The Psychologist July 2013

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psychologist vol 26 no 7

july 2013

Working as an expert witness We meet Gisli Gudjonsson and others in the legal system

Incorporating Psychologist Appointments ÂŁ5 or free to members of The British Psychological Society

letters 466 news 478 looking back 496 careers 522

psychology in the operating theatre 498 HIV in the UK 504 big picture: what is uniquely human? centre digital piracy and the moral compass 538

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letters 466 diagnosis debate – attack or thoughtful critique?; from silence to a public voice; retired psychologists; self-dosing and the e-cigarette; NLP; and more news and digest avatar therapy; MyConnectome; charitable giving; new Little Albert theory; registered reports; a review of a one-day conference on scientific research with psychedelic drugs; and the latest nuggets from the Society’s free Research Digest service

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Expert witness work – time to step up to the plate David Crighton introduces a special feature Interview: A thirst to learn the truth Jon Sutton talks to Gisli Gudjonsson CBE Day in the life: Working as an expert witness We hear from four psychologists about their interactions with the legal system Looking back: Psychologists in the witness box Graham Davies and Gisli Gudjonsson

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Psychology in the operating theatre Michael Wang, Catherine Deeprose, Jackie Andrade and Ian F. Russell ask what anaesthesia can tell us about consciousness, learning and memory

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HIV in the UK Poul Rohleder, Tomás Campbell, Audrey Matthews and Jenny Petrak consider the ongoing challenges

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society 510 ten things you didn’t know about new Society President Richard Mallows; welfare fund; Psychologist bath; Psychology4Graduates; and more careers and appointments

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we meet Ciarán O’Keeffe, ‘the parapsychologist’, and two counselling psychologists working with children, young people and families

july 2013

THE ISSUE This is my first contribution to The Psychologist, but as incoming Society President I will have the opportunity through the President’s columns for a few more. My personal vision for the British Psychological Society is to securely position the Society as the learned Society for psychology and to be more outward looking in the world.

The Society is busy working on its next strategic plan and this is the chance for all members to contribute.

I have long been a fan of The Psychologist because you never know when an item will catch your imagination, be professionally supportive or inspirational for teaching. I have often followed up items in The Psychologist directly with the authors, most recently over the ‘Scottish Referendum Question’.

A few years ago I responded to an article about ‘altruism’ as I contemplated retirement and involvement with the BPS. This issue of The Psychologist contains a special feature on expert witness work following in the tradition of The Psychologist being unafraid of challenging issues.

Dr Richard Mallows Society President 2013/14

reviews 530 Chelsea Flower Show; Man of Steel; TED talks; The Human Swarm; secular Sunday service; reader recommends; and more in our broader ‘Reviews’ section new voices 538 digital piracy and the moral compass: Steven Brown with the latest in our series for budding writers (see www.bps.org.uk/newvoices) one on one

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…with Jacqueline Akhurst

read discuss contribute at www.thepsychologist.org.uk

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LETTERS

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Distortions and maps of wonderland

contribute

Given the importance they attach to evidence, it is surprising that Essi Viding and Uta Frith (Letters, June) should use the words ‘attacking the DSM-5’, implying both aggression and lack of justification, for what is in fact a thoughtful, evidencebased statement by the Division of Clinical Psychology (DCP) on psychiatric classification.

In criticising the statement and subsequent ‘pronouncements in the media’, Viding and Frith present the current situation in mental health as one led by evidence, in which researchers and clinicians take due account of both environmental and biological factors in understanding ‘the symptoms that mark mental illness’. This is far from the case.

For the last 30 or 40 years, research and practice in this area has been dominated by approaches which privilege genes and biology, depict emotional and behavioural problems as akin to physical illnesses, and systematically de-emphasise the potential causal role of people’s social and personal contexts. This is in spite of a poor evidence base for all three of these

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stances. This situation itself has a social context, which may help explain both its persistence and the strength of feeling often evoked by attempts at change (Boyle, 2011; Cromby et al., 2013; Pilgrim, 2007).

And contrary to Viding and Frith’s claims, the DCP argument is not based on a ‘false dichotomy between genes and environment’. It does position itself for a reconceptualisation of the role of biology and against a model that sees mental, emotional and behavioural difficulties as symptomatic of biologically based illness.

It also argues for due acknowledgement of the vast amount of evidence that many of these difficulties are meaningful responses to often extremely challenging life circumstances.

Finally, Viding and Frith imply that those who claim a causal link between child abuse and

Professors Viding and Frith (Letters, June 2013) excoriate critics of DSM-5 who, they say, ‘are in danger of muddying mental health issues by ignoring… biology’. They write approvingly of Simon Wessely’s Observer article (12 May 2013) and endorse his claim that ‘a classification system is like a map. And just as any map is provisional, ready to be changed as the landscape changes, so is classification.’

Let me outline how history illustrates the value of this metaphor of mapping the mind.

In 1952, when the first Definitely Scientific Map (let’s call it ‘DSM-1’) was published, only 106 cartographic entities were in the atlas. A good index of the success of the cartographers of the mind is the phenomenal productivity of their subsequent explorations – new islands, continents, rivers, mountain ranges, swamps, and so on, were added, and although many old ones were thrown out they achieved an average rate of increase over the next 42 years of close to one every eight weeks: DSMap-4 (1994) showed 365 entities.

These pages are central to The Psychologist’s role as a forum for discussion and debate, and we welcome your contributions.

Send e-mails marked ‘Letter for publication’ to psychologist@bps.org.uk; or write to the Leicester office.

‘schizophrenia’ are ‘not slowed down by a need for an evidence base, but instead irresponsibly make unsubstantiated and alarmist pronouncements’. This is completely unjustified. There is good evidence, some of it cited in the DCP statement, that the links between child abuse and psychosis are likely to be causal, and such claims are not made lightly. This evidence may be difficult for many to hear and unfortunately, Viding and Frith’s ad hominem response, rather than one engaging with the evidence, is not untypical.

I hope the DCP statement will encourage truly informed debate on these issues to the benefit of researchers,

How had they achieved this fecundity? Untiring effort was the answer. Year in, year out their exploration vessels sailed the seven (7.34 ± 1.56) seas, proudly flying the Cartographers’ flag, a banner inscribed ‘BP’. (Crew members gave different answers when asked what the letters stood for: ‘Big Pharma’, said some,

Letters over 500 words are less likely to be published. The editor reserves the right to edit or publish extracts from letters. Letters to the editor are not normally acknowledged, and space does

‘Big-time Psychiatry,’ said others, but the groups worked together as one big happy family regardless).

It was not always smooth sailing. For example, when explorers sent descriptions of the landscape to the head office of the Cartographers of the Mind Association (CoMA) for official rulings, one might

not permit the publication of every letter received.

However, see www.thepsychologist.org.uk to contribute to our discussion forum (members only).

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clinicians and, above all, service users themselves.

Professor Mary Boyle University of East London References Boyle, M. (2011). Making the world go away, and how psychology and psychiatry benefit. In Rapley, M., Moncrieff, J. & Dillon, J. (Eds.) De-medicalising misery. London: Palgrave Macmillan.

Cromby, J., Harper, D. & Reavey, P. (2013). Psychology, mental health and distress. London: Palgrave Macmillan.

Pilgrim, D. (2007). The survival of psychiatric diagnosis.

Social Science & Medicine, 65, 536–547.

We welcome contributions to the debate that has been raised by the DCP Position Statement on Classification, which can be read in full at http://dcp.bps.org.uk/dcp/ the_dcp/news/dcp-position-statement-onclassification.cfm The statement is not about DSM specifically but about conceptual systems ‘based on a “disease” model’. This would include ICD. Nor do we see it as an ‘attack’ but as a thoughtful critique based on a two-year process of reviewing the evidence and consulting within all the DCP Faculties, where it has widespread support.

It is difficult to convey a complex

be told that a tenant was on Mount Skitzos while a second tenant in the same building was on the Isle of Catatonia, a third on Lake Normalia.

But none of this impeded the enlightened help BP could provide to the inhabitants – the holds of the vessels of exploration were brimming with curative chemicals that were equally effective everywhere on the Map. There were of course sceptics, people who thought, for example, that it might be more effective to build warm buildings in (bi?) polar regions instead of filling inhabitants with chemicals that made them complain less about the cold. As a gesture of goodwill (and to try to rid themselves of the distractions of repetitive complaints), exploration vessels started to carry small amounts of

argument through the media. We regret that some of the reporting has badged this as a psychiatry versus psychology battle.

We have been working hard to counter this. The statement itself makes it absolutely clear that, to quote: ‘This position should not be read as a denial of the role of biology in mediating and enabling all forms of human experience, behaviour and distress… It recognises the complexity of the relationship between social, psychological and biological factors’ (p.2).

We are unhappy with responses that, quite wrongly, represent us as presenting ‘a false dichotomy between genes and environment’ and hope that all members of the Society will take the opportunity to correct such misinterpretations.

Nevertheless, our position, supported by a great deal of evidence, is that it is neither accurate nor helpful to conceptualise the experiences that may lead to a functional psychiatric diagnosis within a ‘disease’ model, in which biological causal factors such as genes or biochemistry are hypothesised to be the primary causal ones. We do not do this for other responses to life events – for example, bereavement – and by analogy, our argument is that the increasing amount of evidence for the causal role of all kinds

building material, pumps to drain swamps, and so on.

CoMA itself even professed to subscribe to a Bio-PsychoSocial model of disorder: their banners accordingly now read ‘BPS’ not ‘BP’. (This new image has perhaps brought to light a little-researched version of the Stockholm syndrome, with scientists who are not members of the BP team taking up cudgels on the team’s behalf).

Sceptics even argued that the metaphor itself is flawed.

Geographic cartographers, they say, draw representations of things we are reasonably sure exist independently of the maps drawn of them: mountains, islands, and so on, they disingenuously claim, are real. DS Maps of mental disorders, they say, are different. They are not representations of realities:

read discuss contribute at www.thepsychologist.org.uk

of traumas and life circumstances in psychiatric breakdown makes it implausible to do so in many of these cases as well. The DCP is, in conjunction with the BPS Media Centre, monitoring the media coverage closely and working to correct any distortions of our message.

The point is well made that we need to explore the possibility of alternative clustering systems, and internationally there are a number of groups engaged in this task. The DCP has funded its own project to outline the principles of an approach that identifies common patterns of responses, both psychological and biological, to life events and social circumstances, and that might supplement and support the use of individual formulation.

Clearly, the existing classification system will be with us for some time.

However, the DCP believes that it is vitally important to ‘achieve greater openness and transparency about the uses and limitations of the current system’ and ‘to open up dialogue with partner organisations, service users and carers, voluntary agencies and other professional bodies in order to find agreed ways forward’ (p.4).

Richard Pemberton Chair, BPS Division of Clinical Psychology

the entities they purport to describe are constructions of the minds of Cartographers of the Mind. They are Maps of Wonderland.

Professor Justin Joffe London N2

The American critic H.L. Mencken once remarked, ‘For every subtle and complicated question, there is a perfectly simple and straightforward answer, which is wrong’. The question of how to respond to psychological distress is subtle and complicated. The answer that has dominated recent Western thinking, namely that there exist mental illnesses and that these are illnesses like any other, has the virtue of being simple and straightforward. But it may also be wrong – or at least, partial, misleading and, in some cases, actively unhelpful.

The DCP’s recent statement is to be commended for not trying to replace one ‘simple, straightforward and wrong’ answer with another.

The document acknowledges the subtle and complicated nature of the issues. Contrary to what some commentators have suggested, it does not pit clinical psychology against psychiatry or deny the role of biology – indeed, it states explicitly that what is required is ‘multi-factorial and contextual approach, which incorporates social, psychological and biological factors’. It highlights problems with the current system of classification, but does not object to classification per se.

It offers no off-the-shelf alternative, calling instead for wide-ranging dialogue to develop new approaches. Even the document’s most striking

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suggestion, a move away from the system of diagnosis described by the DSM-5, is hardly radical. Similar arguments have recently been made by influential and mainstream groups such as Mental Health Europe (see tinyurl.com/bqdgos9) and the US National Institute for Mental Health (see tinyurl.com/cl5ekbc).

