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Pain Christopher Eccleston, Christian Jarrett, Amanda C. de C. Williams and Ronald Melzack in a special issue
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letters 398 news 406 big picture centre careers 462
childhood enemies 426 interview: an insight into ‘nudge’ with David Halpern 432 ‘One on one’ with Jaak Panksepp 472
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letters 398 the Middle East; IAPT; chronic fatigue; religion; boys and psychology; and more
THE ISSUE
news and digest 406 building a happier society; a negative side of positive psychology; the Academy meets academia; nuggets from the Society’s Research Digest; and more
As anyone with kids of a certain age will tell you, naturalist and TV presenter Steve Backshall is a tough guy. Perhaps this is what makes his reaction to being stung by hundreds of bullet ants, as part of a tribal ritual, all the more powerful. Watch it at tinyurl.com/d6z4b9 for a graphic illustration of how pain can completely take over your body and mind. Interestingly, Backshall has also suffered recently with chronic pain (see tinyurl.com/63l39mz), which is more the focus of this special issue. Christopher Eccleston gives an overview of the area; Amanda C. de C. Williams talks to three people who have used their own pain to ease that of others; Christian Jarrett looks at individual differences in pain; and we have a ‘Looking back’ from one of the giants of pain research, Ronald Melzack. Also in this issue, we talk to David Halpern, a psychology graduate who advised Tony Blair and now leads the Behavioural Insight Team for the government. Gerry Mulhern signs off as President in his final column, Sophie Scott’s research features in the ‘Big picture’ poster, and we meet Jaak Panksepp in ‘One on one’. Dr Jon Sutton
media 412 Gail Kinman on media coverage from the Society’s Annual Conference in Glasgow
Ouch! The different ways people 416 experience pain Christian Jarrett examines the psychology of pain perception A normal psychology of chronic pain Christopher Eccleston explains how psychology is working to help people disabled by pain
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426 Pain – the patient’s viewpoint Amanda C. de C. Williams talks to three people who have used their own pain to ease that of others 428
Childhood enemies Noel A. Card and Deborah M. Casper ask whether they are necessary challenges or markers of social maladjustment
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An insight into ‘nudge’ Christian Jarrett fires some questions at David Halpern, Director of Research at the Institute for Government
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book reviews 436 a novel contribution to the theory of mind; rethinking psychosis; protecting children from violence; and more society
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the final President’s column from Gerry Mulhern; new obesity report; Doctoral Award winners; proposed special group; IAPT register; Society website; and more
careers and psychologist appointments
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how to get ahead in the psychology of advertising: Ian Florance talks to Daniel Müllensiefen and Sarah Carter from advertising agency DDB; David Lurie, Managing Director of Setsights Ltd, seeks insight at Psychology For All looking back
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an author of the hugely influential gate theory of pain, Ronald Melzack, on an important paradigm shift over the last half-century one on one
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…with Jaak Panksepp
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FEATURE
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Ouch! The different ways people experience pain Christian Jarrett examines the psychology of pain perception
H
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eadache, stubbed-toe, injection, broken bone – most of us have suffered pain in one form or another, but our experience of that pain will have varied wildly. In the lab, the same level of stimulation, from extreme cold to electric shock, has been shown to cause a yelp in some but a barely discernible wince in others. Moreover, whereas many people are lucky enough to experience pain as a fleeting encounter,
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Applegate, K.L., Keefe, F.J., Siegler, I.C. et al. (2005). Does personality at college entry predict number of reported pain conditions at mid-life? A longitudinal study. The Journal of Pain, 6, 92–97. Campbell, C.M., Edwards, R.R. & Fillingim, R.B. (2005). Ethnic differences in responses to multiple experimental pain stimuli. Pain, 113, 20–26. Campbell, C.M., France, C.R., Robinson,
for others pain is a constant companion. The sensitivity and tolerance people show towards pain varies predictably according to several factors, including gender, ethnicity, personality and culture, all interacting, overlapping and playing out in the tissues and synapses of the body. Indeed, the topic of individual differences in pain is like a microcosm of science – it’s where biology, psychology and sociology all meet. So, although the
M.E. et al. (2008). Ethnic differences in the nociceptive flexion reflex (NFR). Pain, 134, 91–96. Campbell, C.M., France, C.R., Robinson, M.E. et al. (2008). Ethnic differences in diffuse noxious inhibitory controls. The Journal of Pain, 8, 759–766. Diller, A. (1980). Cross-cultural pain semantics. Pain, 9, 9–26. Conrad, R., Schilling, G., Bausch, C. et al. (2007). Temperament and character
studies that we’ll hear about often focus on either psychosocial or biological mechanisms, it’s worth remembering that a person’s beliefs and cultural upbringing can change the way their body and brain respond to pain. ‘It’s important that we not fight it out as to who’s winning – the psychologists or the biomedical folks,’ says Professor Roger Fillingim, a clinical psychologist at the University of Florida and a leading expert in the field. ‘We need to integrate all of these factors to better understand how they work together to ultimately create the experience of pain.’
