscience and Mental Health. After completing a BSc and PhD in

Neuroscience at the University of Southampton, he took up a postdoc position at the University of California, San Francisco. He has since set up his own lab at the University of Bristol and a lab at the Intramural Program at NINDS/NIH in Bethesda, USA. In 2010, he returned to the UK to work for Eli Lilly and Co. in Surrey, UK. This March, he will be visiting the IoPPN to give a talk on the various schemes offered by the Wellcome Trust. This is a brilliant opportunity to ask questions and gain insight into working with or for the Wellcome Trust. Date: Weds 25th March, 2015 Time: 14:00-16:00 Location: IoPPN Main Building (Denmark Hill), Wolfson Lecture Theatre

IoPPN Student Showcase The IoPPN research student showcase is always a great opportunity for students to present their work, show support for colleagues, and generally gain an insight into the kinds of research currently being undertaken in various departments across the institute. This yearâ&#x20AC;&#x2122;s student showcase will

take place on March 31st, 2015. Poster and oral presentations will be held throughout the day and prizes awarded for the most outstanding submissions. For more details see: https:// internal.kcl.ac.uk/ioppn/events/ eventrecords/2015/mar/IoPPNresearch-student-showcase-2015.aspx

Winners of the 2014 PhD Showcase

News Improvement on the Research Excellence Framework The end of 2014 saw the publication of the latest Research Excellence Framework (REF) results, and we are delighted to say that the IoPPN made

a notable improvement since the previous round of review (previously called Research Assessment Exercise, RAE). As part of the assessment, the IoPPN submitted research papers for each academic, an Impact Case Study for every ten researchers, and an overall Research Environment Statement describing strategy, facilities, processes, and procedures. The majority of eligible staff (89%) submitted work, and men and women were fairly equally represented (44% were women). Submissions, rated by a committee of peers, were assigned ratings of ‘world-leading’ (4*), ‘internationally excellent’ (3*), ‘internationally recognised’ (2*) or below. Across the board, 88% of our submissions were rated as worldleading or internationally excellent (4*/3*). Both our research environment and the impact of our work were judged to be 100% worldleading or internationally excellent. This is fantastic news for us as students, as it means we are receiving an exceptional level of supervision and producing quality research ourselves, giving us the best possible start to an academic or clinical career. Following these results, we have been named second in the world for psychiatry and psychology (behind Harvard), according to U.S. News Global Best Universities list.

King’s Rebranding Since 2012, the King’s College London brand has been under review to place greater emphasis on the success of our staff, students, and alumni. Over two decades, King’s has changed quite remarkably – now with the power to award their own degrees and the merging of several significant institutions within the King’s umbrella, among other changes. After a period of consultation, the new brand name, ‘King’s London’, was announced. However, the

announcement was greeted with a wave of negative feedback from many in the King’s community who were unhappy with the proposed change. Following further discussion with staff, students, and alumni, the rebranding was dropped. The recently appointed Principal, Professor Ed Byrne, reported that despite the failure of the rebranding, a lot has been learned from the process, including an improved understanding of the way we view ourselves. He said, “the impression the world has of us is based on the quality of the education we provide and the research and innovation we contribute in many fields. Constant improvement in these areas continues to be the major way in which we improve our image as one of the world’s truly great universities.” Despite the rejection of the changes by the King’s community, ongoing improvements and alternative changes have been proposed including using ‘King’s London’ as a promotional name and continuing to use ‘King’s’ informally, whilst keeping our legal name as ‘King’s College London’. A programme of initiatives has been set up under the label of ‘King’s Futures’, aiming to strengthen our profile in areas such as business, technology, and the natural sciences, as well as to enhance the student experience, and introduce greater internationalisation to our curriculum and student body. The new branding will slowly be phased in over three years.

for the Athena SWAN Silver Award. The application was submitted in November, two years on from the renewal of our Bronze Award. This period has seen rigorous assessment, evaluation, and the implementation of real changes overseen by Professors Elizabeth Kuipers and Ann McNeill, and Project Officer Sabina Khanom. The Athena SWAN charter was launched in 2005 to recognise commitment of institutions that promote and advance careers of women in science, technology, engineering, mathematics, and medicine (STEMM) in academia. Going through the Athena SWAN application process also helps identify best practice for working environments of all staff, not just women.

For more information you can visit the FAQs page, where more detail is given about the introduction of the new brand. If you have further questions, please get in touch with brand@kcl. ac.uk.

The Athena SWAN silver award will recognise that a significant improvement has been made to promotion processes, visibility, and achievement of women professors, as well as the introduction of an induction programme, early career grant writing workshops, and a mentoring programme. We will know the result of our submission in April 2015. If successful, Professor Shitij Kapur plans to continue to implement our three-year plan of improvement. If unsuccessful, we will review the feedback and resubmit in November 2015.

Athena SWAN Silver Application

You can find further information on our Women in Science intranet pages: https://internal.kcl.ac.uk/ioppn/wisi/ iop-athena-swan.aspx

Professor and Executive Dean of the IoPPN, Shitij Kapur, has welcomed us into the New Year with the announcement that 2015 will see the outcome of the IOPPN’s application

MISSING in action Our Editor-in-Chief asks where all the men were at the latest Inspiring Women talk

dreary, sodden autumn at the IoPPN was brightened in November by another talk in the Inspiring Women series, organised by the Athena SWAN team. Professor Jackie Hunter CBE was interviewed by Professor Til Wykes about her success, and the advice she would give to any who might attempt to emulate it.