That such a measured and non-polemical statement

should provoke howls of outrage perhaps tells us something about the tenuous foundations of the medical model. If proponents had the confidence of their convictions they would have nothing to fear from – indeed would welcome – critical interrogation. By contrast, those who raise problems with diagnosis, or with the concept of mental illness as such, are accused of ‘anti psychiatry

prejudice’ and of having no interest in relieving suffering (see tinyurl.com/no88tpb).

Most baffling of all is the response that criticising diagnosis is somehow antiscientific – particularly absurd when, as the DCP statement makes clear, many of the difficulties of the DSM arise from a failure to follow the scientific method.

Although the DCP statement makes no new

arguments, it performs a valuable service by bringing vital critiques of the medical model of mental illness to wider public attention.

Personally, I am proud to see the BPS finding its voice and raising subtle and complex questions.

Dr Sam Thompson Institute for Psychology, Health and Society University of Liverpool

Methodological shortcomings of biological research I read with interest Essi Viding and Uta Frith’s response to the DCP’s recent statement concerning DSM-5. They write that the DCP representatives are ‘in danger of muddying mental health issues by ignoring the biology’ and that ‘their present stance will fail to deliver help for those who suffer from mental health problems’. I thought this was a curious response, given the outright failure of behaviour genetics research over several decades to benefit service users in any way whatsoever. This failure to deliver anything of use to those on the

NOTICEBOARD I Clinical and counselling psychologists are invited to participate in an international research study on the relationship between core beliefs, stress and burnout. This study will help us to develop resilience training to strengthen coping skills amongst psychologists. To access the survey, please go to tinyurl.com/kkbfnfo. This study has been approved by the University of South Australia’s Human Research Ethics Committee.

Susan Simpson susan.simpson@unisa.edu.au I As part of PhD studies at the University of Greenwich I am seeking personal accounts by therapists of anomalous experiences in, or in connection with, counselling/psychotherapy.

Participation in this study would ask you to complete an online questionnaire.

If you would like further information on the nature and purpose of this research, please go to tinyurl.com/q5qjtsr Paul Atkinson ar57@gre.ac.uk

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sharp end should not be considered surprising given that the case for a genetic basis for the behaviours and experiences which are categorised as serious mental illness has been vastly over-stated.

A recurrent feature in this work has been the poor reliability of diagnostic categories, absence of biological markers and an automatic interpretation that data from twin and family studies favour a genetic interpretation when in actuality the greater genetic similarity of MZ twins compared to DZ twins is confounded by their greater shared environment. It is simply not the case that the equal environments assumption can be so blithely ignored or that the use of structural equation modelling as a research tool can circumvent the problems. It is well known – or at least ought to be – that in any multivariate model where there are two potential predictors of an outcome of interest and these are strongly related (as is the case for genetic similarity and degree of shared environment in twin studies) the one which is measured with greater precision will seem to be the more strongly related with the outcome than is actually the case (Davy Smith & Phillips, 1996; Phillips & Davy Smith, 1991).

Twin studies incorrectly interpreted have led researchers to expect huge genetic effects that have simply not materialised in molecular genetics research. The recent ‘breakthroughs’ proposing a common genetic pathways in five psychiatric disorders for example (Cross-Disorder Group of the Psychiatric Genomics Consortium, 2013) is but one example. The authors were only able to explain between 1 and 2 per cent of the variance in any of the target disorders (ADHD, ASD, bipolar disorder, major depressive disorder, and schizophrenia)

with the expressed possibility that their results could have been inflated by diagnostic overlap. Given the sample size they used (over 30,000) the findings may have no clinical significance whatsoever.

Their preference for biological theorising made clear, Viding and Frith, with a rhetorical wave of the hand, then refer to ‘unsubstantiated and alarmist pronouncements about child abuse causing schizophrenia’. That child sexual abuse is a risk factor for almost all forms of ‘psychopathology’ (including schizophrenia) is not unsubstantiated but is in fact well attested by a large body of research (e.g. Roberts et al., 2004). Viding and Frith are of course correct to point out that current interventions (both medical and psychological) are far from effective, but that situation is not likely to improve until the poor track record and methodological shortcomings of biological research in mental health is acknowledged.

Ron Roberts Kingston University References Cross-Disorder Group of the Psychiatric Genomics Consortium (2013). Identification of risk loci with shared effects on five major psychiatric disorders: A genome-wide analysis. Lancet, 381, 1371–1379.

Davey Smith, G. & Phillips, A.N. (1996). Inflation in epidemiology: ‘The proof and measurement of association between two things’ revisited. British Medical Journal, 312, 1659–1661.

Phillips, A.N. & Davey Smith, G. (1991). How independent are ‘independent’ effects? Relative risk estimation when correlated exposures are measured imprecisely. Journal of Clinical Epidemiology, 44(11), 1223–1231.

Roberts, R., O’Connor, T.G., Dunn, J. et al. (2004). The effects of child sexual abuse in later family life: Mental health, parenting and adjustment of offspring. Child Abuse & Neglect, 28(5), 525–545.

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Stepping from the shadow We are writing to commend the immediate and comprehensive use of the DCP statement on formulation to all of our colleagues. It has appeared at the very time when the shortcomings of psychiatric diagnosis have been exposed in the critical international response to the publication of DSM-5 by the American Psychiatric Association. Our current context then provides the profession of clinical psychology with a unique historical opportunity to adopt a clear position of scientific humanism.

DSM and other forms of psychiatric nosology are incompatible with a psychological approach to helping people with their problems, which should be both humane and scientific. Our approach to helping others should be based on identifying specific problems (defined As 210 clinical psychologists and mental health professionals, we support the DCP’s call for a paradigm shift in how we think about mental distress and the need to move away from psychiatric diagnosis. We are pleased by the media coverage and the debate this has stimulated in the wider public.

It is essential that diverse voices are heard and that rather than considering individuals as receptacles of disorders, deficits and distortions, we make sense of distress in more helpful and evidence-based ways. We need to focus far more on people’s lives, experiences

by clients themselves but, for obvious practical purposes reflecting a common lexicon) and working with them to develop individual and context-bound formulations. These would include the unique events in a person’s life past and present, the meanings they invest in, or attribute to, those events and strengths to build upon that he or she has exhibited to date in coping with challenges in their life.

David Pilgrim Professor of Health and Social Policy Peter Kinderman Professor of Clinical Psychology Richard Bentall Professor of Clinical Psychology University of Liverpool

and social contexts and to consider how people embody and are shaped by the world around them.

We note that organisations such as the Hearing Voices Network and Mental Health Europe, which represent the service-user perspective, have recently challenged the diagnostic and professional expert-driven status quo, and we believe that clinical psychology needs to support and work with these groups. We

Following the publication of the DCP’s Position Statement on Diagnosis, which we have already endorsed, the Psychosis and Complex Mental Health Faculty is keen to work on bringing about the changes in practice and conceptualisation that it envisages in our services. Most of us in the Faculty work closely with colleagues in other professions in a team context, so that collaboration, both with them and with service users and carers, is a priority. We are seeking to further this agenda at the Faculty conference and AGM to be held on 20 November at the

need to step out from the shadow of biological reductionism and consider the multifaceted nature of what it is to be human and to be part of the world around us. We wish to support the DCP and the growing number of service users, carers, professionals and organisations who are questioning the dominant paradigm.

This is a very important step for the profession and one that is long overdue.

Dr Mel Wiseman Wellingborough and 209 other signatories (For the full list see the html version in ‘Letters’ at www.thepsychologist.org.uk)

BPS London office under the heading ‘Developing the narrative – Creating a shared paradigm shift towards a holistic view of mental health’.

This should further the process of moving beyond restrictive, illness-based conceptualisations in partnership with the other groups and professions concerned with complex mental health, in line with the second recommendation at the end of the position statement.

Isabel Clarke Chair of the PCMH Faculty of the DCP on behalf of the Faculty Committee

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The recently published Francis Report calls for a change in the culture of the NHS, repositioning the patient at the centre of care and enshrining values of responsibility and accountability in everyday practice (among 290 recommendations). The stars aligned with the publication of DSM-5 and the DCP’s position statement ‘Time for a paradigm shift’; this seemed like a timely way to generate debate, about the influence of diagnostic categories on constructions of distress and thus mental health care provision.

The response to the DCP statement from some quarters has left me stunned and greatly concerned for the profession.

It makes me think of Menzies-Lyth’s (1960) work on socially structured defence mechanisms in the face of anxiety. Some of the defences proposed include atomisation of tasks and the ceding of responsibility to higher-ranking staff. This potentially entrenches hierarchies and negates questioning dominant narratives in services.

Bringing this back to the here and now, it seems there is a real danger that a great many healthcare professionals work in systems that do not encourage questioning.

This is self-evident following Francis and possibly not confined to the NHS services of Mid Staffordshire. The Francis Report calls for a new culture of patient care, which surely includes a fresh examination of the paradigms that support this care.

This poses a series of questions for commissioners, providers, and practitioners. Do we want healthcare professions not to question? Will this lead to greater responsibility and accountability?

Can we put patients’ needs in the centre of our practice without critically examining our models, the evidence we draw on, and the language we use to define others’ distress?

If we don’t critically reflect on what we do, whose needs are we serving?

For those that have come out strongly against the DCP position statement I think its positive that a genuine debate might at last happen. And, reflecting on the work of Žižek (2008), can I ask you one last question – in entering the debate in this way have you taken the right step, but the wrong direction?

Ima Nusm Trainee clinical psychologist University of East London References Menzies Lyth, I. (1960). Social systems as a defence against anxiety. An empirical study of the nursing service of a general hospital. Human Relations, 13, 95–121. Žižek, S. (2008). In defence of lost causes. London: Verso.

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Are we competent to recognise our incompetence?

It is fashionable to seek to connect disparate things, and in response to three parts of The Psychologist, June 2013, I offer these thoughts. I want to connect editor Jon Sutton’s quote from Bertrand Russell (‘One of the painful things about our time is that those who feel certainty are stupid, and those with any imagination and understanding are filled with doubt and indecision’) and the letters on the DSM vs. DCP conflicts with the letter about Farrelly’s Provocative Therapy.

My challenge to DSM people and DCP people is this: you are incompetent, you have clearly failed to make progress with people’s mental health in general and should rethink your position. If you cannot outline a positive way forward then you should all go home.

Examples of failure? Well, an obesity crisis is surely self-harm on a massive scale and almost total failure to create a response to genocidal climate change (killing off a future generation is genocide in my book) shows total disregard for priorities let alone anything else.

My own view of why you are incompetent, that you fail to accept a paradigm of multiplicity – that a persona which might have a biological response system should be switched to a persona which will respond to an environmental response (and vice versa is an option of course: see Rita Carter, Ornstein and even William James) – is not actually relevant. What is relevant

is that whatever paradigms you are adopting (and most times you fail to declare them) they are failing and after 90 years of trying you should give up.

For those who think I am singling out clinical I am happy to challenge educational psychology (which paradoxically is regulated through the medical model) that you should also all give up and go home because the school system is not much better if at all from 50 years ago. Likewise, in forensic you fail to make any inroads into prisoner rehabilitation and for organisational psychologists, you are dismal failures when it comes to having any success with governments current and past (as the audit trail shows they aren’t even getting the maths right, though maybe that is the fault of the educational psychologists) and even more so with company executives and leadership, management and teamwork, where your pay should yield a better return than the worst recession in decades – why haven’t you run over the cliffs like lemmings do? (Or don’t to be accurate.)

So, let’s own up to our incompetence at recognising our incompetence, give up what we are trying to do and failing, and do something else, help save the planet maybe (but not as psychologists, please).