Gender The question of whether men or women have the greater pain threshold is guaranteed to liven up the most soporific of dinner parties. From a lay perspective, evidence exists on both sides. There’s no shortage of stories of feminine bravery – for example, in the grip of prolonged labour. On the other hand, it’s men who have the greater reputation for a warrior instinct and physical risktaking. Although some studies turn up negative results, the research points overwhelmingly in one direction. Whether in the lab or in the clinic, men demonstrate greater tolerance of and less sensitivity to pain than women. Women are also far more likely to be diagnosed with chronic pain conditions like fibromyalgia (see box). Consider a 1998 paper, typical of the field, in which Pamela Paulson and colleagues scanned the brains of 10 women and 10 men while they experienced a heat stimulus applied to their forearm. The participants were told the experiment was testing their ability to discriminate temperatures using a scale from 0 ‘no heat sensation’ to 10 ‘just barely tolerable pain’. Not only did the female participants consistently rate the higher 50oC stimulus as more painful than the male participants, but their brains also showed a greater change in activation in response to it, including in the
personality profiles and personality disorders in chronic pain patients. Pain, 133, 197-209. Fitzgibbon, B.M., Giummarra, M.J., Georgiou-Karistianianis, N. et al. (2010). Shared pain: From empathy to synaesthesia. Neuroscience and Biobehavioural Reviews, 34, 500–512. Hobara, M. (2005). Beliefs about appropriate pain behaviour: Crosscultural and sex differences between
Japanese and Euro-Americans. European Journal of Pain, 9, 389–393. Keefe, F.J., Lefebvre, J.C., Egert, J.R. et al. (2000). The relationship of gender to pain, pain behaviour, and disability in osteoarthritis patients: The role of catastrophising. Pain, 87, 325–334. Levine, F.M. & De Simone, L.L. (1991). The effects of experimenter gender on pain report in male and female subjects. Pain, 44, 69–72.
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anterior cingulate cortex (a region known to be associated with the evaluation of painful stimuli) and posterior insula (which regulates internal body states). These kinds of studies are not without problems. For socio-cultural reasons men are less likely to want to admit that they’ve found a stimulation painful. The sex of the experimenter can play a role here. Several studies have shown that men report lower pain intensity ratings and exhibit greater pain tolerance when the experimenter is a woman. Fredric Levine and Laura Lee De Simone in a 1991 study even chose especially attractive researchers to amplify the effect. At least one study has found that women too report higher pain tolerance when tested by the opposite sex. Other research has shown that the degree to which participants identify with masculinity and femininity influences their response to pain. For example, Cynthia Myers at the University of Florida showed this in relation to the widely used cold-pressor task in which participants are required to hold their hand in icy water for as long as they can. Male and female participants who identified more with masculinity tended to hold their hand in the ice for longer. Whilst findings like this highlight just how important it is to consider genderrole influences when investigating sex as a factor, this doesn’t mean that there aren’t also underlying physiological differences in the way the sexes experience pain. Myers, for example, found that sex still
Myers, C.D., Robinson, M.E., Riley, J.L. III & Sheffield, D. (2001). Sex, gender and blood pressure: Contributions to experimental pain report. Psychosomatic medicine, 63, 545–550. Nayak, S., Shiflett, S.C., Eshun, S. & Levin, F.M. (2000). Culture and gender effects in pain beliefs and the prediction of pain tolerance. Cross Cultural Research, 34, 135–151. Komiyama, O., Kawara, M. & De Laat, A.
Extremes of pain According to the Chronic Pain Policy Coalition over seven million people in the UK are affected by chronic pain and it’s the second most common complaint cited by claimants for incapacity benefit (www.paincoalition.org.uk). Chronic pain can be associated with illnesses such as cancer or arthritis. However at other times, as in the chronic pain syndrome of fibromyalgia, the cause is unclear. Fibromyalgia, which is 10 times more common in women than in men, is typically associated with all-over body pain, increased pain sensitivity and also tenderness on specific parts of the body. At the other extreme, people with chronic indifference to pain (CIP) lead lives with no experience of pain whatever (Stieg Larsson fans might recall that the unstoppable blond hulk Ronald Niedermann had this diagnosis). CIP may sound like a blessing but the tribulations of those with the condition – undetected bumps, bruises, burns and shortened lifespans – are a reminder of how pain in moderation can serve a useful role. In some cases CIP has been traced to a mutation in a single gene that codes for a protein involved in the sodium channel of nerve endings. A different mutation of the same gene is associated with an opposite condition whereby patients experience even mild touch as excruciatingly painful. Another form of extreme pain experience is so-called pain synaesthesia. People with this condition have an exaggerated empathy for the sight of other people’s pain. Few cases have been documented so far, but the condition seems to manifest in a person after they themselves have suffered a traumatic pain experience. In a review published in 2010 Bernadette Fitzgibbon cites the case of a man (now deceased) with hyperalgesia, who experienced physical pain whenever his wife hurt herself. If she knocked her finger, he would grasp his own finger in excruciating pain. Fitzgibbon also describes phantom limb pain triggered in amputees (most of whom had lost their limb in traumatic circumstances) by the sight of other people’s painful experiences or even merely by stories about those experiences.