one woman’s rise to success in a STEM career. However, despite being interesting and valuable, I found myself distracted by a couple of niggling criticisms as I sat listening to Prof. Hunter’s advice and anecdotes. My first feeling was that the talks in this series show a distinct lack of consideration for intersectionality, the idea that a person can be subject to more than one form of discrimination (e.g. racism, Currently the CEO of the BBSRC sexism, homophobia), which may interact (Biotechnology and Biological Sciences or come to the fore depending on context. Research Council), Prof. Hunter’s long Inevitably, most of the women who star in career began in academia, after which the Inspiring Women series are white and she crossed over into industry, though middle-class. I probably would not have maintaining collaborative links with noticed this were it not for Prof. Hunter’s academic colleagues. With a background advice to ‘outsource’ household chores. in physiology and psychology, her current Tired of ironing your husband’s shirts? Hire role demands attention across broader an ‘ironing lady’ (her words, my emphasis) scientific fields. She also maintains an to save yourself time whilst you concentrate interest in diversity within science, which on more important matters. Whilst such prompted her to accept the invitation to a luxury might be a handy solution for be interviewed for the Inspiring Women some, for many it’s simply unaffordable. series. Prof. Wykes introduced her guest by Regardless of this, I would question why outlining an intimidatingly impressive CV. Prof. Hunter’s husband cannot iron his own Unsurprisingly, Prof. Hunter was confident shirts anyway. throughout the interview but she also proved to be warm and good-humoured. Of course, as a white woman, from a fairly middle-class background (though The talk certainly justified its namesake sometimes struggling to afford London by providing an inspiring example of The Looking Glass

Prof. Jackie Hunter, CBE admires the Inspiring Women: Professors at the IoP photographic exhibition living on a PhD wage), I could easily overlook these omissions. However, to do so would do a disservice to many other women who are unlucky enough to be subject to multiple forms of discrimination and inequality, besides just that related to sexism. Which brings me to my biggest niggle, well major problem – the ease with which people overlook issues that don’t directly affect them. One of the most glaringly disappointing features of this talk was the low turnout of our male colleagues. Whilst this is probably unsurprising, it should nonetheless be a concern.

insisting that thinking of bright and talented people as a threat is an unhelpful attitude, and one that is likely to leave you lagging. Don’t be too prescriptive about your career early on, she continued. Later, when your confidence increases, and you are more aware of what you are capable of and what you have to offer, you can be more strategic in planning your career. Likely, the job you end up in may be something you would not currently consider for yourself. And be resilient, but also know when to quit. Knock backs are expected in life, knowing when to fight back and when to admit defeat is an invaluable quality. None of this advice is intrinsically gender-directed.

issue, they will be fighting a losing battle. No amount of careful balancing will do anything to change the unconscious biases of their male colleagues.

This was not the only double standard that Prof. Hunter highlighted. Naturally, she was asked about how she balanced her personal and professional life (I wonder if a man being interviewed about his career success has ever been asked the same question). She recounted a story about how, when travelling a lot for work, she was asked ‘Who is looking after your children?’ She sensibly replied, ‘Their father!’ No man who travelled a lot for work would ever have this question put “Making feminism a fight to them. This reveals one unconscious fought only by women is a Even advice that on the surface seems bias many people possess, assuming to be solely for the females in the room that the mother is the primary caregiver. mistake.” could be put to good use in the hands of The question disguises disapproving Yes, feminism and equality tend to be men. For example, Prof. Hunter discussed undertones that if she’s working too hard, more of a concern for women (though of the need to promote yourself and where she can’t possibly be a very good mother, course some men do support or actively you work. On average, women are worse leaving her poor neglected children at campaign for equality alongside women). at self-promotion and often get judged home alone with only their father. He, of It’s very easy to ignore inequality and harshly when they attempt it. Behaviours course, could not possibly be looking after prejudice when you are part of the group enacted by men deemed to be assertive them, he’s working! Having more equity that it benefits rather than oppresses. (‘he’s such a go-getter!’) can be seen both at work and home for parents would However, whether some men ignore negatively when women attempt them benefit fathers too, as Prof. Hunter pointed the efforts of Athena SWAN wilfully or (‘she’s bossy, aggressive, arrogant…’). So, out. If we stop expecting mothers to care not, there is no real reason why they women must learn to balance effective and fathers to work, men will have more should feel that the Inspiring Women self-promotion to prevent them from opportunities to spend quality time with talks would not benefit them too. Surely, becoming invisible or missing out on their children and become more involved hearing the experiences and advice of a having their work noticed, without in their care, should they wish. successful person should be inspiring and encountering criticisms from others about Often, when talking about careers for informative for any who care to take an their behaviour. Fair enough. However, women it comes down to whether we interest. both men and women are guilty of judging can ‘have it all’. This phrase always riles these assertive behaviours differently Of course, some of the advice we heard me in its ridiculous simplicity. Of course, depending on gender. Both should be was specifically relevant for women trying we can’t have it all. Nobody can have it made aware of such unconscious biases to navigate a male-dominated world. all. Life is about choices, priorities, and so that they can consider their own Nonetheless, much could be applied compromise. It was refreshing to hear prejudices and try to avoid being biased. more generally to anyone aiming to be Prof. Hunter say as much, suggesting that They might also be able to identify bias in successful in science. Surround yourself whilst you can’t have it all, you can have a colleagues or their workplaces. If women with good people, Prof. Hunter suggested, lot. Particularly if you have the are solely responsible for addressing this 23

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Brief Bio: Prof. Jackie Hunter CBE Degree(s): BSc Physiology and Psychology, University of London; PhD ‘Chemical communication, aggression and sexual behaviour in the owl monkey (Aotus trivirgatus griseimembra)’, Bedford College, London. Previous experience: 30 years in bioscience research, across both academia and industry; served on the Council of Royal Holloway University of London and the governing body of Babraham Institute; founder of OI Pharma Partners. Current role(s): CEO of BBSRC; personal chair at St George’s Hospital; member of the Council of the University of Hertfordshire; Fellow of British Pharmacological Society; Fellow of the Academy of Medical Sciences.

confidence to arrange your life and career in a way that works for you. Her example was to ask your superior for permission to bring your child along with you to a meeting. Naturally, this assumes that workplaces will accommodate women and their personal needs. However, if you don’t ask you’ll never know how they might react. How they react might just inform your choice of what companies and organisations you are happy to benefit from your skills and abilities, or which need a bit of shaking up to bring them further towards the 21st century.

the disinterest or opposition of the other.

