The Psychologist December 2015

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psychologist vol 28 no 12

december 2015 www.thepsychologist.org.uk

A matter of life and death Celia Kitzinger and Sue Wilkinson on psychologists’ role in helping people with Advance Decisions

letters 950 news 960 careers 1012 looking back 1028

giving a voice to people with dementia 976 the uncensored truth about morality 982 attachment – beyond the interpersonal 986 interview: Gerd Gigerenzer 994

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Contact The British Psychological Society St Andrews House 48 Princess Road East Leicester LE1 7DR 0116 254 9568 mail@bps.org.uk www.bps.org.uk

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The Psychologist www.thepsychologist.org.uk www.psychapp.co.uk psychologist@bps.org.uk

A matter of life and death Celia Kitzinger and Sue Wilkinson argue there’s a role for psychologists in helping people with their Advance Decisions

tinyurl.com/thepsychomag @psychmag Advertising Reach 50,000 psychologists at very reasonable rates.

Display Aaron Hinchcliffe 020 7880 7661 aaron.hinchcliffe@redactive.co.uk Recruitment (in print and online at www.psychapp.co.uk) Giorgio Romano 020 7880 7556 giorgio.romano@redactive.co.uk

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Giving a voice to people with severe dementia 976 Amanda Henwood and Maggie Ellis on ‘Adaptive Interaction’

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The uncensored truth about morality 982 Chelsea Schein, Amelia Goranson and Kurt Gray consider why immoral acts always seem to be those that cause harm – especially to children Attachment – beyond interpersonal relationships 986 Antigonos Sochos considers whether a familiar concept can be extended to social groups, ideological systems and social institutions

November issue 55,364 dispatched Printed by Warners Midlands plc on 100 per cent recycled paper. Please re-use or recycle.

New voices: Can we be scientific about science education?

992 Zayba Ghazali with the latest in our series for budding writers

ISSN 0952-8229

976 Cover Tim Sanders www.timonline.info

© Copyright for all published material is held by the British Psychological Society unless specifically stated otherwise. As the Society is a party to the Copyright Licensing Agency (CLA) agreement, articles in The Psychologist may be copied by libraries and other organisations under the terms of their own CLA licences (www.cla.co.uk). Permission must be obtained from the British Psychological Society for any other use beyond fair dealing authorised by copyright legislation. For further information about copyright and obtaining permissions, e-mail permissions@bps.org.uk.

The publishers have endeavoured to trace the copyright holders of all illustrations. If we have unwittingly infringed copyright, we will be pleased, on being satisfied as to the owner’s title, to pay an appropriate fee.

...digests thinking in metaphors; that dress; sexist packaging; iffy practices; and more from our free Research Digest (see www.researchdigest.org.uk/blog) 966

The Psychologist is the monthly publication of The British Psychological Society. It provides a forum for communication, discussion and controversy among all members of the Society, and aims to fulfil the main object of the Royal Charter, ‘to promote the advancement and diffusion of a knowledge of psychology pure and applied’.

Managing Editor Jon Sutton Assistant Editor Peter Dillon-Hooper Production Mike Thompson

Journalist Ella Rhodes Editorial Assistant Debbie Gordon Research Digest Christian Jarrett (editor), Alex Fradera

Associate Editors Articles Michael Burnett, Paul Curran, Harriet Gross, Rebecca Knibb, Adrian Needs, Paul Redford, Sophie Scott, Mark Wetherell, Jill Wilkinson Conferences Alana James History of Psychology Matt Connolly Interviews Gail Kinman Reviews Kate Johnstone Viewpoints Catherine Loveday International panel Vaughan Bell, Uta Frith, Alex Haslam, Elizabeth Loftus

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the issue ...debates letters the Human Genome Project; volunteering; alien abduction; men; Jeb Bush; reward systems in classrooms; obituaries; and more

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...reports news new Antimicrobial Resistance Champion; Hubbub investigate rest; Antarctic challenge; gender and science subjects; Samuel Johnson Prize for Non-Fiction; new play research centre in Cambridge; and more

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society President’s column; book awards; new Sections; stories in clinical psychology

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...meets interview 994 Lance Workman meets Gerd Gigerenzer, Director of the Max Planck Institute for Human Development and the Harding Center for Risk Literacy in Berlin careers we meet Chartered Psychologist and financial adviser Kim Stephenson; talk community psychology with Maggie Peake; and Emma Nielsen and Kavita Solder remove the ‘clinical’ blinkers and experience the career peaks and troughs together