predicted pain tolerance even after the influence of gender identity was taken into account. There’s no shortage of potential biological mechanisms that could underlie women’s greater sensitivity to pain than men. These include hormonal effects – for example, women’s response to pain varies across the menstrual cycle, during and after pregnancy, and with the
(2007). Ethnic differences regarding tactile and pain thresholds in the trigeminal region. The Journal of Pain, 8, 363–369. Paulson, P.E., Minoshima, S., Morrow, T.J. & Casey, K.L. (1998). Gender differences in pain perception and patterns of cerebral activation during noxious heat stimulation in humans. Pain, 76, 223–229. Paine, P., Kishor, J., Worthen, S.F. et al.
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intake of hormone replacement therapy or the contraceptive pill. Hormones are likely to exert their effects via the inflammatory response, but these pathways are still being worked out. There’s also evidence that the body’s natural pain killer system – the ‘endogenous opioids’ – works differently in women compared with men. For example, in a 2002 study, Jon-Kar Zubieta
(2009). Exploring relationships for visceral and somatic pain with autonomic control and personality. Pain, 144, 236–244. Palmer, B., Macfarlane, G., Afzal, C. et al. (2007). Acculturation and the prevalence of pain amongst South Asian minority ethnic groups in the UK. Rheumatology, 46, 1009–1014. Pud, D., Yarnitsky, D., Sprecher, E. et al. (2006). Can personality traits and
gender predict the response to morphine. An experimental cold pain study. European Journal of Pain, 10, 103–112. Rahim-Williams, F.B., Riley, J.L. III, Herrera, D. et al. (2007). Ethnic identity predicts experimental pain sensitivity in African Americans and Hispanics, 129, 177–184. Sargent, C. (1984). Between death and shame: Dimensions of pain in Bariba
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and colleagues used PET and a deep-tissue pain stimulation and found less μ-opioid system activation in the brains of female compared with male participants. Men and women respond differently to pain treatments too, with women generally showing more of a response to opioid-based analgesics, although this research is patchy. There are also cognitive factors that could explain gender differences in pain response. One of these concerns ‘catastrophising’ – that is perceiving a pain as particularly threatening and believing that it is too severe to cope with. Typical items used to measure this factor include: ‘it is terrible and I feel it is never going to get any better’ and ‘it is awful and I feel it overwhelms me’. Several studies have shown that women tend to catastrophise about pain more than men. In 2000, for example, when Francis Keefe at the Duke University Medical Centre and his team studied 168 patients with osteoarthritis of the knees, they found that the female patients reported more pain but that this gender difference disappeared once levels of catastrophising were taken into account.
Ethnicity Alongside gender, substantial evidence has also accumulated suggesting an association between pain experience and ethnicity. Generally, white Caucasian people are found to be less sensitive to, and more tolerant of, pain than individuals of African or Asian descent. Claudia Campbell and colleagues in association with Fillingim’s Lab at the University of Florida, for example,
culture. Social Science and Medicine, 19, 1299–1304. Schmahl, C., Bohus, M., Esposito, F. et al. (2006). Neural correlates of antinociception in borderline personality disorder. Archives of General Psychiatry, 63, 659–667. Schmahl, C., Greffrath, W., Baumgaertner, U. et al. (2004). Differential nociceptive deficit in patients with borderline personality disorder and self-injurious
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reported in 2005 that 62 African American participants were on average less tolerant of heat pain, cold pressor pain and ischaemic pain than white participants. Another study by the same research team found that African American participants exhibited the nociceptive flexion reflex – an automatic withdrawal movement – to an electrical pain stimulus at a lower intensity than did white participants. This paradigm has the advantage of not requiring participants to report the pain they’re experiencing, so bypassing some of the socio-cultural confounds that that entails. Although most studies in this field have compared African Americans and white Americans, there are some exceptions. Osamu Komiyama’s team at the Nihon University School of Dentistry at Matsudo, for example, compared white Caucasian Belgian and Japanese participants, finding that the latter were more sensitive to needle-like stimuli
behaviour. Pain, 110, 470–479. Vossen, H.G., van Os, J. & Lousberg, R. (2006). Evidence that trait-anxiety and trait-depression differentially moderate cortical processing of pain. Clinical Journal of Pain, 22, 725–729. Zubieta, J-K., Smith, Y.R., Bueller, J.A. et al. (2002). µ-Opioid receptor-mediated antinociceptive responses differ in men and women. The Journal of Neuroscience, 22, 5100–5107.