Which brings me back to my main point, and the reason why the scarcity of male faces in the audience was such a disappointment to me… because the same need for men and women to work together for fairness is present in workplaces, organisations, institutions, and society. We need to get men interested as much as women in making the world we live in more equitable. Not just because they feel compelled, or because women fight hard enough for them to give in to the pressure (the thought of that long, Perhaps if women weren’t seen as the hard slog by women alone is a dispiriting inevitable (unpaid) child carer in families, one). Men should be just as interested and things might be different. If both men as invested because women are human and women were seen as equal partners beings too, who contribute to society in the upbringing of their children, then, and science in a multitude of ways, and besides a nine month period that really is who would contribute even more if they the work of women only, there would be had the equal opportunity to do so. Men less of a need for companies to try to meet should be invested in equitable workplaces the needs of women. Instead, the necessity because they respect and value the work would be to simply realise that workers of their female colleagues and because have personal lives that may at times not they believe in that work being valued and fit ideally with work. If men were equally respected in the same ways that their own expected to care for children, employers is. would likely be more understanding. Prof. Hunter’s advice to women was to ensure “the same need for men and that relationships are equitable from the women to work together for start. Again, this is advice for women that fairness is present in workplaces, really should be directed at men too. I personally would question the worth of a organisations, institutions, and partner who doesn’t actively work towards society” equality, let alone one who opposed my own attempts to ensure it. Any equitable It might not rid the world of sexism relationship requires that both partners entirely, but if men were to attend the are invested in making it so. Otherwise the Inspiring Women talks, they might see attempts of one will be always thwarted by

some very bright examples of the valuable contributions such women have made to their field. They might also hear about the struggles and barriers that had to be overcome in order to be so successful. However liberal and well-educated my male friends may be, some of them are simply unaware of the sorts of barriers women still come up against. Is it wishful thinking to hope that events such as this might inspire them to work alongside their female colleagues and friends towards removing these barriers? Making feminism a fight fought only by women is a mistake. Saying that the victim of discrimination needs to change, rather than targeting and changing the causes and the perpetrators, would not be accepted in other cases of prejudice. Men and women alike must be invested, interested, and actively involved in opposing inequality, in ensuring diversity and fair representation, and in eradicating the privileges of the few to the advantage of many. The Inspiring Women talks are a brilliant forum for celebrating the achievements of some of the most successful women in science. Hearing from the likes of Prof. Hunter is illuminating both in terms of understanding different routes to success within the sciences and in terms of understanding the barriers that might impede such a journey. Prof. Hunter related her experiences with the poise and self-confidence that often characterise people who have gone far in their careers. Despite my criticisms, having a platform for women to be recognised for their successes and to inspire and inform the next generation of researchers (men and women alike) is invaluable. We just need to encourage our male colleagues to come along and be inspired too!

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REVIEWS Films The Deer Hunter Two Days, One Night

The Deer Hunter (1979) Director: Michael Cimino Starring: Robert De Niro, Christopher Walken, John Savage Michael Cimino’s critically the killing they experience appears to acclaimed The Deer Hunter provides be neither courageous nor noble. emotionally-charged insight into the effects of war on the lives of During their time in Vietnam, the people in a small industrial town soldiers are subjected to various in Pennsylvania. Be warned, this gruelling ordeals, which include stark portrayal contains scenes of a harrowing scenes of Russian roulette, violent and gritty nature, and is not pushing their mental and physical for the faint of heart. It is, however, resilience to an extreme. It is at this a fantastic analysis of the impact of point we see their behaviour start to war on the soldiers, their friends, change in their attempts to cope with and lovers, supported by outstanding the situation. What this film does so performances from a star-studded well is to record this psychological break-down of the characters as an cast. effect of their trauma. The theme The film focuses on three small- of post-traumatic stress disorder is town steel workers, and best friends, explored throughout the film, which whose lives are inextricably changed portrays the character of Stephen forever when drafted to serve in the being unable to integrate back into Vietnam War. The three distinctive society. ‘acts’ to the narrative provide an insight into the before, during, and The long-term psychological impact after of their experiences of the war, of their trauma is also apparent in as well as the repercussions for those the character of Nick (Christopher left at home. It begins with Stephen’s Walken), whose personality changes (John Savage’s) wedding, introducing dramatically after the Russian the characters’ relationships with roulette scenario. His emotional each other, and the dynamic of their instability and social disengagement friendship. These scenes also provide lead him to make decisions that later a symbolic farewell to their old lives, seal his permanent fate. Further, and their moves into a more hostile the character of Michael (Robert reality. Other early scenes of the De Niro) allows the audience to men hunting deer in the mountains explore the rehabilitation of Vietnam offer a compelling contrast to the veterans back into their normal later scenes of war. In this scenario, lives, and the spectrum of emotions the men regard the hunting as encountered by doing so. This is courageous and manly, and the depicted in scenes showing Michael’s killing of the deer as noble. However, embarrassment when congratulated during their time in South-East Asia, by his neighbours, as well as his fear

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and guilt for his fellow veterans, which contrast with his relief at being back home. Interestingly, Michael may be more traumatised than he lets other people see. He returns to the mountain for another deer hunt, but when it is time to shoot, he pulls the rifle up and fires into the air. Michael’s experience is accompanied by Meryl Steep’s character, Linda, who provides her insight into the war as an onlooker, battling the emotional turmoil of loneliness, loss, and guilt. Whist this film has been criticised for inaccurately depicting the Vietnam War and exaggerating the victimisation of the American soldiers, the raw portrayal of characters’ experiences as an effect of the war is still poignant. In particular, the Russian roulette scenes, which have been criticised as unrealistic, are an important metaphor for the psychological impact of the war as a whole. By its very nature, Russian roulette can be described as a deliberately random act of violence, as the war also appears to be. Indeed, in response to such criticism, Ciminio explained that the film was not intended to be political, polemical or literally accurate. Despite such criticism, the climatic end-scene alone makes this film well worth the watch, and has secured its iconic status in film history. Reviewed by Sasha Walton