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one on one with Marcus Munafò, Professor of Biological Psychology at the University of Bristol

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...reviews A Little Life; Ai Weiwei exhibition; Mental – the vacuum cleaner; How to Be Happy; Love and Mercy; Robert Newman’s The Brain Show; and more 1022

‘Do you risk being dead when you’d rather have been alive, or alive when you’d rather have been dead?’ These words, in an e-mail to me from Celia Kitzinger, cut straight to the heart of an issue of personal significance: Celia’s sister, Polly, was kept alive in a vegetative and then minimally conscious state, from which she has emerged to full consciousness but profound physical and neurological disabilities. Celia and Sue Wilkinson now raise awareness of ‘Advance Decisions’: if you might want to refuse treatments in advance of losing the capacity to do so, you can write a legally binding document.

My conversations with Celia and Sue prompted much personal reflection, and they offered to help me write my own Advance Decision.

A draft accompanies the online version of their article: I welcome your feedback. Is it unethical for me to make such calls on behalf of my future self? We hope this article contributes to that debate, but I’m convinced there’s a sea change: people are increasingly demanding control over their own bodies, brains and, ultimately, their destinies.

Dr Jon Sutton Managing Editor @psychmag

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...looks back Madness from the outside in Gail A. Hornstein considers artistic depictions of insanity

The Psychologist and Digest Editorial Advisory Committee Catherine Loveday (Chair), Phil Banyard, Emma Beard, Olivia Craig, Helen Galliard, Harriet Gross, Rowena Hill, Stephen McGlynn, Peter Olusoga, Peter Wright

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Three years ago Go to www.thepsychologist.org.uk for our archive, including a special issue – the five senses and beyond

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Big picture centre-page pull-out Psychologist and medical doctor Jennie Jewitt-Harris uses drawing, collage, and 3D stereo photography to consider the psychology relating to how our memories and opinions are shaped

NEWS

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Tackling the antibiotics problem The potential role for psychologists in combating the rise in antibiotic misuse has been highlighted by Dr Helen Lambert, the new Antimicrobial Resistance (AMR) Champion for the Economic and Social Research Council. Lambert said the rise in resistance to the drugs is as much a societal problem as a technological one.

Lambert, the first to hold the champion position which was set up as part of a £150,000 grant, said social science research was as important as laboratory research in tackling the problem, which is affecting people worldwide. She added: ‘Social organisation is just as important as what happens in the laboratory. We need to find answers to questions such as why antibiotics are often overused, how pharmaceutical supply chains and the organisation of healthcare affect access to antibiotics, or what part farming practices might play in AMR transmission.’ Lambert, a Reader in Medical Anthropology from the University of Bristol’s School of Social and Community Medicine, said she would aim to engage with social scientists to undertake research in the field as well as highlighting the need for social science evidence to lead to new ways of dealing with the threat of infections caused by antibiotic-resistant bacteria.

Professor Karen Rodham (Staffordshire University), Chair of the British Psychological Society’s Division of Health Psychology, pointed out why AMR poses such a problem and how health psychologists in particular could be part of the solution. She outlined evidence that has shown health professionals do not always recognise it as a problem. She said: ‘In a 2013 study by Wood, Phillips, Brookes-Howell and colleagues, 80 primary care clinicians in nine European countries were interviewed and most stated that antibiotic resistance was not a problem in their practice. Another contributory factor concerns patient behaviour, both those who fail to take the whole prescribed course of antibiotics and those who can be very forceful in their demand for antibiotics from their GP.’ But what exactly should be done to take on this issue?

Rodham said knowledge translation was one of the key lines of attack – not only for the health professionals who know that they should not be over-prescribing antibiotics, but also for the

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patients who demand antibiotics inappropriately. She outlined three ways in which health psychologists could lead the way.

First, by providing communication skills training to increase health professionals’ confidence in their ability to have the challenging conversation with patients to explain why the prescription of antibiotics is not appropriate; second to train health professionals to engage in shared decision-making with their patients; and third, by designing theory-informed awareness-raising materials to address misconceptions about the efficacy of antibiotics.

She concluded: ‘In short, health psychologists are very well placed to contribute to solving this thorny issue, and I encourage the members of the Division of Health Psychology to heed the call to arms from the AMR Champion to join the multidisciplinary social scientist army.’