Graham Rawlinson Chichester

Public protection – a moral maze In today’s media-focused culture, moral judgements about other people’s behaviour are made every second. Most people would probably agree that health and care professionals are given unique trust by the public. However, there is less clarity around the expectations that go with this trust, and the consequences for breaches of trust. Consider the following: A health professional is arrested for shoplifting. Does this have an impact on his fitness to practise?

A health professional has been charged with drink-driving after attending a party whilst off duty. She drank four or five glasses of wine – and has not shown a history of alcohol abuse. Does this impact on her ability to do her job?

The Health and Care Professions Council wanted to explore this complex area in relation to public understanding of ‘protection’, and what health and care regulators should be doing as the gatekeepers of professional standards.

We commissioned a study, to which 270 people contributed, including members of the public, those from patient and service user groups, professionals, educators and employers (read the report at www.hcpcuk.org/publications/research).

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Participants were asked to share their experiences of care, and explore different scenarios like the ones above. The majority saw the first scenario as more serious in relation to fitness to practice.

This was because it signified a deliberate, premeditated act, whereas in the second, participants thought it might not impact on a professional’s ability to do their job.

A comprehensive understanding of the individual circumstances would usually be required to make a judgement about fitness to practise.

This case-by-case consideration of the evidence, taking account of the context in which actions occur, reflects the HCPC’s approach to all fitness to practise referrals.

Maintaining public safety is paramount.

Clearly, a drink-driving conviction is a serious breach of the rules. However, it would likely have greater implications for a professional if they were on duty at the time or travelling to or from work, if it were a repeat offence or if the professional showed no insight into the impact of drink-driving on safety.

There was agreement amongst the participants that repeated behaviour or practice that did not meet standards, a premeditated decision to do something known to be illegal or other dishonest behaviour should trigger an investigation by the regulator. They also agreed that,

where actions had consequences for patients or service users, the professional’s fitness to practise should be investigated.

In the aftermath of the Francis Report, we are looking closely at this research and its lessons. There are lines that can be drawn, where the majority would agree there are implications for both public safety and public confidence. HCPC standards exist as a framework, a Highway Code, designed to guide. But context is a hugely important factor when making judgements about other people’s actions, and informed judgements are almost always about understanding the context.

What professionals – and regulators – must do is maintain high levels of selfawareness and moral questioning, which militate against making bad choices, but can never totally eliminate them.

I hope that this report will be discussed by patient and service-user groups and professionals. The need to engage in this debate about ethics and behaviour grows ever more urgent as more and more reports of poor care and overstretched staff emerge. The future of health and care professional practice depends as much upon our individual response to ethical obligations as it does on our technical competence.

Anna van der Gaag Chair, Health & Care Professions Council

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I was moved (both in the emotional sense and the ‘moved to actions’ sense)

by Jade Weston and Nic Horley’s letter (‘Can we be lobbyists for social change?’, April 2013). It reminded me of the position of the Just Therapy group (Waldegrave et al., 2003) that states that for those in the helping professions to witness the stories of hardship and how social injustices impact on the well-being of those who consult with us and to remain silent is an immoral act. It made me question why I, and my profession, have been too silent about the real and potential impacts of the current changes to health care and the welfare system on the lives of those who consult with us.

The anonymous letter in The Psychologist, May 2013 (‘Lobbying for social change’) makes the important point though that we should not idealise or romanticise poverty or other disadvantages. Unfortunately the moral high ground has never belonged to any one socio-economic group. Those from poorer backgrounds who have been so inclined have found ways to abuse the benefit system, just as some from financially more privileged positions have found ways to abuse the tax system.

In my view though this is not a moral question for the individual on whether we

s our at ct th ges d chan ing are gomost t and ety. ci of so nical believe , we lly mora for ocate ts. This clien and d ngageelfare ial w make and tomental e ri et wer d s. We nt ir live in a rece urtherhat

are ‘good’ and deserving human beings (however we might want to define what that means) and thus entitled to a decent quality of life and decent services. Rather, it is a moral question for society. The welfare state holds that all are entitled to good education, good health care and a humane standard of living whatever your social circumstances. The current changes, from my perspective, change this and lead to a position where those from deprived backgrounds can find themselves unable to maintain a basic quality of life and where they no longer have access the an equal standard of healthcare provision.

RETIRED… BUT STILL A PSYCHOLOGIST As a retired independent practitioner, I am delighted that independent practitioners will hopefully now have a voice – it would have meant a lot to those practitioners like me who felt themselves marginalised. [The Society’s Trustees have supported a proposal to establish a Special Group for Independent Practitioners; the next step is the vote of the membership to establish it.] Now, following on from letters to The Psychologist (Peter Topham, February; Harry Gray April; Janie Penn-Berwell, May), might be a good time to establish a special interest network for retired psychologists.

As Penn-Berwell indicated, leaving a lifelong profession is a form of bereavement. As an occupational psychologist I found it relatively easy to identify a workable alternative career path (copy writing) but I’m still a psychologist – sort of incognito. I think retired psychologists have lots to offer each other, the BPS and the public. By establishing a relevant group, the BPS could offer those approaching retirement good reasons for remaining active members after they’ve filed their Practising Certificates under ‘Miscellaneous’.

Eleanor Lancaster Bangor, N. Wales

read discuss contribute at www.thepsychologist.org.uk

In my view it is the duty of psychologists and others who witness the direct impact of changes to the benefit system and National Health Service on the lives of those who consult with us to make these impacts visible to our professional community and to society.

I was so impressed by the strong stand the DCP and BPS have taken in response to the DSM-5, highlighting the problems associated with an individualised understanding of human distress and emphasising the importance of fully acknowledging and responding to the social contexts for that distress.

Maybe these challenging times are activating us as a profession to have a stronger and more political public voice and to become influential lobbyists for social change. In the meantime, Weston and Horley’s letter makes it difficult for us as individual psychologists not to consider what position and action we each wish to take.

Lizette Nolte Clinical Psychologist University of Hertfordshire Reference Waldegrave, C., Tamasese, K., Tuhaka, F. & Campbell, W. (2003). Just therapy – a journey: A collection of papers from the Just Therapy team, New Zealand.

Adelaide: Dulwich.

Self-dosing and the e-cigarette It would seem from the comprehensive review of smoking addiction in the May issue of The Psychologist by Lynne Dawkins that despite years of research there is still no real progress in helping smokers to quit. One significant factor in the maintenance of the habit, however, is not discussed in the article, namely the way in which smokers can automatically adjust their nicotine input to some ‘optimum’ level according to the perceived level of stress.

It is over 40 years ago that Heather Ashton and myself first demonstrated this behaviour in human

participants (Ashton &Watson, 1970). Our study was prompted by earlier research which suggested that a smoker has ‘literally fingertip control of how much nicotine he takes into his mouth’ (Armitage et al., 1968).

Our study demonstrated that the effects of nicotine depend largely upon the dose and rate of self-administration by smoking and that critically the rate of self-administration is controlled more by the puff rate than by the depth of inhalation of each puff.

During a complex motorperceptual task smokers of cigarettes with high-retention filters took more frequent

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puffs obtaining nearly the same amount of nicotine as smokers of cigarettes with lowretention filters during the tasks; and in the following resting period low-nicotine cigarette smokers took more frequent puffs than those smoking high-nicotine cigarettes (participants were unaware of the different filters).

The results suggested that the smokers were striving for a nicotine-alerting effect whilst engaged in the task. Both groups of smokers also showed a significant increase in puff rate during the resting period after the tasks, and the amount of nicotine obtained per unit of time also rose during this period. This suggested that the subjects may have been attempting to obtain a ‘tranquilising’ effect of a higher dose of nicotine.

All participants showed a

slightly higher nicotine abstraction rate during the most stressful task. It was concluded that the rate of self-administration is controlled more by the puff rate than by the duration or depth of each puff.

Armitage et al. (1975) substantiated these findings using arterial nicotine concentrations as a measure of nicotine levels and concluded that smokers adjusted their way of smoking in order to achieve a desirable psychological effect – small frequent doses of nicotine produce effects associated with central stimulation (desynchronisation of electrocorticogram and increased cortical acetlycholine release) whilst larger doses given less frequently may cause depressant effects (decrease in cortical activity and acetylcholine). More

recent research, such as that

by Corrigal et al. (1994), has also implicated the role of dopamine release by the activation of the nicotinic acetylcholine receptors in the brain, which we suspected at the time but were unable to measure.

Although sensory and learned behavioural aspects of smoking a cigarette may have some influence on the maintenance of the habit, it would seem that with reference to the studies described above that for the electronic cigarette to be effective it must replicate the ‘finger-tip control’ the smoker has in varying their nicotine intake by altering their puff rate to achieve a desired pharmacologically mediated psychological effect. If it does not allow this self-dosing then the e-cigarette may be no more successful than the campaign

some years ago to encourage all smokers to change to lowyield nicotine cigarettes.

Don Watson Faculty of Health and Life Sciences University of Northumbria References Armitage, A.K., Dollery, C.T., George, C.F. et al. (1975). Absorption and metabolism of nicotine from cigarettes. British Medical Journal, 4, 313–316.

Armitage, A.K., Hall, G.H. & Morrison, C.F. (1968). Pharmacological basis for the tobacco smoking habit.

Nature, 217, 331–334.

Ashton, H. & Watson, D.W. (1970).

Puffing frequency and nicotine intake in cigarette smokers. British Medical Journal, 3, 679–681.

Corrigal, W.A., Coen, K.M. & Adamson, K.L. (1994). Self-administered nicotine activates the mesolimbic dopamine system through the ventral tegmental area. Brain Research, 653, 278–284.

All-or-nothing thinking about NLP All-or-nothing thinking is often regarded as inferior to the more considered thinking of the analytical mind as it is usually triggered by strong emotion, and I am surprised how often I find this type of thinking associated with those three letters NLP (neuro-linguistic programming). In my experience the polarisation that occurs is the result of a lack of understanding and education in psychologists.

The predictions in the 1980s that NLP was just another fad to come out of the Human Potential movement that will blow itself out has not eventuated and it is now stronger than ever. I know a Google search is not the most scientific way to conduct research, however on 8 April 2013 I typed in ‘NLP’ and I got 72.5 million hits. This is substantially more than the most popular branch of psychology, clinical psychology, which trailed behind with 51.3 million, and my own discipline occupational psychology with only 11.6 million.

Professor Rob Briner conducted a similar piece of research and Googled ‘chartered occupational psychologist’ associated with a number of other terms.

He found NLP (84,900 hits) compared with say coaching (31,700 hits) or Belbin (674 hits) (Briner 2012). Even though

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Briner acknowledges these numbers are not reliable it does beg the question why should Chartered Psychologists wish to be even remotely associated with something which for some of their colleagues is the devil’s spawn?

Yes there is unethical practice in NLP, yes there are numerous exaggerated claims; however this is one end of the curve; at the other end there is good, ethical and responsible practice. Often it seems psychologists make generalisations from the undesirable extreme across the whole field. On the other hand NLP practitioners deride what psychology has to offer in terms of conceptual clarity and hypothesis testing.

A typical example comes from Jon Sutton’s (2012) comments in The Psychologist where he describes NLP as an easy target in the context of a ‘series of pops’. In examining the source material I read: ‘Meanwhile, the field (or cult) of “neurolinguistic programming” (NLP) sells techniques not only of selfovercoming but of domination over others’ (see tinyurl.com/8jkndqc).

Tosey et al. (2009) make it quite clear in their academic review, NLP it is not a cult and the description of NLP above is frankly insulting to anyone who takes the field seriously. I often ask psychologists:

Have you read about the recent applications of NLP in the field of psychotherapy (Wake et al., 2013) or coaching psychology? (Grimley 2013)?

Do you know since 2008 ANLP have hosted NLP research conferences at UK universities? And are you aware there is good-quality research out there (see, for example, tinyurl.com/nlpconf) that supports NLP?. If psychologists do take time to source and read this type of material they might be able to more professionally and ethically comment on a field that has been popular since the early 1970s.

Bruce Grimley Achieving Lives Coaching St Ives, Cambridgeshire References Briner, R.B. (2012). Does coaching work and does anyone really care? OP Matters, No 16, pp.4–12.