Two Days, One Night (2014) Directors: Jean-Pierre Dardenne, Luc Dardenne Starring: Marion Cotillard, Fabrizio Rongione, Catherine Salée The Dardennes, a fraternal filmmaking duo from Belgium, have steadily produced one criticallyacclaimed film after another to become a pair of Europe’s biggest art-house darlings, being two of only seven film-makers ever to walk away with two Palme d’Ors at Cannes. Despite such lofty plaudits, their films carry a distinctively low-key feel: the majority take place in the small Belgian town of Seraing where the brothers were born, and they frequently cast unknown actors. How are they able to derive so much from so little? What elevates their films from the provincial to the universal is their ability to use stories about ordinary people as a prism through which to observe all of humanity. In the tradition of social-realist drama, their focus is on the working class; people eking out an unglamorous yet vital existence, often having to make difficult, lifealtering choices amongst a wealth of externally-imposed compromises. In Two Days, One Night, young wife and mother, Sandra, is a factory worker returning from sick leave after recovering from a depressive episode. It transpires that, in her absence, the management have offered the staff a thousand-euro bonus each if they vote to make her redundant, which they do. Out of desperation, Sandra manages to negotiate for another vote to be held on Monday morning, meaning she now has the weekend to convince all 16 of her co-workers to vote in her favour, at the cost of their bonuses. This imbues the narrative with

a thriller-like intensity, with one festival director calling it a “Western” wherein our “cowgirl” protagonist faces a series of duels before a climactic showdown decides her fate. The camera rarely leaves Sandra as she doggedly goes door to door to appeal to each colleague, with alternatingly indifferent, hostile, or moving results.

With its social-realist setting and a faceless corporation pressuring work colleagues to turn on one another, it is tempting to see this as a Ken Loach-style socialist rabble-rouser. Rather, the Dardenne brothers are primarily concerned with individual acts and experiences, allowing a more subtle critique of modern, anti-union, short-term contract capitalism to linger menacingly in Key to the realistic aesthetic is a the background. It is this illustration deceptive simplicity. Everything of the societal through the personal in the Dardenne universe is kept in which the Dardennes excel. bare, whether it is the naturalistic performances, the lack of a score, While the film doesn’t depict working the muted cinematography or the class solidarity per se, it does show no-nonsense, linear storytelling. moments of human solidarity, in This unsentimental approach means which small acts of kindness resonate the events depicted on-screen have beyond their social context. For a matter-of-fact immediacy that is instance, Sandra’s husband, a chef both quotidian and shocking in its in a chain restaurant, is a veritable rawness. guardian angel, showing endless compassion and magnanimity in the The one concession made towards face of her deteriorating well-being. mainstream appeal is the casting It’s a refreshing change from typical of Oscar-winner Marion Cotillard depictions of working class men as as Sandra. Marion, who seems to dominant, insensitive boors. specialise in inhabiting characters perpetually on the edge of a nervous From a clinical perspective, it is breakdown, is excellent. She remarkable how her husband’s somehow manages to appear mousy behaviour mirrors that of a model and vulnerable, yet determined carer, remaining compassionate, and dignified, refusing to be pitied. goal-oriented, and objective, while Having stated in interviews that she staying dedicated to his wife in a spent time with patients suffering time of crisis. Similarly, the ending from depression, her body language displays a notable parallel with the and expressions demonstrate that empowerment model of mental she’s gone beyond stereotypes. health recovery. By the film’s end, we Depression isn’t simply about being find that Sandra has attained the most very “sad”, but about a restricted range important step in her own recovery: of emotion, as well as low motivation a sense of agency, achieved through and self-worth. These facets are her unwillingness to compromise carefully sketched throughout the regardless of the outcome. A truly film, making Sandra’s up-hill battle to moving experience. retain her job all the more herculean. Reviewed by Raphael Underwood

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thinking outside the box business technology and psychology

This month, we speak with Dr Patapia Tzotzoli – a clinical psychologist with an entrepreneurial drive. We chatted about her various interests, what the web-based services she is developing can offer struggling university students, and the doors opened by training in psychology to a broad range of careers.

Can you tell us a bit about yourself: your background and your current work? I am a clinical psychologist, chartered by the British Psychological Society and registered with the Health and Care Professions Council. I’m currently working as a neuropsychologist at Queen’s Hospital, Romford, as well as running two businesses. The first is a private practice, based across Bank and Harley Street, where I offer clients psychological therapy in person or via Skype. You can find out more about my work, read my blog or get in touch via my personal website (www.patapiatzotzoli.com). The second is iConcipio Ltd., a support provider for students based on web technology solutions. The variety and challenge of these three projects satisfy different urges, ambitions, and goals, - the need for this is a core aspect of my personality. What is iConcipio, and what does it offer students? iConcipio is a spin-out company following an award I received in 2011 from King’s College London’s Graduate Business Plan Competition, called the “Lion’s Den Challenge”. Our service is an online system, called MePlusme, which addresses the psychological and educational needs of students in higher education. Using our system, students in a private space can explore their difficulties either by answering an interactive questionnaire, which helps identify the issues they are facing, or by going directly to a list of techniques where they can choose which are relevant to them. Either route leads to a tailor-made set of animated videos. These videos present well-established psychological and/or study skill techniques, the effectiveness of which has been demonstrated by extensive scientific research. Students can practice these techniques over time, using a rating system to monitor their progress. There is also a social network which allows students to connect anonymously with others to provide mutual support. With the financial support we received from the Technology Strategy Board (Smart Award) we carried out a proof of concept study in five universities across the UK. Data from almost a thousand students confirmed there is a need for support, and gave us the green light to strive for our next milestone: building the system and running a feasibility study. Those interested in keeping up to date with developments at iConcipio can sign up at our website: www.iconcipio.com .