Sarah Golding (University of Surrey) has recently begun a PhD looking into antibiotic use in vets and farmers. She said we should not underestimate the use of antibiotics in the farming industry. She told The Psychologist: ‘Over half of all bacteria that infect humans are transmitted between animals and humans, so it is vital that the problem of increasing AMR is also tackled within veterinary medicine. The One Health initiative is based upon the idea that human, animal, and ecosystem health are inextricably linked and it encourages doctors, veterinarians and public health experts to work together.’

Psychologists who work alongside these professionals, Golding added, can help to tackle AMR by researching methods of knowledge exchange, and evaluating the effectiveness of public health messages. She said: ‘The potential consequences to society from a lack of effective antibiotics are enormous. Multi-drug resistant bacteria are already causing infections in people and animals that simply cannot be treated; rates of these infections are predicted to increase, with potentially devastating effects on our economies, our health and healthcare systems, and our food security. Health psychologists can assist by encouraging different groups of people, including patients, parents, pet-owners, farmers, doctors, pharmacists, and veterinarians, to use antibiotics responsibly.’ ER

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Hubbub actively investigates rest The first ever recipient of the Wellcome Trust Hub award, Hubbub, has celebrated its first birthday. The group comprises an international team of 50 researchers, scientists, broadcasters, public engagement professionals and mental health experts all looking into the dynamics of rest, noise, tumult, activity and work in the modern world.

At the group’s one-year celebration, held at the Wellcome Collection in London, contributors to the work gave short talks on what Hubbub had done so far and its aims for in the future. At the Wellcome Collection’s Hub workspace, where Hubbub is based, there were fascinating demonstrations of research already being carried out in the area.

Dr Felicity Callard (University of Durham), Director of Hubbub, opened the talks and asked what doing nothing at all really meant. She suggested that rest was not only a physiological phenomenon but also a political question. Her Durham colleague, psychologist and writer Professor Charles Fernyhough, discussed the difficulty of describing one’s personal experience of the world and said cognitive neuroscience had been ‘rubbish’ at integrating observations of brain activity and subject experience.

Fernyhough described a new method, descriptive experience sampling (DES), which he has used in work for Hubbub (see tinyurl.com/onft7ng and tinyurl.com/p634qsd). The technique

involves participants wearing a beeper during everyday life, and when the beeper sounds at random intervals they record what they were thinking, and their experience, at that moment. Using DES during fMRI scans, he and his colleagues have found large individual differences suggesting the resting-state itself differs substantially from one person to another.

In other work he found distinct neural activation differences between inner speech and inner hearing during resting states.

BBC Radio 4 All in the Mind presenter and psychology graduate Claudia Hammond (see interview at https://thepsychologist.bps.org.uk/volume22/edition-5/careers) spoke about individual differences in the meaning

assigned to rest. She said the show would be launching the Rest Test (www.resttest.org), a survey designed to

look into people’s attitudes towards rest and how much rest and sleep people from different parts of the world get. The Rest Test will also examine wellbeing and personality to assess whether there are any similarities or differences across certain groups.

In one of the final talks of the evening the Director of the Neurology Department at the Max Planck Institute for Human Cognitive and Brain Sciences, Arno Villringer, asked why it was important for different disciplines to collaborate on large projects such as Hubbub. He said research is often driven by what funders and research boards are looking for, rather than by academics. He added: ‘Hubbub is not just interdisciplinary but is also intrinsically motivated by researchers themselves.’ Villringer gave the example of a DJ at the Max Planck institute who was interested in researching music, emotion and exercise. From his extensive work he patented fitness machines that produce music as someone works out; this in turn has been used to help the recovery of stroke patients. He said Hubbub and large-scale research projects of its kind were like a rocket exploring the universe of potential human knowledge.

In the next year Hubbub is funded for, the research group are hoping to continue their investigations with further collaborations both in the UK and abroad.

Keep an eye on their website – http://hubbubgroup.org. ER

Tweeting about the Bush Republican Presidential Candidate Jeb Bush felt the wrath of psychology graduates on Twitter after he made comments suggesting the best you can hope for with a degree in the subject could be working in a fast-food outlet. Psychologists and others working in the US took to Twitter using the hashtag #thispsychmajor to prove him wrong.

Bush said during a town hall meeting: ‘Universities ought to have skin in the game. When a student shows up, they ought to say, “Hey,

that psych major deal, that philosophy major thing, that’s great, it’s important to have liberal arts … but realize, you’re going to be working at Chick-fil-A.”’ Did his comments hold any truth, and where does this perception of psychology being a pointless degree come from?