Grimley. B. (2013). The theory and practice of NLP coaching: A psychological approach. London: Sage.

Sutton, J. (2012). Never mind the neurobollocks. The Psychologist, 25, 813.

Tosey, P. & Mathison, J. (2009). Neuro-linguistic programming: A critical appreciation for managers and developers. Basingstoke: Palgrave Macmillan.

Wake, L., Gray, R.M. & Bourke, F.S. (2013). The clinical effectivenesss of neurolinguistic programming: A critical appraisal. London: Routledge.

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Choice in controlling relationships I am a barrister and former solicitor in the field of human rights, with experience in domestic violence and human trafficking cases. I hope to draw attention to the anomaly that is consent to controlling relationships, and should value your readers’ views/comments on the issue. My concern is that the appearance of choice in such dynamics may not be choice at all, but a symptom of deception. This would help to explain both why victims remain in controlling relationships, and how their partners get away with subordinating them to their will.

A prerequisite to choice is knowledge of what one is choosing. Take the customer who is unwittingly sold an imitation Rolex. She does not choose the fake watch any more than she chooses to be deceived; she believes it is something different. And, logically, the same applies to a person who is deceived as to her partner’s identity: she cannot choose to be with that person as such.

Critically, then, an individual’s belief that she is making a choice is no guarantee that she is. And, whilst that is primarily a matter for her, it seems negligent to ignore the possibility that she is deceived as to what – or indeed who – is on offer. As the 20th-century philosopher Simone Weil (1952) observed: ‘Liberty, taking the word in its concrete sense, consists in the ability to choose’ (p.12). It follows that an individual who does not Whose choice? choose is not free. In assuming that she is, therefore, we risk reinforcing her confinement.

Of course, in theory, an individual may choose to relinquish choice altogether, by submitting herself to another’s will. Yet, as such, it would be her last choice, annulled the instant it was made. And, to that extent, the scenario is unimaginable, as to remain in active submission would require further/ongoing choice.

In practice and in law, even people in ostensibly controlling relationships have been found to demonstrate their capacity to make independent choices, an indication that they are not, ultimately, controlled. For example, on sentencing Mairead Philpott to 17 years in April, Mrs Justice Thirlwall recognised that her husband had treated her as a ‘skivvy or a slave’, but emphasised that in repeatedly refusing him a divorce, she had

‘made a choice that was not his choice’. But – stepping back – if a person believes that her relationship is consensual, then is she not likely to demonstrate that belief by appearing to make independent choices, whether or not she actually is? The point is that we should expect a victim of deception to believe that she is not deceived. But whether her choice is real or illusory, will depend on whether she is deceived as to what it is she is allegedly choosing.

The fake Rolex of controlling relationships is, it seems, ‘fake support’. Its peddlers present as guardian angels, unconditionally supportive of their victims’ entitlement to a better life (with them, of course…). Inevitably, however, tangible signs of control start to emerge: the victim’s emotional and/or geographical isolation from her loved ones, for instance, servile behaviour towards her ‘partner’, etc.

Yet, any critical doubt on the controllee’s part as to the nature of her situation is overridden, it seems, by her desire to believe the deceiver’s fanciful message. Indeed, as clinical psychiatrist Arthur Deikman (1994) astutely observed, ‘wanting to believe is perhaps the most powerful dynamic in initiating and sustaining cult-like behaviour’ (p.137).

‘Guardian angels’ target those most likely to want to believe their message of hope: the vulnerable person in need of help; the disillusioned romanticist; the idealist, etc. They pop up in the courts and in the press from time to time. Yet, by the time they do, it is usually too late for their victims. Worse still, those same victims are often labelled as accomplices to their fate. They are not, are they?

Or does a slave choose her master?

Tom Gaisford London N7 References Deikman, A.J. (1994). The wrong way home: Uncovering the patterns of cult behavior in American society. Boston, MA: Beacon Press.

Weil, S. (1952). The need for roots. London: Routledge & Kegan Paul.

Working with media agendas With reference to the psychologists working with the media article ‘Psychology on the back seat?’ (June, 2013), I would like to offer my own reflections on this experience.

It is without doubt exciting, and a bit of a giggle, to be asked to make a contribution to the media, and easier to be swept up in that

excitement. Let’s face it, most people would love the opportunity to be on the telly.

We dress this up with thoughts of: ‘what a brilliant opportunity to promote psychology’, ‘…to promote the service/department’, ‘a chance to demonstrate to the public the value of psychological perspectives in understanding the human condition’, ‘at last!

read discuss contribute at www.thepsychologist.org.uk

Recognition!’, and ‘I’ll be needing a new suit’.

In my case I’ve made radio and television appearances to promote the Veterans Community Mental Health Service, on behalf of Tees Esk & Wear Valleys NHS Foundation Trust. The key learning point for me is that the media always have an agenda! Whether dealing with

a director, producer or journalist, they will have already decided what direction they want the programme to go in, what they want from you, and how they want to present you, their contributor.

They make no secret of this, and if you ask them they will tell you. Where conflict begins is when the contributor is unaware of the programme’s

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agenda, and is seeking to follow their own agenda. So, while my agenda might be to promote the service, and the psychological perspective of veterans mental health issues.

The media agenda might be that there are not enough services for veterans, and isn’t it a pity?

As the producers of the programme have the editorial control, their agenda will always take prominence. So, that insightful monologue I gave succinctly relating the observed phenomenon to psychological theory, and formulating a solution, ends up on the cutting-room floor.

So, how to move forward?

Talk to the producers, the directors, the presenters, the journalists, ask them how they are presenting the situation, and what perspective they are looking for from you the contributor. Assuming you are ethically comfortable with the programme agenda, then the

challenge is to acknowledge that agenda, and incorporate yours into it, ideally in collaboration with the producers. Of course, if you are not comfortable with their agenda, or the programme, then you should talk to the producer about your concerns and not get involved until they are resolved. As a last resort you can approach the industry regulator. If you can facilitate the media and your own agenda, then you succeed in promoting psychology, and sharing psychological knowledge. A checklist of questions: What is the programme about?; Why do they want my input?; What is the programme agenda?; Is the programme ethically sound?; Will the participants benefit from taking part in it?; If there are vulnerable people involved, are there adequate safeguarding structures in place?; Are the participants able to give informed consent,

and withdraw that consent?; Will there be follow-up care for any service users /vulnerable people involved in the programme?; How will my involvement benefit the participants, listeners, viewers, myself, and my profession?; Should I do it, what does my

I am writing in response to Sarah Rose’s letter published in the June 2013 edition of The Psychologist entitled ‘Clinical psychology heartache’. My aim is to emphasise the necessity of greater support and provision of opportunities for graduate psychologists. To illustrate the need for this, I feel it would be beneficial to share my own experiences, which I think are likely to be representative of many others’ trials, tribulations and utter

CRIME, JUSTICE, LAW, INTERVENTIONS

frustrations at trying to ‘make it’ in the psychology field.

I graduated in 2009 with a first class honours degree that was accredited by the British Psychological Society.

I also won two graduate awards; one of which was the BPS Award for Undergraduate Psychology (2009). I was ecstatic with my results, and eager to pursue a professional career in psychology. I had undertaken varied work experience during my studies through being an agency

no 70

The winner will receive a £50 BPS Blackwell Book Token.

If it’s you, perhaps you’ll spend it on something like this...

FORENSIC PSYCHOLOGY

Phil Boyes Yarm, Teesside

The future we want?

prize crossword Forensic Psychology present an exciting and broad range of topics within the field, including detailed treatments of the causes of crime, investigative methods, the trial process, and interventions with different types of offenders and offences. It draws on a wealth of experience to produce a new edition that will both interest and enthuse today’s generation of students.

Price £34.99 ISBN 978 1 1199 9195 3 Visit www.bpsblackwell.co.uk

clinical supervisor/clinical lead think?; Is my trust’s /university’s or employer’s communications/PR department aware of my involvement, do I need their consent and/or advice?

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2 Send your entry (photocopies accepted) marked ‘prize crossword’, to the Leicester office (see inside front cover) deadline 12 August 2013. Winner of prize crossword no 69 Les Hearn, London NW5 no 69 solution Across 1 Constitutional, 9 Aside, 10 Alzheimer, 11 Sobriety, 12 India, 14 Site, 15 Untidy, 17 Gas, 18 Ear, 19 Gamete, 20 Dada, 23 Felon, 25 Imitated, 28 Recovered, 29 Evade, 30 Reinforcements. Down 1 Classes, 2 Nail-biter, 3 Thesis, 4 Trait, 5 Tizz, 6 Obesity, 7 Armed, 8 Dreams, 13 Gift, 16 Numb, 17 Gear train, 18 Effort, 19 Genevan, 21 Address, 22 Stream, 24 Lucre, 26 Medic, 27 Ergo.

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support worker, and also gained voluntary work experience in Her Majesty’s Prison Service shortly after graduation.

Despite appearing to be well prepared for a future psychology career, I encountered rejection after rejection when submitting job applications after graduation.

When I sought feedback from prospective employers, I kept getting the reply that I did not have sufficient or specific enough experience to be considered at the application stage. In fact, one prospective employer said to me: ‘Unless you have direct experience in working with patients who have neurological disorders, don’t bother to apply.’ This brought the question to mind of how I was supposed to gain the experience I needed.

Eventually after months of enduring the misery of repeated rejections for the same unchanging reasons,

I was able to secure a post as a psychological assistant in Her Majesty’s Prison Service.

The irony of this is that after all of my hard work, this job had no requirement for degree-level education.

However, I had a real interest in forensic psychology, and so perceived this to be a great opportunity. The post started really well, and I absolutely loved the role.

However, after one year of being in the post and receiving excellent appraisals during that time, I received Support? a global e-mail from an Area Psychologist which included devastating news. New changes were being introduced which meant that completion of an accredited MSc would

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Lesson given with drug shot – this should lift the spirits (6,7) Psychologist’s first consideration having left gem (5) Appears to have heart that’s edible (3) Position of control in personality psychology? (5) Celebrated boisterously – scheduled about one (9) Liking for smack (5) Newspaper in charge of living matter (7) Itinerant man one doc treated (7) Part-decorated internally in 1920s style (3,4) Function for each school group (7) Action taken against something during dream phase (2,3) I’d try to get around composition of unpleasant tasks (5,4) Longs to drop number for a very long time (5) Afterthought I added in Greek letter (3) Rider moving large number west in less damp conditions (5) Nineteen moles somehow very at home (2,4,7)

Zero assessment for declaiming (7) 3 Suddenly together (3,2,4) 4 Most of realm I caught based on practical experience (7) 5 Seed-spilling Biblical character put on continuously (2,3,2 ) 6 & 8 down Dual nature of Yugoslav character? (5,11) 7 Struck and worked out without hesitation (7) 8 See 6 down 11 Marches keep disturbing one who’s 2 down (11) 16 Suffering short modern lines with passenger vehicle overturned (9) 18 Coach takes monarch to see landscape (7) 19 One giving name to complex work about English princess (7) 20 One-sided description of instinct in psychoanalytic theory (7) 21 Dark blue appears neat on boy (7) 23 Craftsman, parent and child (5)

read discuss contribute at www.thepsychologist.org.uk

now be a requirement to apply for Forensic Psychologist in Training posts (FPiT), and that the Prison Service would no longer fund this course. I was given an ultimatum in the email: either apply for upcoming FPiT posts anyway, knowing that I may be rejected at any time as soon as the changes came in, or decide not to apply.

I researched opportunities to complete the MSc but was unable to raise the funds to do this, due to considerable financial commitments.

I applied for the FPiT posts anyway, but was rejected due to lacking experience of specialist risk assessments that other candidates gained as a result of working with a higher-risk population.

I was devastated; once again, I’d been rejected. I kept telling myself that surely the standard of my degree would set me apart, but in fact, it was never even considered.