Want to find out more? Anyone interested in finding out more, can always get in touch directly via email: Patapia@iconcipio.com

What are some of the most common challenges faced by students today? Entering university is a huge challenge in itself, as it marks one of the more important transitional phases in the life of a young individual. Overnight, a school pupil becomes a student, and the responsibilities reach completely new levels. And all this is taking place far from home, whilst one feels invisible among a crowd of other students. For many young individuals, this new setting can be a good match, providing challenges and opportunities to develop. However, for others, it becomes the catalyst for difficulties to start emerging. A large proportion of students experience psychological or study skill-related difficulties that keep them from achieving their true academic potential and enjoying the university experience to its fullest. On top of these, there are also those students experiencing diagnosable conditions. It is hardly surprising that a number of recent reports have documented the high prevalence of mental health problems amongst students. At the same time, the obvious sources of formal support available to students, support services provided by their institution, are stretched due to increased demand and recent budget reductions. As a result, there is a higher risk of problems escalating and students dropping out (the figure for which recently rose to more than 22%), jeopardizing career prospects. Therefore, a more practical approach to delivering student support is imperative and urgently needed. Why did you choose a website as the format for trying to address these problems? Current technologies can revolutionize health service delivery. Our system is flexible, easy to use, interactive, and online. A website supports the system and animated videos are used to present the techniques, thus translating psychological and educational knowledge into a contemporary and more engaging format. For increased flexibility, the system is also accessible via smartphones and other mobile devices. The technology provides a platform, which facilitates privacy, immediate help, and increased self-efficacy by giving the control back to the students. It permits them to choose when to come in and out of the system, and learn how to improve their personal effectiveness, at their own pace. It also entrusts them to be responsible, and thus accountable, for their own wellbeing and academic competence, which encourages motivation to change and confidence. This acts as an empowering component, removing stigma and supporting self-help. What psychological approach do you use and why is this appropriate? iConcipio’s system is built on current scientific knowledge and best practice, drawn from both the psychological and the educational fields. The psychological techniques are derived from Cognitive Behavioural Therapy (CBT), which has a significant amount of scientific evidence supporting its effectiveness in addressing a range of emotional difficulties and associated behaviours. Students are offered techniques from different angles (e.g. cognitive or behavioural) to address the same problem, thereby allowing flexibility to adjust the intervention

according to learning style and preference. This ensures variety and maximum outreach. In addition, the videos seek to normalize student experience and hence engage them in using simple techniques to cope more effectively. The educational techniques aim to help students focus their efforts and develop successful study skills and strategies. The techniques consist of the most up-to-date practical skills, and have been extensively tested and shown to improve students’ performance. On top of these, the system design also embeds ‘hidden’ psychological techniques (e.g. nudge theory techniques and motivational emails) to provide structure, enhance engagement, and ensure effectiveness. This intervention is a mosaic built on implicit and explicit state-of-the-art psychological techniques and practices. What inspired you to do the work that you do? People ask questions. Psychology gives answers. Emerson, an American essayist, lecturer, and poet defined success as the knowledge that someone breathed easier because someone else lived. I find in this idea an infinite strength to persevere and inspiration to keep creating. Psychology is not panacea but it has a high level of relevance to everything that involves people. What are your plans for the future of iConcipio? We are currently developing the system and we have ethics permission to run a feasibility study with UK universities that are already on board. We will then implement a soft launch of this service and prepare for an evaluation study whilst rolling out to the national and international market. What advice can you give for someone who is thinking about setting up their own business? Network as if it is your last day – everyday! (By the way, if you are good at this, get in touch with me!) What opportunities are there for those with psychology training to use their skills in ways other than Clinical Psychology? Infinite. Psychology is a multifaceted discipline. You can use its knowledge to help others, sell anything, make huge financial deals, raise children, be good at sports, enjoy life regardless what it brings your way… Where does your entrepreneurial drive come from? It must be an old defective Greek gene, resistant to systemisation and open to chaos! I suspect I inherited this from my father. We share a passion for creativity. What opportunities are there for people to get involved in the work you do? At present, the focus is on the development of the system so experienced psychologists with clinical or educational backgrounds can participate in this process. We also have research projects in the pipeline so interested psychologists with research backgrounds can get involved too. This is a pioneering project and an innovative system with commercial prospects, so it is an amazing opportunity both for people interested in having their name involved with this work at these early stages, and also for those interested in opening up career prospects within a company.

THE BEST FROM THE WEB

Reefer Madness? LONDON – Is cannabis harmful to mental health? That question has provoked much debate over the years, often generating more heat than light. The bottom line is this: within the scientific community, there is a general consensus that most people who use cannabis will not develop significant mental-health problems. Certain individuals, however, are more susceptible to the negative effects of its use. It was long thought that cannabis was a relatively harmless drug, and that concerns about its use were overstated. Some psychiatrists had reported that excessive use could lead to a psychotic state, including hallucinations, delusions, and thought disturbance. But the first significant indication of a link between cannabis use and psychotic illness came only in 1987, from a large Swedish study that followed more than 50,000 subjects over 15 years. Reported cannabis use at the study’s start increased the likelihood of being diagnosed with schizophrenia in the next 15 years. The greater the use, the higher the likelihood of being diagnosed. Curiously, this finding did not spur much interest, and no similar studies were reported until 2002. Since then, however, many studies have explored the association between cannabis use and psychotic illness. In 2007, a compilation of the best studies concluded that frequent (daily) cannabis use doubles the risk of a psychotic outcome. Since the lifetime prevalence of a psychotic illness is roughly 1% of the population, daily cannabis use would increase this to 2%. Of course, the existence of a positive correlation between cannabis use and psychosis does not allow us to draw a direct causal link between the two. Psychosis could cause cannabis use, rather than vice versa, or an unknown mediating factor could cause both cannabis use and psychosis.