applied to their cheek, gums or tongue. Intriguingly, this same study also found that, despite their increased sensitivity, the Japanese participants gave the same stimuli lower pain ratings. The researchers said this likely reflects the ‘Japanese cultural emphasis on stoicism and the desirability of concealing pain and emotions’ (see ‘Cultural differences’). Besides the role played by cultural influences, several physiological and psychological mechanisms underlying ethnic differences have also been identified. One of these is the endogenous pain control mechanism called ‘diffuse noxious inhibitory controls’. This is the physiological reality behind the folk belief that one way to alleviate an ache is to induce pain somewhere else in the body. Another study by Claudia Campbell and colleagues in 2008 investigated this in relation to an ischaemic pain, induced via a tightened arm tourniquet, and a painful electric zap to the leg. In the wake of the arm pain, white participants showed greater reductions in sensitivity to the electric stimulation to their leg than did African American participants. As regards psychosocial factors, a team led by F. Bridgett Rahim-Williams in Roger Fillingim’s lab found that pain sensitivity was greater among African Americans and Hispanics who expressed more identification with their ethnic group – for example, they agreed with statements like ‘I’ve spent time trying to find out more about the history and traditions of my ethnic group’. Consistent with this, Ben Palmer and colleagues at Manchester University Medical School and the University of Aberdeen found that reports of all-over body pain were four times higher, on average, among a sample of South Asian participants in the UK compared with white Europeans, and crucially, that such reports were negatively correlated with participants’ degree of assimilation into British culture. One possible explanation for these effects of ethnic identification and assimilation is that ethnic differences in pain experience are largely cultural and so people who identify more with their ethnic group are more likely to be susceptible to these cultural influences. Again it’s important to remember that cultural influences are also likely to have neurobiological correlates, as a person’s
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Cultural differences includes items such as ‘Men (or women) should be able to tolerate pain in most circumstances’ or ‘It is acceptable for men (or women) to cry when in pain’. Using this questionnaire in a 2005 study, Mieko Hobara at the New York State Psychiatric Institute found that 32 These lines come from a Bariba proverb quoted in a 1984 article by Japanese men and women consistently rated it as less appropriate the anthropologist Carolyn Sargent, now at Washington University in for people of either gender to express pain compared with 32 EuroSt Louis. The Bariba are an ethnic group located in Benin and Nigeria American men and women. Using in West Africa and whenever Sargent the same scale in a 2000 study, attempted to talk to them about pain, she Sangeetha Nayak and colleagues found that they turned the discussion to found that college students in India issues of honour and shame, many of them similarly rated expressions of pain citing the proverb above. The Bariba, at as less acceptable than their least at the time of Sargent’s study, believed counterparts in the USA. In line with that expressions of pain were a shameful their beliefs, the Indian participants sign of weakness. Boys were circumcised in also showed greater pain tolerance groups and taught not to show a flicker of than the US sample. pain (girls too were circumcised but were Other researchers have examined allowed to cry). Women were expected to differences between cultures in their deliver their own babies and any outward linguistic terms for pain. Anthony signs of pain were considered taboo. Do Diller writing in 1980 noted that these behavioural mores have any influence some languages have one general on pain perception? Bariba women told term for pain which is then tailored Sargent that there was pain in labour but with modifiers – for example, sharp there was no point in crying – if you’re going pain or stinging pain – whereas other to die it won’t help, they said. Recalling her languages, such as Thai, have clitoridectomy as child (a practice that has several different words that refer since been outlawed) another woman told directly to different types of pain. He Sargent that no pain is as excruciating and The Bariba believed that expressions of pain were a also notes that the Khamti language that after that experience no pain will ever shameful sign of weakness (Sargent, 1984) of Assam in India has four different overwhelm a person. words for itchy and that the Japanese have different terms for pain Several psychologists investigating cross-cultural attitudes to pain have used the ‘Appropriate Pain Behaviour Questionnaire’, which depending on the status of the sufferer. ‘between death and shame, death has the greater beauty’
beliefs and upbringing can affect the way their body responds to pain. ‘My simplistic assumption is that the only way culture can influence pain is via some psychological mechanism, because for me that’s the conduit through which it’s manifested in the individual,’ says Fillingim. ‘So if I grow up in a culture that believes pain is noble and a sign of a higher power, that would alter my beliefs about pain, would alter my cognitive appraisals of pain and then those beliefs and appraisals would influence my behavioural, biological and physiological responses related to pain.’