My next steps were to source opportunities in clinical psychology, but I faced many further rejections despite reframing my forensic experience within the context of clinical formulation and intervention. I often missed out on the chance to even apply for vacancies in the clinical field, as jobs would often open and close during the same or next working day, and I did not have internet access at work in order to apply. I also found a distinct pattern of Clinical Assistant Psychologist posts being of a temporary and/or part-time nature, or in some cases completely honorary, which entirely ruled out a chance of me applying for the role.

I left university feeling like I had a talent for psychology; something which my grades strongly imply. I was often given positive feedback about my critical thinking and original and novel approaches to assignments;

and I genuinely feel that I had a lot to offer the discipline.

I must admit that I’m exhausted, frustrated, uninspired and utterly demoralised at the prospect of further pursuing a career in psychology. What I now have to manage is the intense guilt and sense of failure I feel at myself for not succeeding in this discipline. I’m not sure if or when I will ever be able to let this go. I will always tell myself that there is something more I should have done, even if right now, I genuinely cannot see what more I can do.

I have not written this letter as an opportunity to complain, but rather as a firm and resounding request for the BPS as a professional body to work in collaboration with public, private sector and voluntary organisations in order to offer support to graduates in obtaining relevant work experience. Additionally, to review the entry criteria for professional training in psychology so that this more fairly measures aptitude and the potential to contribute to psychology, as opposed to the unrealistic requirement for graduates to have secured elusive and unobtainable posts.

The above is essential if applied psychology is to avoid becoming an elitist discipline, dominated by those who have the resources to pursue academic training and shortterm, ad hoc work experience placements. I feel that I have been undervalued and let down by the discipline and it is my understanding that many other graduates feel the same. Consequently, psychology runs the risk of losing many novel critical thinkers, clinicians and theorists of the future with the emergence of an elitist discipline.

Is this the future we want for psychology?

Lisa Molloy Wiltshire

Editor’s note: Society representatives have been invited to respond in a subsequent issue.

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BIG PICTURE

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A little boy looks into a mirror, and at the same time into the remote past.

What is uniquely human?

What sets us apart from our closest relatives, the great apes? A concept of the self maybe? The vast range of emotions we can experience, or the astounding cognitive capacities we are equipped with?

The photographer, Eiko Fried, is a PhD candidate at the Cluster Languages of Emotion at Freie Universität Berlin. ‘The focus of the labgroup I am situated in – mostly primatologists and

What is uniquely human?

Photo by Eiko Fried. Send your ‘Big picture’ ideas to jon.sutton@bps.org.uk

psychologists – is trying to figure out what is uniquely human by studying cognition, theory of mind, emotion, and communication in human and nonhuman primates,’ he tells us. ‘The photograph reflects on

potential differences, but also the many similarities between us and our closest relatives – and depicts the fundamental barrier that makes it so tremendously difficult to understand the mental states of others.’

www.thepsychologist.org.uk

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REVIEWS

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Participation in the garden The Chelsea Flower Show is not a typical venue for The Psychologist, so it was particularly interesting that at this year's centenary event psychologists were involved in a show garden. Not always obvious, given the predominance of plants and design, but psychology in collaboration with others.

The 'Digital Capabilities' social media garden was created by myself and colleagues in Social Computing and Architecture at the University of Lincoln, and Harfleet the garden designers. The concept of the garden arose from a combination of my research interests in the psychology of people and their gardens and Shaun Lawson’s interests in people’s interactions through social media.

Key to the garden design was to challenge typically passive engagement with flower show gardens by introducing interactivity and movement. The garden plot was small (6m x 3m) by Chelsea standards and was divided diagonally into two halves: an outer space filled with familiar plants in a cottagey style and an inner space filled with unusual tropical and subtropical planting. These were Chelsea Flower Show 2013 separated by the ‘Twitter wall’ made Royal Horticultural Society up of 20 motor-actuated panels controlled by a single raspberry pi computer, which accessed Twitter to determine volume of tweets around any given topic (e.g. #RHSChelsea; garden) and opened or closed the panel to reveal/conceal elements of the inner garden. In this sense, the garden’s behaviour was determined by the audience on Twitter, both on site and remotely. Also, tweets directed to the garden received a picture from the inner space.

In the context of Chelsea this garden was certainly a novelty and provoked enthusiastic comments from the throngs of visitors, many of whom had seen the garden on TV and made it a specific destination. Even those professing little interest in social media were captivated by the ‘mesmerising’ movement of the panels, the planting and the concept of representing digital interaction in this way. The concept was a bit tricky to convey and required some explanation (‘no it’s not a greenhouse!’), mixing real and virtual interaction with the garden.

It was a beautiful and exciting installation and won a Gold Medal.

Encouragingly, other gardens had a psychology theme: 'Digital Capabilities' backed onto the 'Mindfulness Garden', another Gold Medallist, which attracted big crowds.

Elsewhere in the show, an Exeter University psychologist was demonstrating healthy offices and the 'Get Well Soon' Artisan garden celebrated the ways that gardens and plants benefit health. Who knows what will be showing next year; maybe worth putting RHSChelsea 2014 in the diary?

I Reviewed by Harriet Gross who is a Professor of Psychology at the University of Lincoln

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‘Avatar therapy’ Health Check BBC World Service The BBC World Service’s Health Check (http://bit.ly/Hcheck) provides a weekly round-up of topical health issues. In a recent episode (29 May), Health Check’s Lorna Stewart investigated a fascinating new technique being used in the psychological treatment of voice hearing in psychosis, ‘avatar therapy’ (see also ‘News’, p.478). This therapy, being developed

by Professor Julian Leff at University College London, aims to help people develop a new relationship with their voices, and to Professor Leff’s astonishment, for three of the 16 participants in his trial, appears to have helped them lose their voices altogether.

Talking to Health Check, Professor Leff explained that avatar therapy is ‘intended to enable the patient to take control of something that otherwise is uncontrollable’. With the help of computer software, the voice-hearer is able to create a physical likeness, an avatar, for their voice. No longer do they have to engage with an invisible, repetitive and often non-responsive entity. Furthermore, because the voice-hearer creates their own avatar, they know it can’t harm them.

The client sits in one room, while the therapist sits in another room, observing the situation and controlling the avatar via a computer interface. At the beginning of therapy, the avatar matches the person’s voice in its persecutory content; however, over the course of several sessions the therapist encourages the client to stand up to the avatar. The avatar gradually changes, accepting the misery that it has caused and becoming supportive.

In addition to those patients whose voices went away, for others the voices became quieter and less bothersome, while the patients developed strategies to

A challenge Time /No Time: The Paradox of Poetry and Physics Seán Haldane In Time/No Time clinical neuropsychologist and poet Seán Haldane [see interview in The Psychologist, January 2011] takes the reader on a dizzying ride through the fields of cosmology, quantum physics, neurophysiology and poetry. The book is written with the ostensible purpose of encouraging poets and scientists to be more open to one another’s ideas, and the basis for this is a challenge to conventional wisdom about a subject intimately bound up with all these disciplines, namely time.

It is a brave venture, but the book proves more challenging than convincing for a number of reasons.

For one thing, great reliance is placed upon personal anecdote, as Mr Haldane builds much of his case for ‘the non-existence of objective time’ on chains of coincidence he has observed in his own life. These may be impressive, but clearly there is room for a certain selectivity here: life has a lot of non-coincidences too.

Nor does the book convince that at the primary creative level poets and scientists can really interact in any significant way. Their enterprises are qualitatively different, and both sides will rightly be wary of a

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deal with the voices. The study also reported a reduction in depression that occurred after the therapy stopped, as well as a reduction in suicidal thoughts and behaviour. One of the trial’s participants spoke to the programme; Claire (pseudonym) had experienced persecutory voices for 10 years, and neither medication nor three years of psychotherapy helped significantly with the voices. Following avatar therapy, in addition to a reduction in her voice hearing, Claire reported having greater self-esteem, stopping self-harming and socialising more than before.

From my perspective as a clinical psychologist, the study (http://bit.ly/avatarth) is a great example of the innovative, evidence-based and empowering approaches being developed for the treatment of psychosis. Working with people’s beliefs about their voices, helping them overcome feelings of helplessness and giving them a sense of power over their voices is a key intervention in modern CBT for psychosis. The avatar system, although it needs more study, appears to provide a powerful tool for working with voices.

More broadly, it’s fantastic to see a topic relating to psychosis being covered in a sensitive and intelligent manner in the media, as well as to see a new therapeutic technique described so clearly. I did, however, feel that the article was a little rushed and in particular, in its interview with Claire, that it failed to provide a sense of how it felt to participate in the avatar therapy. The rationale for the therapy could have been explained in more detail, but then I always feel that such topics deserve a little more space. Perhaps Claudia Hammond’s new BBC series The Truth About Mental Illness, which is airing now, will deliver that space.

I Reviewed by Fergus Kane who is a newly qualified clinical psychologist working in psychosis

sciolistic appropriation of knowledge not truly their own.

Sir Peter Medawar observes that for the scientist, science is what goes on at the rest point of the mind.

And what goes on at the rest point of the poet’s mind is poetry, but I am doubtful that the poet’s chaotic shifting landscape of the personal, lit by wandering shafts of insight and analogy, has much in common with the ordered impersonal investigations of science.

As for the ‘true nature’ of time, the blithe assertion that past and future are illusions and there are only ‘endless nows’ is all very well, but that’s just not the way the temporal cookie appears to crumble, and whatever quantum physics may have to say on the matter poets have for centuries been united in a common perception of time: it exists and it’s a bastard. In the words of Philip Larkin, ‘Truly, though our element is time,/We are not suited to the long perspectives/Open at each instant of our lives./They link us to our losses’. Or as W.B. Yeats still more succinctly puts it, ‘Man is in love, and loves what vanishes./What more is there to say?’ From the point view of understanding time, quite a lot, if this book is to be believed; from the point of view of experiencing it, rather less.

I Parmenides Books; 2013; Pb £11.99 Reviewed by David Sutton who is a poet (and the editor's Dad!)

Rediscovering ‘forgotten’ research A History of Psycholinguistics: The pre-Chomskyan Era William J.M. Levelt The traditional view of the history of psychology is one that started with structuralism and functionalism, followed by the counter movements of Gestalt psychology and behaviourism.

It is now becoming clear, however, that this view is wrong and grew out of the American introductory books of psychology (e.g. Brysbaert & Rastle, 2013). The origins of psychology are much older than 1879 (when Wundt started his laboratory of experimental psychology) and the first studies in psychology were much less based on introspection than is generally assumed.

Levelt’s book is a beautiful illustration of just how rich research in scientific psychology was in the second half of the 19th century and how much has been forgotten. The book starts with the observation that in current writings ‘[i]t is a widely shared opinion that the new discipline of psycholinguistics emerged during the 1950s [when Chomsky published his scathing criticism of Skinner’s behaviourist book Verbal Behavior and presented his own alternative]’. The remainder of Levelt’s book is a detailed refutation of this shared opinion.

In 600 pages Levelt shows how the psychology of language has a history going back into the 18th century, based on four pillars: (1) Historical research into the genealogy of languages, (2) Medical research into the consequences of brain damage, (3) Educational research on the development of language in young children, and (4) Experimental research on word processing in adults.

These four lines of research were reviewed and integrated in a much underestimated book of Wilhelm Wundt Die Sprache (‘Language’) (1900)

read discuss contribute at www.thepsychologist.org.uk

but became lost as a result of two world wars in Europe, which completely annihilated language research, and the lack of access to (and interest in) the publications in American experimental psychology.

As a result, when cognitive language research started to take off in the 1950s, it looked as if it was brand new, whereas in reality quite some insights were a recapitulation of previously well-known theories.

Along the lines Levelt unearths the true, 19th-century, origins of word association studies, the cohort model of spoken word processing, the evidence that sign language is a fully developed language on par with spoken language, the serial model of word reading, the importance of the first letter in visual word recognition, the characteristics of speech errors, the first theories sentence parsing and phonemes, and the motor theory of speech perception.