By Robin Murray and Amir Englund evidence suggesting that the maturing sign of a link has been found, there is brain is more susceptible to the negative better evidence for the addictive potential impact of cannabis. of cannabis. Roughly 10% of people who smoke cannabis go on to develop Recent research has shown that a particular dependence, which produces withdrawal variant of a gene called AKT1 mediates symptoms when use is stopped, such as the risk of psychosis. For carriers of the craving, irritability, sleep disturbances, C/C variant (which occurs in roughly 20% abdominal pain, and nervousness. Again, of the population), the risk of psychosis CBD seems to offset the addictive effects of increased seven-fold – but only for the cannabis, and seems to provide relief from people who used cannabis every day. Using withdrawal symptoms. cannabis on weekends or less often posed no increased risk, which was also the case Many studies have focused on the possible for daily and weekend use among carriers negative impact of cannabis use on of the C/T and T/T variants of AKT1. memory and other cognitive functions. It is generally accepted that frequent and Moreover, different strains of cannabis prolonged cannabis use impairs cognitive pose more or less risk for psychosis. A functioning, but that these effects are reversible following abstinence of 3-12 months. However, a recent study that followed people from birth to age 38 found that those who started using cannabis early, every day, and for several years had a permanent 8-point drop in IQ scores. (The study has not yet been replicated.)

comparison of the two most common types of cannabis in the United Kingdom, hash and sinsemilla (“skunk”), found that using skunk implied a significantly greater risk of psychosis, while hash did not. The explanation for this difference lies in the composition of the two main components of cannabis, delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Skunk in the UK has high levels of THC while being virtually devoid of CBD; hash, on the other hand, has roughly equal quantities of the two components. This was highlighted in our lab when healthy volunteers were given either pure THC, or THC and CBD. Those who received only THC had a significant increase in paranoid thoughts, psychotic symptoms, and memory impairment, while those who received the combination experienced no paranoia, had fewer psychotic symptoms, and maintained memory function.

Other factors already complicate the relationship. For example, the age at which cannabis use begins appears to be an important factor. People who started using cannabis before the age of 16 have a higher Some studies have also explored the risk of psychosis compared to those who role of cannabis use in disorders such start after 18. This is in line with biological as depression and anxiety. While little

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A final, and often overlooked, source of harm to mental health associated with cannabis is the legal fallout of being caught with it. Penalties for cannabis possession range from none (for example, the Netherlands and Portugal) to legal warnings, fines, and even life imprisonment (Southeast Asia). A criminal record can negatively affect future employment, education, and ability to travel. Such consequences may carry independent risks to mental health; for example, unemployment poses a significant risk for suicide, anxiety, depression, and psychosis. So, does cannabis use harm mental health? Yes and no. Much depends on how old you are when you start, your genes, and how much, how often, and what kind you use – and, of course, on whether you get caught.

This article was first published in August 2013 at: http://www.project-syndicate. org/commentary/the-effects-of-cannabisuse-on-mental-health-by-amir-englundand-robin-m--murray

On the couch with... Dr Tamara Russell

Earlier this month, newly appointed Assistant Editor for The Looking Glass, Malvika Katarya, met with Dr Tamara Russell, a woman of many talents whose varied roles include clinical psychologist, researcher, neuroscientist, and martial artist. They chatted about Dr Russell’s career, the mindfulness therapy she researches, and how Kung-fu fits into the mix... Tell me a bit about your career and how I went to Australia, where I got some you became interested in mindfulness funding to do a remediation study research in particular. and published a few papers using eye movement methods to show how the I did a BSc in Psychology, then the training was working. But, it was difficult MSc in Neuroscience at the Institute of to get funding and I saw the way that the Psychiatry (IoP). During that MSc, I had funding was going. Of course, as I was the opportunity to do an fMRI study in working more and more with patients patients with schizophrenia, looking at around social remediation and how they theory of mind (ToM), which was one were getting on with their ‘real life’, I of the first imaging studies of ToM to be became more interested, and thought conducted in such individuals. After that, how can we actually treat these patients? I did a PhD in experimental psychology, I was getting a little more interested in the conducting a study looking at elements clinical and therapeutic side of things. of ToM in different subgroups of patients with schizophrenia. Then, I was lucky enough to get on to the clinical course at UCL and so came back For a few years, I researched in the field to England to do the three years of clinical of social affective neuroscience, as it’s training. As I was doing my clinical training now called. I was particularly interested I came across the mindfulness research. In in remediating social cognitive deficits, my mind, I’d been trying to work out how such as facial emotion processing deficits. to develop martial arts-inspired, bodyEven though I didn’t know it, that was sort based therapies for working with patients of my early foray into something akin to with schizophrenia, because I saw the mindfulness, because social cognitive poor physical health and the difficulties to processing mostly occurs outside of engage some of them with some therapies. awareness but when you’re training I’d already been developing the body in people to do it, you have to bring it into mind training programme, but it wasn’t awareness. That was what I was doing specifically couched in this mindfulness in the remediation studies: deliberately framework at that point. bringing into awareness processes that normally lie outside of awareness. Then I started reading the mindfulness literature, such as the MBCT (Mindfulness-