As psychologist Dr Vaughan Bell wrote on the Mindhacks blog (tinyurl.com/q79bpnk), the facts don’t back up Bush’s statements: ‘Essentially psychology is slightly below average in terms of

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employability. Tenth out of sixteen but still a college major where more than 9 out of 10 (91.2 per cent) find jobs as recent graduates.’ He also went on to point out that Bush had three psychology majors working in senior positions on his campaign team.

The hashtag inspired some excellent examples of how a psychology degree can be used, sometimes in surprising ways. The mother of one psychology major tweeted that her son was now a Democratic campaign manager, another tweeted that he had become

a paramedic and priest. On the more psychological side many psychologists used the hashtag to speak of their work helping people with debilitating anxiety and suicidal thoughts.

But what is the picture like in the UK? The British Psychological Society’s ‘Destinations’ project is surveying psychology graduates and following their progress after graduation.

Although less than 20 per cent of graduates will end up as psychologists, it has found that psychology graduates leave their degrees with many

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employability skills as well as their more specific psychological training.

Professor Catriona Morrison (Heriot Watt University, and Chair of the Society’s Education and Public Engagement Board) said: ‘Looking at their careers in the short term following graduation will not give us an accurate picture of the gains they have from having studied psychology. Psychology furnishes graduates with the skills they need for a hugely diverse range of occupations – literacy, numeracy, scientific

analysis, group and individual working skills, confidence in data analysis, and so on.’

To inspire some hope in today’s psychology undergraduates, that their degree will be valued even if it may not immediately lead to a career as a psychologist – we propose a UK version of the hashtag, using #thispsychgrad.

Why not add your voice and story to the debate? Copy us in on @psychmag. Also, search ‘graduate employability’ at http://thepsychologist.bps.org. uk to find much more on the topic. ER

CHILDREN OF WAR A psychologist will launch a new programme of joint research projects with the aim of creating interventions to help children whose mental health has been ravaged by the effects of war. The devastating trauma that can affect young minds has been the subject of extensive research by Dr Panos Vostanis (University of Leicester), who launched a cross-cultural research group in November.

Vostanis’s work has observed how war affects children directly through exposure, violence, witnessing and associated fear, through its impact on parents and support networks like communities and schools, and through its aftermath of poverty, displacements and lack of basic needs. Professor Vostanis said: ‘We now have sufficient evidence on the devastating effects of war and other conflicts on children worldwide. We also have increasing access to effective approaches in helping children in the most remote parts of the planet.’

The joint research projects, led by the University of Leicester with collaboration from centres in eight other countries, will look into a number of different mental health problems and form part of the global World Awareness for Children in Trauma (WACIT) campaign.

The programme will focus on promoting child wellbeing by integrating cultural diversity in schools and clinical and community settings such as orphanages.

The launch started with a conference in November entitled ‘Promoting Children’s Health, Development and Wellbeing: Integrating Cultural Diversity’ at the State Islamic University Jakarta, with which the University of Leicester signed a memorandum of understanding last year. During the event Vostanis presented recent research findings from the Greenwood Institute child mental health group at the University of Leicester on how different traumatic events such as war and ethnic conflict affect children, he told The Psychologist: ‘Children express their distress emotionally through nightmares, extreme anxiety, low mood and negative thoughts; but also through aggression, and not functioning with everyday life.’

During Vostanis’s visit to Jakarta, a training model was also implemented with volunteers and staff of non-governmental organisations in the city, on helping children who have experienced trauma and establishing sustainable networks. Vostanis added: ‘The vision of WACIT is to build on our knowledge and experience, and to develop programmes that can be easily used internationally by charities and statutory organisations across different settings and circumstances.’ ER I For a blog post from Vostanis’s visit to Jakarta and more information on WACIT see tinyurl.com/qccd8t5

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Antarctic challenge An intrepid psychologist is taking part in an Antarctic expedition to carry out research into coping in extreme environments.

Nathan Smith (University of Northampton) will join a group of 24 others in March as part of the Leadership on the Edge programme led by famous explorer Robert Swann.

Dr Smith, a lecturer in sports psychology, will be embarking on the 2041 International Antarctic Expedition, which sets sail from the Argentinian port of Ushuaia – a town nicknamed ‘The End of the World’. The 24 expedition members will spend more than two weeks together, in sub-zero temperatures that can get as low as –25C. The expedition group will sail across the Drake Passage to the Antarctic Peninsula where they will disembark at several points along the coast.

The international group will be assessed on a number of psychological factors by Smith. Prior to the expedition participants will fill out surveys assessing personality, personal values, motivations to participate and typical coping strategies used in challenging situations. Smith said: ‘There has been a good deal of research on personality in extreme conditions.