Personality Another major factor that’s associated with the way a person experiences pain is personality. Although research in this area is hampered by the use of varied personality measures, a consistent finding is that people who score higher on neuroticism or a neuroticism-like factor tend to show greater sensitivity to pain and reduced tolerance. Helen Vossen at
Maastricht University in a 2006 paper showed this sensitivity is also reflected in an exaggerated cortical response to pain as measured by EEG in an electrical pain paradigm. Aspects of personality also seem to predict the way a person responds to pain relief. Dorit Pud of the Pain Relief Unit at the Rambam Medical Centre in Israel found that men and women who scored more highly on ‘harm avoidance’ (a trait resembling ‘neuroticism’ that’s derived from Robert Cloninger’s Tridimensional Personality Questionnaire) showed a larger response to morphine in terms of their subsequent performance on the cold pressor task. Personality isn’t only related to acute pain sensitivity and tolerance, it’s also predictive of chronic pain conditions in later life, and people diagnosed with a chronic pain condition tend to exhibit a characteristic personality profile. For instance, Katherine Applegate and colleagues at Duke University Medical Centre caught up with over 2000 university students after a 30-year gap and found that those who’d scored highly
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in their youth on the Minnesota Multiphasic Personality Inventory measures of ‘femininity’ (male participants only), ‘paranoia’ (female participants only), ‘hypochondriasis’, or ‘hysteria’ also tended to be more likely to have a chronic pain condition in middle age. As for the typical character profile of a chronic pain patient, Rupert Conrad at the University of Bonn in a 2007 paper compared 207 patients with 105 pain-free controls, finding that the patients scored higher on ‘harm avoidance’ and lower on ‘self-directedness’ (a mix of the Big Five factors of Conscientiousness and Extraversion) and ‘cooperativeness’ (akin to the Big Five factor of Agreeableness). The patients also tended to score higher on depression and state anxiety, with 41 per cent meeting the psychiatric criteria for a personality disorder (PD) – most frequently paranoid or borderline PD. It’s obviously sensible to take rest, relax and take precautions after a painful injury. However, Conrad says a person who scores high in harm avoidance will
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continue to behave in this way even after their injury has healed. He adds that a related personality factor associated with chronic pain is low self-efficacy: ‘That means a feeling of helplessness and a conviction of not being capable of controlling a situation or being able to overcome obstacles associated with chronic pain.’ ‘As a consequence,’ he explains, ‘chronic pain treatment should aim at psychological mechanisms enhancing self-efficacy and lessen avoidance (e.g. cognitive behavioural therapy) and at pharmacologic agents improving supraspinal modulation of pain. It is important to note that psychotherapeutic and pharmacologic approaches should be seen as complementary treatments.’ Somewhat paradoxically, whilst the prevalence of borderline PD is elevated among patients diagnosed with a chronic pain condition, the same diagnosis is also associated with reduced pain sensitivity on laboratory measures. In one representative study published in 2004, Christian Schmahl at Johannes Gutenberg-University used an infrared laser as the painful stimulus and found 10 women diagnosed with borderline PD to have higher heat pain thresholds and lower subject pain ratings than 14 non-clinical controls. In 2006 the same researcher and his team linked this reduced pain sensitivity to reduced painrelated activation in the anterior cingulate gyrus and amygdala of patients with borderline PD compared with controls. Recently attention has turned to identifying the physiological mechanisms, not merely the neural correlates, that might account for the link between personality and pain perception. Two years ago, in an unpleasant-sounding experimental paradigm, Peter Paine and colleagues at Hope Hospital in Manchester identified a link between personality, pain and autonomic nervous system activity. They used a balloon inflated in the oesophagus to simulate visceral pain and found that this triggered an increase in parasympathetic nervous system activity, as identified through heart-rate variability, in participants who scored more highly in neuroticism, whereas repetitions of the same stimulus in those lower in neuroticism led to reduced
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parasympathetic activity. One possible explanation is that increased parasympathetic nervous system activity corresponds to a ‘freeze’ response in the participants higher in neuroticism, although how this relates to pain experience remains to be worked out. Conrad says there’s evidence that the personality factors underlying chronic pain may be associated with decreased activation of the prefrontal cortex – a key brain region involved in the top-down modulation of pain. ‘This neuroanatomical structure can be activated by a cognitive anticipation of the potential controllability of pain,’ he says. ‘A personality-based conviction of uncontrollability and helplessness and an avoidance of pain makes activation of these neuroanatomical structures less likely and hampers topdown modulation of pain.’
Applications and controversies We’ve seen how factors like ethnicity and personality are related to people’s experience of pain, a key challenge now is to use this information to improve people’s quality of life. ‘The goal ultimately,’ says Fillingim ‘is to gather all the information we have about an individual – their age, weight, race, sex, genotype data, psychology questionnaire results – put all that into a computer and based on an abundance of evidence that we already have, the computer will tell us, for example, what drug is going to work best for that person.’ And even more helpful, Fillingim says, is that same information might help predict who’s at risk for developing chronic pain. For example, if it’s judged that a patient has a high chance of developing a chronic pain condition after surgery, it might be better to pursue alternative treatment options where they exist. ‘So, it’s not just picking the right drug or dose,’ Fillingim says, ‘it’s really understanding the risk for the development of chronic pain because chronic pain is what we really have trouble helping people with.’