Based Cognitive Therapy) papers that were coming out. I was reading about the body scan and thinking it looked familiar. Paying attention to the body, bringing awareness to what you’re doing, the overlap with Tai Chi, looking at elements of intentionality... What I didn’t have was a much more detailed framework of how to pay attention. That’s what the mindfulness and the Buddhist psychological model brings: really detailed and specific information about how to pay attention to experience as it unfolds over time. So, I was interested in neural networks underlying when things come into awareness and when they are outside of awareness. I was interested in the body aspect of things. The mindfulness framework gave me this sort of umbrella to bring it all together. Since then I’ve been doing little pieces of, what I call, guerrilla research: beg, borrow, and steal projects with MSc students. Really just testing out ideas, piloting what works and what’s helpful. I was developing trainings for healthcare professionals, to start bringing some of these techniques into their working life, for themselves. However, the groups I’m most interested in are the those who would struggle to manage with a traditional seated meditation practice. That includes both The Looking Glass

individuals at the more chaotic end of the mental health spectrum, but also busy health professionals: doctors and nurses. Not quite for the same reasons, they have that same difficulty. When you say, ‘come on let’s do a forty-five minute body scan’, they just laugh at you. So then you look at mindful movement – being mindful when you move around. Can you explain mindfulness and drawing attention to someone who has never come across it before? I work with the definition of Jon KabatZinn, because to me it makes sense and he describes it very succinctly. Mindfulness, he says, is the type of awareness that arises when we deliberately pay attention to what’s happening (in the external environment, but perhaps more interestingly, also internally). We learn to really be alert to thoughts, memories, images, bodily sensations... and we practise attending to all these data. In doing this we discover many things about ourselves. We discover some of the habits we’ve developed that are maybe not so helpful, and some of the habits that are helpful. We have the possibility to do things differently. It’s this process of increasing (we call it widening) the window of consciousness in order to see things we couldn’t see before, because they lay outside of our awareness. With mindfulness we can bring them into awareness and then we can choose what we like and want to keep, and what’s not so good for us and so we want to do differently. So how would mindfulness therapy help someone who has psychosis or schizophrenia? Individuals with psychosis have problems with attention, focus, and concentration, as well as heightened levels of anxiety and arousal. So ‘sit on a cushion’ practices or extended periods of silent practices are probably not recommended. They might be able to build up to that – I really do believe that’s possible – but they’d have to be quite motivated and dedicated. However, the work of Paul Chadwick (also at the IoP) shows clearly that it is possible to help people deal more skilfully with voices using adapted mindfulness. Initially they hear voices and struggle against them, which is like a double dose of distress – the voices are distressing and then the struggle against it is distressing. With mindfulness, they probably still hear the voice but they can work with it. This is the acceptance, the letting go of struggles, letting go of wanting or needing things to be different. We don’t want a voice, it’s probably not nice but that’s the acceptance 31

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of a diagnosis of schizophrenia and that voices are a part of that. But what do you do that adds to the trouble? What do you do that makes it worse than it needs to be? It’s skilful work that takes practise and patience, but it is possible. It’s quite powerful when it happens, but you need to work with the motivation, work with the adaptations, you need huge amounts of patience. The person needs to be really willing to work at it. It’s hard to do, even if your brain is ‘normal’ chaotic. The people with serious mental illness who are able to do this always inspire me – I’ve met quite a few of them now and it’s incredible.

“I think within the field there is a desire to temper the enthusiasm, because there is so much we don’t know.” Were there any findings during your research or your practice that kind of surprised you or encouraged you? Well, I always refer back to this one amazing lady I met taking part in the social cognition remediation study. In the interactions I had with her, I assumed she was in a remission and she’d be in the remitted group, for people who are relatively stable in between periodic episodes of paranoia and delusions. She had a long-standing history of mental illness but she was getting on, she was working part time, she was living independently. When I did the symptom assessment, she started talking and described constantly hearing voices – second and third person auditory hallucinations, paranoia and masses of positive symptoms. I was like, ‘What are you doing? Let me know.’ She said, ‘I’ve got this CD, it’s a guy called Jon Kabat-Zinn. I listen to it every day. It’s called mindfulness. And I do hear the voices but I’ve learnt how not to react to them. They are still there all the time, but I respond rather than react.’ She also gave this beautiful example. She was part of the

Maori tradition from New Zealand, and she said part of the mindfulness training helped her to distinguish the voices that were her illness, part of her schizophrenia, from the more helpful sort of spirit or guide voices that were part of her cultural tradition and heritage. Although the mindfulness field is relatively new it is rapidly growing, what do you think are some of the challenges the field is facing, and where could it go in the future? Lots of challenges and lots of questions. The big challenge from a research point of view is measurement. There’s been a proliferation of scales, not many of them properly validated and a big controversy in the area is about what are we measuring and how. For example, the non-mindful mind reads a question about how mindful you are and doesn’t even know what the question is, whereas after eight weeks training, you do know what the question is. So you’re not actually measuring the same thing pre and post. Also, eight weeks is the standardised training programme, but as far as I’m aware that’s not based on any empirical or pedagogical theory about how long it takes to learn mindfulness. Certainly it’s laughable if we think about mindfulness in it’s original traditions, where it’s lifelong learning. The adequate dose and for whom is a really big open question. There are open questions about what carries on and what the effect is in the longer term. Actually only relatively few studies have adequate control groups and in the two large-scale studies of MBSR (Mindfulness-Based Stress Reduction) and MBCT (Mindfulness-Based Cognitive Therapy) that had active control groups, the results really weren’t that amazing. The control group should be meeting in a group, learning something, having a nice facilitator there, and doing some sort

“All the things that I do really feed into my own development. If you’ve got any kind of job that does that you’re just super lucky.”