Professors Peter Suedfeld, Lawrence Palinkas, Gro Sandal – who is involved in this project – and Gloria Leon amongst others, have consistently examined personal factors in different types of expedition groups. This has led to a good understanding of the type of person who performs well in such conditions. However, most of this research is conducted with trained people, such as full time expedition-goers, military personnel and astronauts.

In the present study, we are interested in the profile of a civilian international expedition group.’

During the trip, participants will be asked to complete a brief daily expedition diary and contribute to a video-diary at the end of each week. Smith will use this to examine changes in emotions during the expedition, and how members have coped with the stressors faced and group interactions and tensions.

Smith added: ‘Given the work that has come before, I would expect most participants to provide a positive account of their experience during this short-duration expedition and report growth on return to everyday life. I am particularly looking forward to collecting data on group functioning during the expedition to better understand how the diverse group members operate when faced with challenging situations.’

The programme aims to educate future world leaders on the benefits of protecting the natural world, and the importance of developing resilient people and communities. Smith is hoping to raise £5000 towards the cost of his research activities – to sponsor the expedition and directly contribute to research on psychology in extremes visit tinyurl.com/osjgawo. ER I For more on ‘psychology at the end of the world’, see https://thepsychologist.bps.org.uk/volume-24/edition1/psychology-end-world

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Opening doors for girls in science A new report released by the Institute of Physics, supported by the Government Equalities Office, offers guidance to schools that want to improve the accessibility of heavily gendered subjects for all students. The report was presented at a launch event in London, supported by the British Psychological Society, and it suggested schools avoid sexist ‘banter’ and create an environment that promotes equality.

Professor Peter Main, from the Institute of Physics, said the number of girls taking an A-level in the subject had remained steadily low between 1985 and 2012 and despite many initiatives over that time to encourage more girls to take it. Further work from the Institute also found half of state-funded co-ed schools sent no girls to do a physics A-level.

However physics is not the only gender-biased subject, computer science is the worst for under-subscription of girls, while subjects such as psychology and performing arts are skewed in the other direction. Main explained that an earlier report from the Institute, Closing Doors, looked at six gendered subjects – physics, biology, maths, economics, psychology and English – and assessed schools on whether their students’ progression was challenging gender stereotypes or following the same pattern.

They found 81 per cent of schools were essentially not changing well-known gender stereotypes.

They found the schools that were best at challenging stereotypical subject choices were good at challenging stereotypes in all six subjects, not just one, which suggested that a holistic approach to changes in school culture was needed. The Opening Doors report, Main explained, was written following extensive school visits to 10 secondary schools located both on the south coast and in the south west of England.

Among the recommendations to emerge from this work were the suggestion someone in the school’s senior leadership should act as a champion for gender equality; the school environment should encourage equality – for example, Main said, many schools have aspirational quotes on their walls, but these are by and large from men; and that teachers should treat sexist language in the same way they treat racist or homophobic language. In the future, Main said, the Institute would like to hold an annual Opening Doors conference and potentially start an Athena

Swan-type project in schools – to encourage girls who take up physics.

After a fascinating talk on the sociological perspective on gender and science participation by Professor Louise Archer (King’s College London), Dr Stephanie Burnett Heyes (University of Birmingham) spoke about the neuroscience of gender differences and whether these have implications for education. She pointed 015 er 2

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to potential causes of gender differences in the brain including sex hormones which a fetus is exposed to in utero as well as during puberty, chromosome differences and environmental influences.

Burnett Heyes said research has found essential differences between male and female brains, including size: males have bigger brains while women have a larger corpus callosum, which connects the hemispheres of the brain; the amygdala is bigger in men while the hippocampus is bigger, on average, in women. However, she pointed out, these differences may simply point to different brains that are ‘designed’ differently to do the same job.

Burnett Heyes concluded that while evidence for gender differences in brains was compelling, male and female brains are essentially more alike than they are different, and that it was important to look not only at differences in brains between genders but also at individual differences within genders as well.

Psychologist Dr Gijsbert Stoet (University of Glasgow) then examined different theories for gender differences in education. He opened by pointing out the different approaches to gender in

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psychology – the evolutionary view suggests inherent differences exist between genders thanks to previous evolutionary pressures to survive, while social structural theories propose a person’s environment has more bearing on a person’s psychological traits than evolution. He pointed out that while gender disparities often focus on girls and science there was a huge gap in literacy among boys. While girls often thrive with languages boys from all countries lag behind. One study even found that boys with the best-educated mothers still had poorer verbal abilities than girls with the lowesteducated mothers.