Levelt’s book is too informative and detailed for undergraduate studies, but it should be on the shelves of all their lecturers, as an example of just how much has been forgotten and rediscovered in the history of psychology. It should also be read by everyone interested in language research. They will not only discover the true origins of their pet theories, but will also have several evenings of pure delight while reading the book.

Brysbaert, M. & Rastle, K. (2013). Historical and conceptual issues in psychology (2nd edn).

Harlow: Pearson Education.

I Oxford University Press; 2013; Hb £60.00 Reviewed by Marc Brysbaert who is Professor of Psychology at Ghent University (Belgium) and Swansea University

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Tasty TED talks Love, no matter what Andrew Solomon We all lead busy lives, in this era of information overload. Our days can feel like one doomed attempt after another to tackle what’s on our plate, to juggle all our staple roles, let alone finding the time to try new flavours. One of the most frustrating things about that, in my view, is that even when people kindly break things down into nice bite-sized chunks for your consumption, it’s still hard to squeeze it in.

I’ve experienced that in my role with The Psychologist itself, and our Research Digest.

If I had a pound for every time somebody said they just don’t get round to reading them… and I can sympathise, because I find myself in the same position with resources as excellent as the online TED talks (see www.ted.com).

TED is a non-profit organisation devoted to Ideas Worth Spreading. It started out (in 1984) as a conference bringing together people from three worlds: Technology, Entertainment, Design. Since then its scope has become ever broader, and its short online talks are an important part of that

Secular Sunday service The Sunday Assembly York Hall, Bethnall Green This month I went to the Sunday Assembly. Describing itself as a ‘godless congregation’, this is essentially a church service for atheists. The hour and half comprised singing (pop songs, mostly to do with love), a guest speaker, a reading, some time of quiet reflection (in lieu of prayer) a description of some charity work and a couple of comedic yet heartfelt addresses by the

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(with more than a billion views). Every day they pop up in my e-mail inbox or on my phone app, and every day I think ‘when I’m retired I’ll watch one of those every morning’.

Today I made the time, and spent half an hour watching Andrew Solomon – a writer on politics, culture and psychology – talk about the line between unconditional love and unconditional acceptance (see tinyurl.com/kulld2l). What is it like to raise a child who's different from you in some fundamental way (like a prodigy, or a differently abled kid, or a criminal)?

Solomon shares what he learned from talking to dozens of parents, including those of Dylan Klebold, one of the perpetrators of the Columbine massacre. I was struck by Solomon’s realisation that ‘all of us who have children love the children we have, with their flaws. If some glorious angel suddenly descended through my living room ceiling and offered to take away the children I have and give me other, better children – more polite, funnier, nicer, smarter – I would cling to the children I have and pray away that atrocious spectacle.’

TED talks are fairly consistent, in that it’s rare to watch one and think ‘that idea wasn’t worth spreading’. Our own discipline is well represented, with speakers including

organisers Sanderson Jones and Pippa Evans (who are also comedians).

The theme of this Sunday’s assembly was happiness, and Richard Layard – programme director of the Centre for Economic Performance at the London School of Economics and the architect of the Improving Access to Psychological Therapies initiative – was a great choice of speaker, given his influence on governmental policies on psychological wellbeing. Unfortunately the sound balance needed work so it was hard to hear the first half of what Layard had to say, but what I did

Sarah-Jayne Blakemore, Dan Gilbert, Alison Gopnik and Martin Seligman. Whether or not TED genuinely disseminates science to new and diverse audiences is a matter for debate: a recent paper (see tinyurl.com/pft76nn) commented that ‘it is altogether possible that those who watched and “liked” these videos were often themselves academics’. The researchers also found that giving a TED presentation appeared to have no impact on the number of citations subsequently received by an academic.

But no matter. As the TED website says, most regular TED Talk listeners ‘would tell you the experience has impacted how they think and what they do’, so that’s the real outcome. ‘Ideas reshape minds and change the way people act’, and ‘more than 10,000 people in more than 100 countries are spending a substantial number of hours ensuring that TED is not just talk, but has on-the-ground impact.’ We should cherish a ‘global community welcoming people from every discipline and culture who seek a deeper understanding of the world’, and ensure we find the odd half hour for its tasty treats.

I Reviewed by Jon Sutton who is Managing Editor of The Psychologist

hear spoke to known psychological benefits of being kind to others, and of attending church, which fits with the Sunday Assembly’s ethos. He explained some of the research into these benefits in a clear and accessible way, and was received well.

Overall there are still a few things for the Assembly to iron out: mainly getting the speaker easily seen and heard: this difficulty might have been a consequence of a recent review in Time Out, resulting in a doubling of their numbers this month (there were apparently about 600 people in the audience). There was a touch too much singing from my point of view too, with the same unfortunate tendency that church services have of pitching the songs in a key which is both too low and too high. But choral singing has been linked to happiness too, so maybe this was more than an aping of a church service and in fact another tactical happiness-boosting technique.

Overall the Assembly is an interesting idea, with charismatic leaders and the potential to be a really stimulating event. It reminded me a bit of the principles of Alain De Botton’s ‘School of Life’ (see my interview with him in the May issue), in that it targets people who like to think about how they live their lives without necessarily doing this through the lens of a religion. Unlike talks at other places, this is free to attend (though you can give a donation if you like). It had the flavour of a community rather than a commercial venture. I’ll definitely be back in a couple of months to see how it’s evolving.

The Sunday Assembly is on the first Sunday of every month.

Check out their website here: http://sundayassembly.com I Reviewed by Lucy Maddox who is Associate Editor for Reviews and a clinical psychologist in the NHS. Her blog is at http://psychologymagpie. wordpress.com

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Rigorous academic discussion Psychology and Crime (2nd edn) Clive R. Hollin This is Clive Hollins’s update of his review of research in criminological psychology, incorporating developments in the field since the first edition in 1989. This version contains 12 chapters, which divide into three general parts. The first part covers some relevant basic concepts from law, criminology and psychology. The second part looks at some specific criminal acts (arson, violent and sexual crime) and the relationship between mental disorder and crime. The third part discusses the investigation, punishment and prevention of crime from a number of perspectives.

The main strength of the book is its comprehensive coverage of relevant literature, mainly from forensic/criminological psychology but also from other domains. Its scope is quite impressive: one chapter, for example, draws from developmental psychology to consider the development of criminal behaviour across the lifespan, while another deals with workforce issues in law enforcement such as officer selection, training, and stress management. As well as reviewing relevant theories and findings across the topics covered, Hollin highlights methodological issues such as the evaluation of crime reduction interventions. For a bit of light(ish) relief, some

chapters also list media references to the subject matter, such as TV shows. In case you were wondering, yes, these do include Cracker.

However, despite (or maybe because of) the book’s depth and scope, I did find some of the chapters difficult to follow as the arrangement of topic headings within them was not very intuitive. The first three chapters in particular seemed to include some repetition of topics and to go back-and-forth between them, so the reader can afford to be selective in how much of these chapters he or she reads.

Incidentally, there will be a companion website with supplementary material that may be helpful to those studying the book.

My overall impression is that Psychology and Crime would serve well as a general textbook in criminological psychology. It contains a wealth of information and will be of value to anyone seeking a rigorous academic discussion of the psychological issues associated with crime.

Act of bravery

Superman – heroic morality

Deadweight: A Case Study Concerning Mental Illness Nicholas Boyd Crutchley

I Routledge; 2012; Pb £34.99 Reviewed by Denham Phipps who is a Research Fellow, University of Manchester

Man of Steel Zack Snyder (Director)

Following a self-described breakdown, Crutchley’s life was suddenly and somewhat permanently contracted by the force of serious mental illness (a schizophrenic diagnosis and its common concomitants, mood disorder, suicidality, hallucinations, etc.).

The author promotes the book as a ‘novelised case study’ of mental illness. Another way to view it is a novelised memoir of mental illness; Sybil meets C.S. Lewis’s less widely known Space Trilogy series.

It is a difficult read. This is not because the story is uninteresting or poorly written. Instead, Crutchley preserves the authentic dialogue of mental illness, which in its organic state looks and reads a bit like poor science fiction (and which the cover illustration does little to challenge), a taxing narrative for the ‘normal’ mind.

To the rational mind, the recounting of a protracted episode of paranoid delusion can be so absurd as to seem fictional, and to that end the story works as a novel but without the present-time voice of the narrator, it is hard to hold on to the intention of the book, which is to humanise the severely mentally ill to professionals, caregivers and the general public.

Still, Crutchley is to be commended for his act of bravery, the book is a raw accounting of serious mental illness, without the pretension of academia or the heavy editing of pop-science.

As a reinvention of Superman for movie-watchers who loved Christopher Nolan’s Batman trilogy, Man of Steel is likely to be a success. Tonally and visually dark, it presents a young and inexperienced Superman forced to confront his genetic legacy: renegade Kryptonians who see Kal-El as a way to revive their lost people. Henry Cavill and Amy Adams do fine jobs in the roles of Clark Kent/Superman and Lois Lane, but the standouts are Russell Crowe as Jor-El and Michael Shannon as General Zod, who steal every scene in which they appear.

Many of the standard superhero themes are present, such as the relationship between power and responsibility, as well as the public’s fear of the powerful (a hot topic in today’s comics as well). Relations between father and son play a significant role, especially between Clark and Jonathan Kent, which climax in a pivotal scene in the middle of the film. The tension between Superman’s Kryptonian and human loyalties are mentioned, but because most of the movie takes place before Clark moves to Metropolis, we don’t see much of the issues of dual identities and ‘Who am I, Clark or Superman?’

In my opinion, the most interesting issues with the film rest with the moral choices Superman makes. Despite his powers, Superman faces moral conflicts and tragic dilemmas like the rest of us, and the way he resolves them is yet another way he expresses his heroism – and one of the ways we can emulate Superman. But some of the choices he makes in the movie are controversial, and may question some viewers’ ideas of what heroism entails and demands.

That said, examples of traditional heroism are not hard to find in Man of Steel, and are not limited to Superman himself. Jonathan Kent, Lois Lane, and Perry White all pitched in as they could, showing that you don’t need super-strength or heat-vision to put your own well-being aside to help others. Ultimately, this is the most important point any superhero movie can make. While Man of Steel may not satisfy everyone’s idea of heroic morality, it is sure to prompt discussion about such issues while providing an exciting and emotional thrill-ride at the cinema.

I Self-published; 2013; eBook £2.49 Reviewed by Stephanie Dinnen-Reini who is at Yale School of Medicine, West Haven, CT

I Reviewed by Mark D. White who is chair of the Department of Political Science, Economics, and Philosophy at the College of Staten Island in New York City and editor of Superman and Philosophy (Wiley, 2013)

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Dipping into death matters Death Matters: Transforming Our Fear of Death Sally Petch Sally Petch writes in Death Matters that she wishes to ‘help us to accept and feel more comfortable with our own journey towards death’. Aiming for accessibility, she adopts a conversational style reminiscent of a cookery writer and a format to encourage ‘dipping-in’.

She covers losses from redundancy to a child dying, and ranges from asking readers to question why they dye their hair to suggesting that a cardboard coffin is lovely for a child.

Perhaps because of the breadth of subjects, the approach jarred me.

While losses have different meanings for people, at best the book skims the surface of the complexity of emotions surrounding death and at worst seems glib.

As a bereavement volunteer, I seek out materials that empower people to talk about dying and death openly such as the website www.dyingmatters.org.

This slight book would not, I feel, help most people in that process.

I Matador; 2013; Pb £8.99 Reviewed by Lucy Fiddick who is an assistant psychology practitioner in LIFT (the IAPT service in Bristol) and Bereavement volunteer for CRUSE

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The Buddha and the Borderline Kiera Van Gelder ‘The difference between being told “There’s no reason to feel that way” and “I can understand how you feel that way” is the difference between taunting a rabid squirrel and giving it a tranquilizer’ Kiera Van Gelder Kiera’s account of her journey is forthright, honest, insightful and with more than a hint of humour. She comes across as very knowledgeable about her diagnosis as well as being well read in terms of therapies and psychological perspectives. Kiera details her passage through services, therapies, relationships, life transitions and finally Buddhism where the mindfulness teachings of DBT are underpinned. Kiera discusses the controversy and stigma surrounding her diagnosis and her perception of the professionals and

Left me cold The Human Swarm Channel 4 Jimmy ‘Jamie Oliver’s mate’ Doherty is off the farm and following every other Tom, Robert and Michael into fronting popular science documentaries. He’s an engaging enough presence but unfortunately this was a title and a presenter in search of a programme.