Conrad agrees, adding: ‘Future studies addressing the issue of chronic pain have to give an even deeper insight into the complex interplay of personality factors, psychological mechanisms and the associated neurobiological mechanisms. The identification of a risk factor such as low self-efficacy by personality questionnaires – for example, temperament and character inventory – may lead to an earlier identification of populations at risk and may lead to an earlier treatment, which may positively affect outcome.’ How long until these kind of benefits might be seen? ‘I’m sure we’ll get there one day,’ Fillingim says, ‘but I’m not sure how far away that is. The more we get into these individual differences, be it genetic, gender, ethnic group or whatever, the more complicated everything looks!’ A particularly compelling justification for continuing to study individual differences in pain experience comes from as yet unpublished research looking at genetic influences on pain perception. Fillingim and his colleagues have identified a marker for a particular gene that’s associated with increased pain sensitivity in one ethnic group but reduced pain sensitivity in another. This means that if biomedical researchers ignore factors like ethnicity and gender, they risk forming conclusions about genetic influences that are too general. ‘This just shows that we’ve got a lot of work to do,’ says Fillingim, ‘but hopefully it will be useful in the long run.’ Inevitably perhaps, this field has attracted criticism from those who fear the findings will be used to bolster stereotypes. Fillingim and others in the field are sensitive to these concerns and don’t want their results to be used in that way. ‘To me the broader concern is with health disparities such that ethnic groups experience poorer health than white people do – that’s obviously driven by many factors including socio-economic status but what we’re finding may imply that there are individual characteristics of people from different ethnic groups making them more or less prone to experiencing pain or disability associated with pain, and unless we understand what’s driving these differences, we’re not going to be able to remove the health disparities even if we fix all the systemlevel problems. So I think the benefits of this kind of research far outweigh the concerns that people have.’ I Dr Christian Jarrett is The Psychologist’s staff journalist. chrber@bps.org.uk
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INTERVIEW
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An insight into ‘nudge’ Christian Jarrett fires some questions at David Halpern, a psychologist working in the corridors of power as Director of Research at the Institute for Government
ow did you find your experience H as a psychology undergrad, and how did you go from there to working at the heart of government? I did experimental psychology at Cambridge. Like many others I went to do physics, etc. as part of the Natural Sciences tripos, but I’d always read psych textbooks just for interest – who could not be fascinated by those fantastic social psych experiments of the 50s, 60s and 70s? Fantastic to find I could study it seriously. After a year I went back and did a PhD in social psychology at the (then) Faculty of Social and Political Sciences as a benefactors’ scholar at St John’s. The route to government was not direct. I was always interested in applying academic approaches to policy. I did a couple of years as a researcher at the Policy Studies Institute (London), then took up a Prize Research Fellowship at Nuffield Oxford, encouraged by the economic historian Avner Offer. While there I hooked up with a few other fellows and we wrote an edited volume called Options for Britain (1996), which looked across the full range of policy issues and drew on a range of academic disciplines. A few years later, I ended up working for Tony Blair and one of my coauthors – Stewart (now Lord) Wood – ended up working for Gordon Brown. Today, would you describe yourself as a psychologist who works in government, or a civil servant with a background in psychology? Both, I guess, but if I had to choose I’d go for the former – partly because that’s how others see me. A recurring ambition reflected in the various roles you’ve filled and books you’ve written is to improve people’s well-being and quality of life. What drives this ambition? What is your moral philosophy, and who is your inspiration? I’m quite an empirically minded person. Governments – indeed firms,
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communities, parents – implicitly or explicitly make claims that what they are doing is to increase well-being, or utility. We might as well try and figure this out a bit more systematically, if it’s what we’re all claiming to do – especially since it turns out that quite often our intuitions about what makes us or others happy are wrong.
was important, the highest income areas were not necessarily the ones with the highest satisfaction levels – other factors such as length of commuting and the strength of community made a big difference too. In short, as most people sense, lots of factors go into explaining variations in well-being, but many of them get insufficient attention both in policy and in the choices we sometimes make in our own lives. Moving on to your current post as head of the Behavioural Insight Team (BIT), do you regret or resent how closely this unit has come to be associated with the book Nudge, given that your remit is clearly much broader than this? Nudge has made many of these ideas much more accessible, and Cass Sunstein (now my opposite number in Washington) and Richard Thaler (who also advises our team) are both formidable thinkers. But yes, there are lots of other books and research out there even within the relatively narrow area of behavioural economics and ‘insight’, from other accessible works, such as Cialdini’s to Dan Ariely’s to more technical works such as that of Danny Kahneman and George Loewenstein. And in policy, you always have to consider the full range of policy levers and options.