There is also a gap in female spatial abilities, and both this and language problems in boys, Stoet said, affect school performance. He also pointed out that, while girls’ stereotypical poorer performance in maths is often spoken about, the gender gap here is still three times less than gaps in language abilities between boys and girls. He also pointed out that gender differences may in part arise from a gender difference in interests. He said men were more interested in jobs to do with things and objects, while women are drawn to careers where they can work with people – this pattern of difference is stable over time even as countries become more developed and opportunities in different careers open up to all genders. However, Stoet did point out that interests are not the only factor when choosing a career.

Stoet concluded that there is a clear gender difference in abilities and attitudes, and biological factors and social influences both play a role. He said too little work had been done on the gap between boys and girls in reading and language abilities, and suggested there should be a rethink of when children are made to make subject choices at schools: could 13 or 14 be too young to make mature choices? ER I To read the Institute of Physics Opening Doors report see tinyurl.com/oohqzry

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A rallying call to respect difference The Samuel Johnson Prize for NonFiction has been won for the first time by a science writer, with Steve Silberman picking up the award for Neurotribes, a book on autism and its history.

Neurotribes was selected from the longlist by the judges who called it a ‘tour de force of archival, journalistic and scientific research, both scholarly and widely accessible’. Chair of judges Anne Applebaum said: ‘We admired Silberman’s work because it is powered by a strongly argued set of beliefs: That we should stop drawing sharp lines between what we assume to be “normal” and “abnormal,” and that we should remember how much the differently-wired human brain has, can and will contribute to our world.

He has injected a hopeful note into a conversation that’s normally dominated by despair.’

Silberman said that the book began as an article for Wired in 2001. He agreed that ‘there’s a tremendous amount of

human suffering in the book, but it also offers the possibility of redemption. It’s an important story that had never been told.

That’s had a terrible effect on global public

health. Since parents don’t know why the number of autism diagnoses went up so startlingly in the 1990s, they are afraid of any number of things.’

Last October, we published a special issue on autism. Several of the contributors to that issue have expressed their admiration for Silberman’s book.

Writing for The Spectator, Professor Simon Baron-Cohen said: ‘His book could serve as a manifesto about extending dignity and human rights for people with autism, just as society has now done with other neurotribes such as the deaf, left-handed or gay. It is for society to respond to his challenge.’

In Science, Professor Francesca Happé said: ‘Neurotribes blows many common beliefs about autism out of the water.

Along the way, it tells the real stories of children and adults with autism, their

TIME FOR SERIOUS RESEARCH ON PLAY ‘It’s an important time for serious research on play’, said Dr David Whitebread, launching the Play in Education Development and Learning (PEDaL) Centre at the University of Cambridge. ‘We need creative, problem solving, deep thinking adults, yet in modern, Westernised, urban environments the opportunities for play are under threat.’

The centre is funded by the LEGO Foundation, and Dr Whitebread said that this seminar celebrated ‘a developed relationship with a company that believes in doing the best they can for children’. LEGO Foundation CEO Hanne Rasmussen talked of ‘building a future where learning through play empowers children to become creative, engaged, lifelong learners.’ She pointed out that children have a natural ‘hands-on, minds on approach to learning – they are our role models.’

To convince the policy makers of this approach, in an era where academic learning and competitive testing are the watchwords, psychologists need evidence. And despite evolutionary, anthropological, neuroscientific and developmental evidence regarding the importance of play (tinyurl.com/n8v82jd), there are still huge gaps. In particular, we don’t know how play has its positive effects: there is not enough research taking a longitudinal approach and seeking causal links. PEDaL will build and share evidence to show value, identify and support programmes that demonstrate results, and look to open minds.

Joining by video link, Professor Kathy Hirsh-Pasek delivered an impassioned plea for schools to stop ‘shoving content into children’s minds’. She advocates the ‘six C’s’, with content alongside collaboration, communication, critical thinking, creative innovation and, above all, confidence – ‘the confidence to build that one block higher and watch it crash down, because even failure has lessons for

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how to have greater success’. It was stirring stuff (although I do hope she had her tongue in cheek when she described ‘playful learning’ as ‘what we might call plearning’).

The audience were then treated to a film of this approach in action, with Bar Hill Community Primary School improving writing skills through playful story making (in research by Whitebread and Marisol Basilio). Children were encouraged to build a LEGO model and use it to ‘storyboard’, moving things around to get ideas for their story. One teacher admitted she initially found it a nightmare, and Whitebread admitted the transition – from ‘fountain of knowledge’ to ‘co-player’ – can be hard.