‘We humans think and move like members of the herd in more ways than we realise,’ Doherty began. For the remainder he said ‘like a human swarm’ every now and then, but that didn’t make it true.

The premise was that changes in the weather, and specifically temperature, can makes us act ‘not as individuals but as a collective mass, a human swarm’.

For example, we buy more porridge when it’s cold. Dr Mark Hetherington, described as an environmental psychologist, was on hand to explain the role of the hypothalamus in making us want to take on more food when the temperature drops. Interestingly, although we crave hot food, even a salad would do. And these days

treatments made available. She also portrays her experience of intimacy with others with candour and wisdom.

This book developed my understanding as a DBT therapist of how patients might experience the therapy that my service delivers; a valuable appreciation of their multifaceted internal world as a result of Kiera’s expert perspective. Far from solely being a fascinating personal account of borderline personality disorder (recommended to friends and family of sufferers), this is an exceptional reference text for clinicians working in the area. For me, this book engendered empathy for the raw pain and confusion endured by my patients as well as the strength and bravery that they show in tackling life’s obstacles like no other text.

I Recommended by Keren Smith who is a clinical psychologist at Maudsley Hospital.

Do you have a favourite book, film or album that has you have found of value in your personal or professional life? Contact Lucy Maddox on maddox.lucy@gmail.com

we only get cold for short periods, and then we take on lots of extra calories and go and sit in a warm office.

A host of other effects were covered. There are 200 extra heart attacks for every one degree drop in temperature, as blood gets more viscous and is pushed into the body. Use of online dating sites goes up. There was also some underplayed stuff about the 2.5 billion GB of data we produce a day, leaving a trail of information that can be used by companies and governments. For example, a ‘sick weather’ website collects information from social networking sites on the use of flu-related words, and one day the NHS could make use of this live flow of data to predict the spread of illnesses – a virus forecast.

But generally the programme got a bit ‘aren’t supermarkets brilliant?’, with lots of assertions that ‘because we respond together, just like a swarm, the supermarkets can predict with certainty that there will be a sharp rise in demand for warming winter food’. I was left none the wiser as to whether that behaviour is in any way like a human swarm… perhaps we’re more like shambolic

zombies, directed by Starbucks and Sainsbury’s, than the collective hive mind of the bee.

I Reviewed by Jon Sutton who is Managing Editor of The Psychologist

contribute

reader recommends

reviews

Sample titles just in: Brainwashed: The Seductive Appeal of Mindless Neuroscience Sally Satel & Scott Lilienfeld The Human Spark: The Science of Human Development Jerome Kagan Permanent Present Tense Suzanne Corkin For a full list of books available for review and information on reviewing for The Psychologist, see www.bps.org.uk/books Send books for potential review to The Psychologist, 48 Princess Road East, Leicester LE1 7DR To review anything else, contact the Editor on jon.sutton@bps.org.uk

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Piaget, Rawlings, Spearman, and Myers all left something to Psychology …

What will you leave?

A lasting contribution The British Psychological Society is the representative body for psychology and psychologists in the UK. Formed in 1901, it now has approximately 45,000 members.

By its Royal Charter, the Society is charged with national responsibility for the development, promotion and application of pure and applied psychology for the public good, and with promoting the efficiency and usefulness of Society members by maintaining a high standard of professional education and knowledge.

With your help the Society works to: ■ To encourage the development of psychology as a scientific discipline and an applied profession; ■ To raise standards of training and practice in the application of psychology; ■ To raise public awareness of psychology and increase the influence of psychological practice in society.

By including us in your will you can help ensure the future of your discipline in the years to come by continuing to support the Society.

For more information on how to leave a legacy please contact Russell Hobbs, Finance Director at russell.hobbs@bps.org.uk or call him on 0116 252 9540.

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changes in sensation, cognition and memory rather than a sudden switch from awake to asleep. In this article, we address some key questions about anaesthesia and what it can tell us about the mind.

Psychology in the operating theatre Michael Wang, Catherine Deeprose, Jackie Andrade and Ian F. Russell ask what general anaesthesia can tell us about consciousness, learning and memory I gratefully look forward to oblivion, but I must be sure of it.

Taylor Caldwell

questions

The aim of anaesthesia is to provide a temporary state of oblivion, from which a patient will awake without memory for surgery. Unfortunately, we will show here that absence of memory for surgery does not guarantee that oblivion was successfully achieved. The operating theatre has become a laboratory for psychologists to investigate the boundaries of consciousness, learning and memory.

I

What mechanisms might underlie the phenomenon of intraoperative consciousness followed by postoperative amnesia?

resources

Deeprose, C. & Andrade, J. (2006). Is priming during anesthesia unconscious? Consciousness and Cognition, 15(1), 1–23. – Reviews the anaesthesia and memory literature from a psychological perspective

references

What is meant by implicit emotional memory?

American Society of Anesthesiologists Task Force on Intraoperative Awareness (2006). Practice advisory for intraoperative awareness and brain function monitoring.

Anesthesiology, 104(4), 847–864.

Andrade, J. (1994). Is learning during anesthesia implicit? Behavioral and Brain Sciences, 17(3), 395–396.

Andrade, J. (1996). Investigations of hypesthesia: Using anesthetics to

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n 1965, Dr Bernard Levinson, a practising psychiatrist and former anaesthetist, dosed 10 dental patients with thiopentone, nitrous oxide and ether in order to perform an unusual experiment. Mid-way through the operation, he staged a mock crisis in which he exclaimed, ‘Stop the operation.

I don’t like the patient’s colour. His/her lips are much too blue. I’m going to give a little more oxygen.’ Thereafter, surgery continued and all patients were reported to have made an uneventful recovery.

However, under hypnosis one month later, four of the patients repeated verbatim Levinson’s statement, and another four had some recall for intraoperative events.

This study is in many ways methodologically flawed: for example, Levinson conducted both the mock crisis and the hypnosis. However, the startling findings provided a starting point for research into psychological aspects of anaesthesia. This research really took off when psychologists provided appropriate tools and frameworks for researching implicit memory (Andrade & Deeprose, 2006; Deeprose & Andrade, 2006). At that point, the operating theatre became a laboratory in which to investigate the boundaries of consciousness, learning and memory.

The main message from this research is that the boundaries are blurred, with loss of consciousness involving gradual

explore relationships between consciousness, learning, and memory. Consciousness and Cognition, 5, 562–580.

Andrade, J. & Deeprose, C. (2006). A starting point for consciousness research: Reply to Thomas Schmidt.

Consciousness and Cognition, 15(1), 28–30. doi:10.1016/j.concog.2006.02.004 Andrade, J., Deeprose, C. & Barker, I.

What does general anaesthesia involve?

We often talk about sending patients ‘off to sleep’, but sleep is not an accurate analogy for anaesthesia. EEG studies demonstrate that general anaesthesia does not have the same electroencephalic signature, architecture or sleep stages of natural somnolence (Schwartz, 2010).

Unlike sleep, unconsciousness resulting from anaesthesia is a state created through artificial means, and, by definition, there is an absence of response to very strong stimulation.

Generally it is held that there are three common aims of general anaesthesia: I analgesia (loss of sensation, to prevent physiological shock); I hypnosis (unconsciousness or oblivion); and I muscle paralysis (to allow for surgical access).

Often at least three different drugs are responsible for these components, and thus they are relatively independent. It is possible to be given sufficient muscle relaxant to produce effective paralysis, with insufficient hypnotic, leaving the patient conscious but unable to move.

A further complication is that the effect of the hypnotic component of the anaesthetic cocktail, that is the anaesthetic proper, is determined by the balance between the dose of anaesthetic and the level of surgical stimulation and psychological arousal. Just as you may have difficulty sleeping in a noisy environment, so you will need more anaesthetic to keep you unconscious during an invasive surgical procedure than during a more minor superficial procedure.

As a patient, your state of consciousness or unconsciousness exists on a continuum of ‘depth of anaesthesia’ between fully awake

(2008). Awareness and memory function during paediatric anaesthesia. British Journal of Anaesthesia, 100(3), 389–396. doi:10.1093/Bja/Aem378 Bargh, J.A., Chen, M. & Burrows, L. (1996). Automaticity of social behaviour. Journal of Personality and Social Psychology, 71, 230–244.

Byers, G.F. & Muir, J.G. (1997). Detecting wakefulness in anaesthetised

children. Canadian Journal of Anesthesia, 44, 486–488. doi:10.1007/bf03011935 Davidson, A.J., Huang, G.H., Czarnecki, C. et al. (2005). Awareness during anesthesia in children: A prospective cohort study. Anesthesia and Analgesia, 100, 653–661.

Deeprose, C. & Andrade, J. (2006). Is priming during anesthesia unconscious? Consciousness and

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and fully unconscious. Where you are on this continuum will vary during an operation, and a difficulty for the anaesthetist is to determine how close you are to moving into the ‘wakeful’ end of the continuum before it is time for you to do so. The reader at this point may wonder why the anaesthetist does not just continually give an overdose of anaesthetic, and often they do, but there are dangers here of increased medical morbidity and (rarely) mortality.

The idea of a continuum of consciousness is supported by studies of the effects of sedative or sub-anaesthetic doses of anaesthetic drugs. These studies have found a progressive, sequential but dissociative loss of sensation. Hearing is commonly the last sense to be affected and electrophysiological studies have shown that limited sense of hearing can continue despite even deep anaesthesia (Koelsch et al., 2006). Importantly, long-term encoding

Cognition, 15(1), 1–23. doi:10.1016/j.concog.2005.05.003 Deeprose, C., Andrade, J., Harrison, D. & Edwards, N. (2005). Unconscious auditory priming during surgery with propofol and nitrous oxide anaesthesia: a replication. British Journal of Anaesthesia, 94(1), 57–62. doi:10.1093/Bja/Aeh289 Deeprose, C., Andrade, J., Varma, S. & Edwards, N. (2004). Unconscious

of memories is impaired before language and working memory functions (Andrade, 1994, 1996).

What’s the risk of consciousness during general anaesthesia?

Consciousness during anaesthesia has traditionally been measured retrospectively, in terms of patients’ recollections of surgery. The standard definition of awareness during anaesthesia refers to a situation where a patient has ‘woken up’ during surgery and recalls doing so when they come round after their operation. Achieving awareness by this definition requires that the period of consciousness is complete enough, in terms of the extent to which sensory and cognitive functions are regained, and long enough to be encoded in memory sufficiently to be recalled and verbalised at a later time. It also requires that

learning during surgery with propofol anaesthesia. British Journal of Anaesthesia, 92(2), 171–177. doi:10.1093/Bja/Aeh054 Ghoneim, M. (2010). The trauma of awareness: History, clinical features, risk factors, and cost. Anesthesia & Analgesia, 110, 666–667 Harris, J.L., Bargh, J.A., & Brownell, K.D. (2009). Priming effects of television food advertising on eating behavior.

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memory encoding is not compromised by the amnestic effects of anaesthetic drugs.

Often these memories of surgery are quite fragile and only become apparent once more vivid memories of the hospital visit have faded. The best studies of anaesthetic awareness therefore interview patients at several time intervals following surgery, to maximise the chance of capturing a faint memory of intra-operative events. These studies of retrospective explicit recall indicate a risk of about around one in every 600 operations for adults (Sebel et al., 2004) and around one in 100 operations for children (Davidson et al., 2005). These incidence rates clearly present a concern given that approximately 2.9 million anaesthetics are conducted in the UK each year (Woodall & Cook, 2011). Moreover, these statistics exclude operations where there is high risk of awareness. Risk of awareness increases if blood circulation is compromised (e.g. during heart bypass or trauma with blood loss), or if the dose of anaesthetic must be minimised (e.g. to avoid anaesthetising the baby during Caesarean section).