In your book, the Hidden Wealth of Nations, you argue that we should aim to be more like the Danes, who place higher value on love, freedom and solidarity, and less on work and money, making them happier in the process. But is this really the role of government, to shape the culture and values of its citizens? For the most part, it’s really for citizens – The work of the BIT is also being for all of us – to make these kinds of closely identified with the present choices. But there are a couple of things government’s economic agenda. As the that governments – and the academic cuts bite, do you worry community – can there is a danger that the legitimately do to BIT’s approach could end help people make “quite often our intuitions up tarred with the same these choices. about what makes us or brush in the eyes of a First, we can give others happy are wrong” disgruntled public? people more It is a tough time, fiscally information about speaking. But it’s worth the consequences remembering that the original of their choices for themselves and others. MINDSPACE report was actually In my view, this will be one of the most commissioned by the previous fascinating and important consequences government. Like it or loathe it, policy of the measurement programme led by the is substantially about behaviour – from National Statistician – the four well-being what we choose to eat or how much we questions have gone into the field, with smoke, to how much energy we use or early cuts of the data available perhaps how we treat others. Economic growth as early as the end of the year. It’s not the is also affected by our behaviour, from headline numbers that will be really whether we trust others around us; how interesting, but the variations across areas much we save; or whether we share our and population segments, as well as the experiences about the products and analysis of covariants that will be possible. services we buy. The sample size will be around 200,000 a year, with representative sample sizes I heard Oliver Letwin – Minister of down to local area level. State at the Cabinet Office – claim that You can get a glimpse of how people he established the BIT. Steve Hilton, might use the data from the work of John Cameron’s strategy adviser, is also Helliwell in Canada. He used their data to known to hold social psychology in compare variations in life satisfaction high regard. Just how deeply does the across Canadian provinces. While income
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belief in behavioural science run in this government? Well, it’s true that this administration has embraced and engaged with the behavioural insight agenda far more seriously than its predecessors. One reason for this is clearly because the administration is less keen on regulatory and legislative solutions – such as bans (from both sides of the coalition) – and it doesn’t have the cash to throw at problems, even if it wanted to. So it fits with the wider context to have a hard look at policy tools that work with the grain of people’s own behaviour and habits, supporting citizens’ own power and ability to make choices for themselves. But it’s a growing interest that is not limited to the UK. The French are very interested in the approach, as is Barosso in Brussels.
Psychological Society, with whom we have already met. We are also creating a more formal academic panel to meet with on a regular basis to challenge and inform what we and other parts of Whitehall are doing. Robert Cialdini has argued that these days there are too few field experiments in social psychology. In a similar vein, you and your colleagues have written about the need for ‘evidence-based innovation’ – a rolling-out of experimental ideas. Can you explain this concept?
Have you had any successes so far using psychological principles to improve the efficiency and effectiveness of the government’s own working practices? Yes. They have been used around the government’s attempt to reduce its energy use by 10 per cent – a coalition agreement pledge – with final results due shortly. Similarly, HMRC have been using these approaches to improve how they operate. We’ve also been running a series of seminars, each sponsored and chaired by a Permanent Secretary – the civil servant in change of a department – for senior civil servants across Whitehall to increase familiarity with these approaches, both in relation to policy and in the transformation of Whitehall itself. Your MINDSPACE report argues that senior policy makers need to have a greater awareness of psychology. Do you think the psychology community is doing enough to disseminate its science? Our programmes with the Senior Civil Service (SCS), and the high-profile backing that our work receives in Whitehall – not least from the personal interest and support from the Cabinet Secretary and the rest of our steering board – has started to increase awareness. But it is striking how most of the studies that people quote are from the US, and often channelled via economists rather than psychologists. We are planning to circulate a digest of interesting new studies and results – or older less well-known but relevant work – on a regular basis, and would welcome suggestions and material from the British
We need to strengthen the conveyor belt of evidence-based ‘punts’ about what will work, but – given the genuine uncertainty about what will work in the field – we have to try out policy innovations in ways that can be robustly evaluated, and of course then go to evaluate them. The design of buildings and layout of our cities have a powerful influence on the way we behave, something you mention in MINDSPACE. And yet psychology, architecture and planning often seem not to talk to one another. Could you comment on this, especially in light of the renowned architect
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Richard Rogers’ recent claims that the disbandment of CABE – the Commission for Architecture and the Built Environment – is likely to see the quality of building design and town planning suffer? As it happens, this is an area I’ve long had an interest in, and have published in [Mental Health and the Built Environment, 1995]. For whatever reason, architecture and planning does not have an empirical, evidence-based tradition in the sense that psychologists or the social (or physical) sciences would understand. There are very few studies that ever go back to look at whether one type of dwelling or another, or one type of office or another, has a systematic impact on how people behave, or feel, or interact with one another. To be honest, though CABE were interested in this area, it itself did not generate this type of systematic evidence either – it remains a fair challenge to the academic and practitioner communities. Related to this, your report recommends the creation of a new Institutional Centre for evaluating behaviour change, and it describes the idea of a ‘Dragon’s Den’ for innovative behaviour ideas. What form do you imagine the Centre and the Den taking – are these roles that the BPS could help fulfil? In the short term, we are working to bring in academic expertise through how we work and how we are seeking to actively involve and consult the academic community. In the medium- to long-term, there is a case for fostering the capacity of institutions independent of government to strengthen the evidence base and ensure that public service commissioners have to hand a clear sense of what works, what doesn’t and what looks promising but is yet unproven. Your MINDSPACE report acknowledges the importance of unintended consequences in government policy. Could that happen with your own work? That is to say, as awareness of nudge principles increases – i.e. the recognition that we have not only a reflective, deliberate self, but also a more easily swayed automatic self – is there a risk that people will develop
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new strategies/habits for resisting nudges? Wouldn’t it be a good thing if people were more aware of how they are influenced, of the short-cuts in our heads that sometimes get them into trouble? After all, most of the nudges in the world aren’t from government, but from businesses, from other people, or sometimes just in the environment around us. But on your main point, the avoidance of unintended consequences is one of the many reasons why an important part of policy making is trialling and evaluation. Do you worry that the tobacco industry and other commercial interests will concurrently exploit the exact same principles that you are advising the government to target, but perhaps with less moral restraint? Often the role of government may be not to introduce new nudges, but to help reduce some that are already out there. The decision to cover-up cigarette displays is a recent example.