of mind-body integrated thing, just not mindfulness. In the MBSR study, the only thing that really showed any significant difference was thermal pain sensitivity, which makes sense because MBSR came from a chronic pain background. However, all these other questionnaires about wellbeing and quality of life showed no difference. Similarly, in the MBCT study with a similar active control group, MBCT didn’t prevent relapse any more than the control. Although, when they subdivided the group into those with early trauma and those without, there was a benefit for MBCT over CBT. So the effects are potentially quite specific and subtle. If you really know the literature, we are not at a point for the wholesale application of MBSR and MBCT for everybody. I think within the field there is a desire to temper the enthusiasm, because there is so much we don’t know. I’m also personally interested in the pedagogical aspects because I do feel that we are of course drawing on some ancient traditions of practices, but we also know a lot about how to motivate and inspire people to learn from our modern educational theories. For example, multimedia learning, multisensory learning. How can we inspire and motivate people to engage with the practice? Of the many roles that you fulfil – as a martial artist, a mindfulness teacher, a therapist, and a researcher – which do you find the most rewarding? I love them all! That’s my problem! They all give me different things, I think. I love working with my clients – they are kind of the main inspiration actually. When I’m struggling with my own practice, I just remember what I see other people doing with minds that are much more “crazy” and chaotic than mine, and I just think, ‘Come on! If they can do it, I can do it.’ The research part of it I love as well (less the admin and bureaucratic aspects, which I

desperately try to avoid!). I like being in a new field. I like being this kind of ‘front runner’ of the research, because I think there’s just so much creativity you can bring before it gets entrenched in a kind of ‘this is what we do’. I love Kung-fu – doing my practice and teaching. I love working with people doing martial arts. You see people blossom in a similar way to how they do in therapy, but it’s through this other route, which I think is just fascinating. Then the mindfulness training develops me. Maybe I’m just really selfish actually! It’s all about me! All the things that I do really feed into my own development. If you’ve got any kind of job that does that you’re just super lucky. What challenges have you faced or adversity have you had to contend with? Well, the “doubt monkeys”. The “judging monkeys”! Trying to bring innovation into a system is a challenge. In my mind, there’s this question of whether I really want to develop a programme and evaluate it to a point where it could be rolled out like CBT or in IAPT. The answer that I came up with is that even if I would like to see that, it would probably kill me. It involves being embedded within a system of grants, academia, and institutes. What I like is really being creative, trying new things and those are not compatible actually. I’m still conflicted about that. I do think that I’ve got something that’s good and helpful for people, but I’m still not exactly sure how it can be in the world and I’m pretty sure I don’t want to go into 20 years of developing RCTs.

other comorbidities, and they’re keen motivated individuals that want to take part in studies. They’ve got supportive families who bring them in and make sure they do the treatment and make sure they’re there. They’re being seen by world leaders and specialists. How does that translate to some clinical psychologist down in Devon with a psychotic patient in front of them who’s also smoking weed, drinking, totally isolated, doesn’t have a family? I don’t think that treatment is going to work for them. Of course, the methodology is there for a reason and I fully respect that, but there are limitations. For the people that really need it – the people that have psychosis, that are still smoking weed and not going to appointments, and not going to go for a traditional talking therapy – how are we helping those people? If they can come to a class and start moving their bodies and maybe engage in something to do with mindfulness, I think that’s important. So that’s the challenge – how to work those two positions in a way that’s still offering something of high quality and has a strong theoretical basis, but maybe doesn’t quite have an RCT level of evidence behind it. Last question, if you hadn’t become a clinician and a researcher, what alternate career might you have had?

When I was younger, I wanted to be an archaeologist, then when I was older, I thought I wanted to do law. However, because I was a little bit naughty and disruptive as a teenager they basically said I wasn’t going to get the grades to get into On the plus side, our whole health system law school, so I better pick something else is changing. I think there are different sorts and I picked psychology! So it wasn’t really of opportunities that are likely to arise in my choice! the future around how people choose what they want as their therapy. If you’re getting I thought at one point I might do Chinese it from the NHS it’s about NICE guidance, medicine – I was really interested in evidence-based, RCTs, and multicentred that. But I’d have to learn Chinese and trials. That’s the language of treatments I got a bit stuck with that. I might have within this NHS, but increasingly we’re not done something with sports or physical going to have an NHS. When you get into education or I don’t know… Now, I do the private sector, the way people choose want to do more learning about the body, how to spend their money (because it’s I keep thinking I’ll do a massage course… their money), is they ask their mate, ‘Did maybe I might do an anatomy course. you like it? Was it helpful?’ They’re not There’s always stuff to learn... asking, ‘Can I see a randomised controlled Read more: trial?’ So it’s totally different, which has Russell, TA. & Tatton-Ramos, T (2014) Body pros and cons. In Mind Training: Mindful movement for One study that was published reported that the patients that are in these RCTs at best represent about 17% of the population of people with schizophrenia. They’re not using drugs and alcohol, they’ve got no

the Clinical Setting Neuro-disability and psychotherapy 2(1/2): 108–136 Russell, T.A. (2011) Body in mind training: mindful movement for severe and enduring mental illness. British Journal of Wellbeing 2 (3): 13-16

The Looking Glass

Editor-in-chief Rhianna Goozée Assistant Editor Steffen Nestler Editorial Board Members Nishita Bhembre Lan Mao Naunehal Matharu Maurissa Mesirow Sophie Smart Sasha Walton Amanda Worker Contributing writers Hannah Deen Amir Englund Zara Goozée Malvika Katarya Anup Mathew Rachel Potterton Raphael Underwood With thanks to Dr Tamara Russell Dr Patapia Tzotzoli Artwork and images Cover artwork: Maurissa Mesirow; Pages 2 – 4, and 8 – 10: Harland Quarrington/MOD [OGL (http://www.nationalarchives.gov.uk/ doc/open-government-licence/version/1/)], via Wikimedia Commons; Pages 5 – 7: Images obtained from the Wellcome Library, London; Pages 11 – 14: http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons; Page 15: Rhianna Goozee; Pages 16, 17, 23 and 28: Provided by KCL Press Office; Page 27: Provided by P. Tzotzoli; Page 30 – 32: Provided by T. Russell.