Studies using post-operative interviewing may underestimate the true incidence of consciousness during anaesthesia. This is because explicit memory, as assessed using retrospective recall, does not necessarily correlate with consciousness at the time of learning: there can be full consciousness with explicit memory, full consciousness with no explicit memory but with implicit memory, unconsciousness with no explicit memory but with implicit memory, or unconsciousness with no explicit or detectable implicit memory. Many lowdose anaesthesia studies have demonstrated that anaesthetic drugs commonly obliterate explicit recall, giving rise to amnesia, despite the fact that the patient was conscious and communicative during the period the drugs were active (see review by Andrade, 1996). This is particularly common in the case of conscious sedation during unpleasant investigative procedures such as endoscopy, when a benzodiazepine such

Health Psychology, 28, 404–413.

Ijerman, H. & Semin, G.R. (2007). The thermometer of social relations: Mapping social proximity on temperature. Psychological Science, 20, 1214–1220.

Kerssens, K., Gaither, J. & Sebel, P. (2009).

Preserved memory function during bispectral index–guided anesthesia with sevoflurane for major orthopedic surgery. Anesthesiology, 111, 518–524.

Koelsch, S., Heinke, W., Sammler, D. & Olthoff, B. (2006). Auditory processing during deep propofol sedation and recovery from unconsciousness. Clinical Neurophysiology, 117, 1746–1759.

Lebovits, A.H., Twersky, T. & McEwan, B. (1999). Intraoperative therapeutic suggestions in day-case surgery.

British Journal of Anaesthesia, 82, 861–866.

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as midazolam is injected intravenously. Many people have complete amnesia for such procedures and imagine they have been unconscious when clearly they have not (Woodruff & Wang, 2004). It is possible to be wakeful during general anaesthesia and have no postoperative recall for this episode.

How can we assess depth of consciousness?

The major focus of research on assessing depth of anaesthesia has been EEG measures of brain function. There is evidence that these measures can help reduce awareness during anaesthesia (Myles et al., 2004), but at best they provide a probabilistic indication of a patient’s state of consciousness. In other words, they tell us that the majority of patients will be unconscious at a particular EEG index reading. But what if the patient is actually at the tail of the normal distribution?

A direct measure of consciousness during anaesthesia would tell us if a patient was awake right now. Such a measure could help prevent the worst awareness cases.

Much, if not most of major surgery in the Western world involves the use of muscle relaxants, which cause whole-body paralysis. If you are unfortunate enough to become ‘wakeful’ in the presence of such drugs, you will be incapable of any movement. Anaesthetic awareness patients tell of strenuous and desperate attempts to signal to theatre staff their predicament, without success. Moreover, most anaesthetists believe, and are indeed taught, that they can detect consciousness in the presence of muscle relaxants because of changes in heart rate, blood pressure, tear secretion and sweating.

However, there is now abundant empirical evidence that this is simply untrue (Moerman et al., 1993).

Despite comments from eminent/learned bodies that ‘Intraoperative

Leslie, K., Chan, M.T.V., Myles, P.S. et al.

(2010). Posttraumatic stress disorder in aware patients from the B-Aware trial. Anesthesia & Analgesia, 110, 823–828.

Levinson, B.W. (1965). States of awareness during general anaesthesia. British Journal of Anaesthesia, 37, 544–546.

Macleod, A.D. & Maycock, E. (1992).

Awareness during anaesthesia and

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awareness cannot be measured during the intraoperative phase of general anesthesia’ (American Society of Anesthesiologists Task Force on Intraoperative Awareness, 2006), the isolated forearm technique provides a simple yet highly effective method for determining consciousness during anaesthesia (Russell, 1993; Russell & Wang, 1997, 2001). Before muscle relaxants are administered, a tourniquet is applied to one arm using a cuff, ensuring the patient is capable of moving the hand during surgery despite the presence of muscle relaxant in the rest of the body.

The patient is then asked to ‘squeeze their fingers’ by the anaesthetist at regular intervals. In early studies of the isolated forearm technique, Russell (1989) found that 44 per cent of patients receiving a once commonly used anaesthetic could respond sensibly to command at some point during the operation. However, on recovery almost all patients had complete amnesia for the surgical period. The incidence for awareness in children measured directly using the isolated forearm technique is approximately 1 per cent (Andrade et al., 2008), similar to the rate estimated by retrospective recall.

During particularly stimulating procedures such as intubation or when anaesthesia is very light, the incidence can be much

post traumatic stress disorder.

Anaesthesia and Intensive Care, 20(3), 378–382.

Messina, A.G., Wang, M., Ward, M.J. et al. (in press). The effectiveness of anaesthetic interventions for prevention of wakefulness and awareness during and after surgery.

Cochrane Database of Systematic Reviews.

Moerman, N., Bonke, B. & Oostings, J.

higher (Byers & Muir, 1997). The incidence of consciousness in adults receiving modern anaesthetics is currently unknown, but is likely to vary significantly according to the specific anaesthetic technique used and surgical procedure.

Early studies suggest the true incidence could be considerably higher than the incidence estimated by recall measures (Messina et al., in press), though the discrepancy between the child and adult data is not yet understood.

The isolated forearm technique is not used routinely in clinical practice, and in our experience, clinicians are either not aware of the technique or resistant to adopting it. Electrophysiological measures are also not routinely used in Europe, as there is little evidence that they reduce the risk of awareness in low- or medium-risk cases. Rather than attempting to assess the level of consciousness of individual patients, efforts to reduce awareness have focused on reducing human error.

Can we form memories during unconsciousness?

Although consciousness at the time of learning does not necessarily result in explicit recall, another form of memory may persist. Implicit memory is the enhanced processing, or ‘priming’ of information, such as improved ability to identify previously presented words embedded in white noise or to recognise or generate a word from its beginning or ‘stem’. Priming memory may occur during moments of undetected consciousness, but also occurs during adequate and even deep anaesthesia – at least as defined using an EEG measure and routine patient observation (Deeprose & Andrade, 2006). Thus research by Jackie Andrade and Catherine Deeprose has shown that, on recovery, patients are more likely to complete word stems with target words if they have heard those words during surgery (Deeprose et al., 2004). If patients had been paralysed, then the anaesthetist as well as the EEG monitor may have missed signs of

(1993). Awareness and recall during general anaesthesia – Facts and feelings. Anesthesiology, 79, 454–464.

Myles, P.S., Leslie, K., McNeil, J. et al.

(2004). Bispectral index monitoring to prevent awareness during anaesthesia: The B-Aware randomised controlled trial. The Lancet, 9423, 1757–1763.

Nilsson, U., Rawal, N., Uneståhl, L.E., et al (2001). Improved recovery after

music and therapeutic suggestions during general anaesthesia. Acta Anaesthesiologica Scandinavica, 45, 812–817.

Russell, I.F. (1989). Conscious awareness during general anesthesia. Baillieres Clinical Anaesthesiology, 3, 511–532.

Russell, I.F. (1993). Midazolam-alfentanil: An anesthetic? An investigation using the isolated forearm technique.

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consciousness (Russell, 2008a, 2008b).

However, patients were not paralysed, and so were free to move and communicate had they woken during surgery. None did, consistent with the conclusion that priming took place during adequate anaesthesia (Deeprose et al., 2005; Deeprose, et al., 2004; see also Kerssens et al., 2009).

What are the implications for well-being?

On the opposite side of the coin, there is some limited evidence that the formation of implicit memory during surgery may be used to benefit patients through priming positive expectations, such as ‘you will make a good recovery’ (Lebovits et al., 1999; Nilsson et al., 2001).

However, it has not yet been demonstrated that the processing of this conceptual type of information can take place during adequate anaesthesia, and early positive findings in this field may reflect unintended consciousness during anaesthesia, which was not detected by anaesthetists or consciously recalled by patients on recovery.

The psychological effects of explicit memory for consciousness during anaesthesia may be persistent and debilitating, including re-experiencing of the traumatic event, avoidance and The impact of psychology on hyperarousal consistent with postanaesthetic practice traumatic stress disorder (Ghoneim, Given the above considerations, 2010; Leslie et al., 2010). But implicit psychology has much to contribute to the memory may also impact on evaluation of what constitutes ‘adequate psychological well-being. There is an anaesthesia’. Unintended anaesthetic intriguing literature in which patients awareness appears to be much more have developed psychopathology widespread than many imagine, and following surgery for which they have evidence suggests that as many as 50 per no memory and which, on the face of it, cent of people who experience this may appeared to be unproblematic at the time go on to develop serious (see review by Wang, psychological problems 2010). However, such as PTSD (Macleod subsequent investigation “unintended anaesthetic & Maycock, 1992). Many of anaesthetic records awareness appears to be anaesthetic awareness has often suggested much more widespread sufferers make no inadequate anaesthesia, than many imagine” complaint, perhaps likely resulting in because of phobic avoidance implicit memory for the of medical personnel or because surgery. It is well they don’t wish to make trouble for established that implicit memory can hospital services. Presently two of us (JA, have a significant impact on behaviour MW) are members of a joint Royal (e.g. Harris et al., 2009; Ijerman & Semin, College of Anaesthetists and Association 2007). For example, experimental work of Anaesthetists of Great Britain and has shown that being ‘primed’ by an Ireland committee that is auditing cases elderly stereotype results in healthy adults of awareness from the whole of the NHS walking away from the laboratory more in the UK and in healthcare services in slowly (Bargh et al., 1996). The influence Ireland (National Audit Project 5 – of implicit memory on post-operative www.NAP5.org). Any reader treating recovery has important implications if the a recently reported case of awareness implicit memory may exacerbate existing should notify the project anxieties, or includes strong emotional (nap5@nap5.com). One of us (MW) content, such as an unfavourable has contributed to the development of prognosis discussed by medical staff a forthcoming NICE report on the use of during the surgery.

42–46.

Russell, I.F. (2008a). BIS-guided isoflurane/relaxant anaesthesia monitored with the isolated forearm technique. British Journal of Anaesthesia, 100(6), 875P–876P. Russell, I.F. (2008b). BIS-guided TCI propofol/remifentanil anaesthesia monitored with the isolated forearm technique. British Journal of Anaesthesia, 100(6), 876P.

Russell, I.F. & Wang, M. (1997). Absence of memory for intraoperative information during surgery under adequate general anaesthesia.

British Journal of Anaesthesia, 78, 3–9.

Russell, I.F. & Wang, M. (2001). Absence of memory for intra-operative information during surgery with total intravenous anaesthesia. British Journal of Anaesthesia, 86, 196–202.

Schwartz, R.S. (2010). General

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EEG monitors to detect consciousness and a Cochrane Review on the prevention of unintended anaesthetic awareness (Messina et al., in press).

Conclusion The research we have reviewed illustrates a point well known to psychologists – that being conscious and being able to remember being conscious are not the same thing. It raises some important questions for psychology. The effects of implicit memory on behaviour have been extensively researched, but effects on psychological well-being are not well understood. Similarly, although we know a lot about explicit and implicit memory, there remain questions about how conscious we need to be, and which brain processes need to operate, to encode memories of different sorts of stimuli.

Finally, this interdisciplinary research shows the usefulness of cognitive psychology for providing a framework for understanding and tackling clinical problems.

Michael Wang is Professor of Clinical Psychology, School of Psychology, University of Leicester mw125@leicester.ac.uk

I Catherine Deeprose

is Lecturer in Psychology, School of Psychology, Plymouth University catherine.deeprose@plymouth.ac.uk I Jackie Andrade

is Professor of Psychology, School of Psychology, Plymouth University jackie.andrade@plymouth.ac.uk I Ian F. Russell

is Consultant Anaesthetist, Hull Royal Infirmary I.F.Russell@hull.ac.uk

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