local governments are to use these approaches, they need to ensure that they have public permission to do so – i.e. that the nudge is transparent, and that there has been appropriate debate about it. For example, the previous government got into trouble over pushing
Organ donation. The gift of life. Information about the NHS Organ Donor Register.
reading
Critics of the BIT, such as Claire Fox (Institute of Ideas) and sociologist Frank Furedi, claim that your agenda suggests policy How does government ensure it has public makers have given up on debate and argument and opted instead for permission to increase organ donation? covert manipulation – ‘playing mind games with the public,’ to quote Fox. for a shift to presumed consent for organ How would you defend your team’s donation – key pressure groups and to work against such charges? some extent the public felt uncomfortable Using behavioural insights doesn’t mean about the approach. In contrast, there not using any other policy tools. As appears to be much more acceptability for Oliver Letwin has pointed out, no one what is called ‘prompted choice’ – having is proposing removing the law against a question that people have to answer murder and replacing it with a nudge. about whether they wish to be an organ And big arguments continue about what donor or not on a driving licence. In fact, prompted choice for organ donation was government should spend more or less proposed earlier this year, and is due to on, who should pay for it, and so on. But start in experimental form on the DVLA there is a subtler argument that I think is website from the summer. important, which is that if national or Gigerenzer, G. (2003). Reckoning with risk: Learning to live with uncertainty. London: Penguin. Halpern, D. (2010). The hidden wealth of nations. Cambridge: Polity Press. Thaler, R.H. & Sunstein, C.R. (2009). Nudge: Improving decisions about health, wealth and happiness. London: Penguin. Nudge blog: http://nudges.org MINDSPACE report: tinyurl.com/ylkuh8s Giving Green Paper: tinyurl.com/3xdpr38
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Do you think you’ll ever be able to convince your critics? One can never convince everyone – now that would be scary! But its worth noting that our environment is full of nudges that, for the most part, make our lives safer, easier and more comfortable. Most people don’t feel that it’s a deep infringement on their rights that we have rumble bars on motorways – but we’re pretty glad someone put them there if we lose our focus or fall asleep at 70 miles an hour. Of course, if you’re really determined to crash your car into the
central reservation, the rumble bar won’t stop you. It’s difficult to see why we should not, as a matter of principle, have the rumble bar. Other critics of the nudge approach such as Gerd Gigerenzer have suggested it would be better to raise the public’s level of understanding of risk perception and probabilities, so that they are able to make better decisions for themselves. Are you sympathetic to this idea? There’s a strong case for raising public understanding of risk perception and probabilities, such as around financial education or just ensuring that people are more aware of the kind of shortcuts and errors they are prone to, especially when in a hurry or a hot state. Another approach is to use intermediaries, such as consumer organisations or sites that collate the experiences of others as decision aids. But it’s not a case of using just one or the other. On a more personal note, are there any aspects of your own behaviour that you’d like to change, but haven’t succeeded in doing so? Being late. Finally, do you have a message for the psychological community? Is there anything more that the BIT needs or wants from us? We’re always delighted to be sent policyrelevant insights or interesting new results. There’s also an important role for the wider academic community to test and evaluate the many policy interventions that are being tried across local areas and different policy domains. There’s particular interest right now especially around growth and consumer empowerment, health, green behaviours and crime. It’s very difficult for anyone to be sure exactly how a lab-based insight will translate into the real world, particularly when there are normally many different effects in play in any given situation. There are other factors that inevitably go into any given policy decision apart from behavioural science, including practicality, public acceptability and the political instincts of the parties in power. But I hope that the psychological community will welcome that the government is seeking to use its expertise. We have had quite a bit of support from this community so far, and look forward to drawing on that expertise still further in the year ahead.
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