The LEGO Foundation, a long-time funder of psychological research (https://thepsychologist.bps.org.uk/volume-25/edition8/when-psychologists-become-builders), clearly see the value of their product – Andrew Bollington, Global Head of Research and Learning at the LEGO Foundation, said ‘with a jigsaw puzzle, there is one solution, with three eight-stud bits of LEGO there are more than a thousand’. But it’s not just about the brick. Bollington clearly relishes partnering with bright academic minds on varied projects, and he concluded that it’s about ‘taking this knowledge and actually making a difference with it in the world’. He has been in township schools in South Africa, where there has been a huge investment in early-years learning. But, Bollington said, ‘this just means the worst of primary education a year earlier. You meet these children… the ability to see anything in their eyes has disappeared. If they are learning anything it’s that there’s one right answer to the question their teacher asks them. It’s hard hitting realities out there.’

In a rapidly changing world, where what you learned yesterday is not necessarily relevant tomorrow but the ability to find solutions is crucial, could playful learning be the answer? JS

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families, and the clinicians and researchers trying to understand their very different minds. Neurotribes is part history, part investigative reporting, part biography, and all poetry. … Neurotribes can be seen, in part, as a tribute to the contributions that eccentric and socially awkward outsiders have made to technology, culture, and 21st-century society. It is a beautifully written and thoughtfully crafted book, a historical tour of autism, richly populated with fascinating and engaging characters,

and a rallying call to respect difference.’

Professor Uta Frith told us the book is ‘a must read for all psychologists. Steve’s writing is absolutely gripping, and I am not surprised that the judges of the Samuel Johnson Book Prize fell under its spell and selected him the winner in a very strong field.’ She told us there is a conundrum: ‘If diagnostic criteria for autism had to be broadened, why were they so narrow in the first place?

Silberman takes us on an epic journey through autism’s fractured history to find

the answer. The most astonishing discovery he made is probably the existence of a previously hidden link between Hans Asperger and Leo Kanner.

But, above all, Steve’s humane understanding exhorts us all to embrace diversity.’ JS I Read an extract from Neurotribes at tinyurl.com/pfcpjn2 and find out much more about autism myths and reality in our October 2014 special issue (digital version at http://issuu.com/ thepsychologist/docs/psy10_14autism)

Sowing the seeds on responsibility Elisa Brann, a research assistant at University College London, reports from a workshop on neuroscience and the law Breakthroughs in science have a rippling effect on all aspects of society. Recently, intriguing findings within the fields of neuroscience have shed light on how the human brain makes decisions and triggers actions. Aside from having significant consequences for psychology and philosophy, such findings could also influence a number of legal fields, potentially redefining ‘responsibility’ in the eyes of the law and consequently impacting the lives of many individuals.

In an effort to bring this important issue to the forefront of public debate, a group of experts from both scientific and legal backgrounds gathered together on Tuesday 20 October, in Senate House, London, for a half-day workshop titled ‘Action and Responsibility in Law and Neuroscience: an Interdisciplinary Perspective’.

During the event, supported by the Arts and Humanities Research Council (www.sciculture.ac.uk/project/ sense-of-agency-andresponsibility-integrating-legaland-neurocognitive-accounts), six speakers examined the contrasting ways in which neuroscience and law view decisions and actions, discussing how these different viewpoints should be managed, as well as how the mechanistic scientific study of

human behaviour should feed into wider society.

Offering a scientific perspective, Professor Patrick Haggard, of the UCL Institute of Cognitive Neuroscience, gave an introduction to the current research being conducted in his lab on the sense of agency – the subjective experience of being in control of one’s actions.

Using a method known as ‘mental chronometry’, his team have been able to demonstrate how subjects, when experiencing either fear or anger, also experienced a reduction in their sense of agency, weakening the binding link between their actions and the consequential outcomes.

Haggard stated that whilst such experimental findings would not absolve an individual of their responsibility for a crime, it does offer evidence in support of the legal ‘loss of control’ defence.

In addition, renowned neuroscientist Professor Mike Gazzaniga, of the UCSB Sage Centre for the Study of the Mind, presented an overview of how different levels of science interact with law, highlighting how brain science cannot directly demonstrate

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responsibility. Rather, experimental evidence should assist decision-making processes on the higher level of society, where responsibility must be accounted for. He

expressed how the influence of neuroscience on law is still in its infancy, although there is potential to develop a legal approach akin to evidencebased medicine.

Contributing the contrasting legal perspective, Professor Nicola Lacey, of the London School of Economics, talked about the cognitive conditions required for legal responsibility, presenting the question as to whether or not we need to be conscious of the

relevant features of our actions in order to be held responsible.

Dr Lisa Claydon, of the Open University Business School, also offered practical insight as to how criminal law approaches the issue of responsibility and the ways in which neuroscience can inform this process.

In addition to the four main speakers, two discussants, Professor Walter Sinnott-Armstrong, of the Kenan Institute for Ethics at Duke University, and Professor David Ormerod QC, of the UCL Faculty of Law, assisted in presenting and moderating questions to the speakers, resulting in interesting debates that touched upon a number of recent topical legal cases and reforms.

This half-day meeting not only brought together a group of experts from the fields of science and law, but also welcomed practitioners, academics and students from a range of disciplines including psychiatry, psychology, neuroscience, law, and policy analysis, stimulating discussion and sowing the seeds of future neuroscientific research as well as legal policy development and reformation.

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Life is different for people who think in metaphors

Some people are literal minded – they think in black and white whereas others colour their worlds with metaphor. A new paper published recently in the Journal of Personality and Social Psychology reports on the first standardised measure of this difference, and it shows that having a proclivity for metaphors has real consequences, affecting how people respond to the world around them and even how they interact with others.

A metaphor uses a concrete concept, often sensory (e.g. ‘light’) or location-based (e.g. ‘forward’), to illuminate a nebulous one, such as emotion or time. While this colouring-in can be useful – and can endure, and transform language – it may not be to everyone’s taste, or necessary for the demands of their dayto-day life. To systematically investigate this, an international research team led by Adam Fetterman developed a measure – which asks people to choose their preference for various metaphors or equivalent literal phrases, for example: ‘She uses her head’ vs. ‘She makes rational decisions’ – and administered it to 132 student participants.

The researchers found a good deal of variability between the students in how they responded, including some who only ever selected the metaphor option, and others only the literal alternative. Scores on the measure correlated with a preference for mental imagery, and they correlated with the amount that participants used metaphoric phrases in a free-writing exercise, confirming the test predicts actual behaviour.

Conversely, the test scores were not In Journal of Personality and Social Psychology associated with personality factors, with intellectual ability, nor with the ability to visualise, suggesting the test is measuring a mental style rather than a capacity. So, then, a metaphoric thinking style is an actual thing you can measure. But does it matter?

It does. Take the way metaphors can affect our feelings (known as the ‘metaphor transfer effect’). In a classic example, people rate neutral words as more pleasant when they are printed in a white font rather than a black one – ‘light’ being associated metaphorically with ‘good’. Before now researchers didn’t agree on whether this kind of effect is truly down to reliance on metaphorical representations – a counter explanation is that these effects reflect fundamental, nonconceptual associations between different stimuli that were formed early in life – e.g. through repeated pairings of warmth and affection. However, when Fetterman and his team recruited

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a further 132 students, they found that those who scored higher on having a metaphoric thinking style also tended to show a greater preference for white-font over black-font words, thus providing good evidence that the metaphor transfer effect is aptly named, after all.

Another study took this out into the real world, tracking 136 people over a fortnight to see whether the amount of sweet food consumed on a given day influenced how agreeable they were in their interactions with other people. I would have imagined that if there were any effect, it might be simply due to a glucose buzz.

But no. The link between sweet food consumption and people’s behaviour that the researchers found was mostly down to thinking style. That is, the effect was much stronger among the highly metaphorical participants: when they were sweet in tooth, they were also sweet in nature (thus adding a nuance to previous research on this link).

Remember, too, that metaphors are supposed to illuminate, particularly when it comes to abstract concepts that can be hard to pin down, like the subtleties of emotions. In another experiment, Fetterman’s team measured participants’ ability to correctly judge most people’s typical emotional response in different situations, such as when something unpleasant was happening that couldn’t be stopped. In this example, the correct response was ‘distressed’. Crucially, people who scored highly in metaphoric thinking style tended to perform better at this task.

This suggests their colourful thinking style actually gave them greater insight into emotions.

In a final experiment, 50 participants spent five minutes each day for a week writing about their negative emotions, and they were encouraged to be either literal, ‘I felt anxious or confused’, or metaphorical: ‘I felt like a leaf in the wind’. The participants’ depression symptoms and negative emotion ratings, which were recorded at the start and end of the week, were found to drop in the metaphorical condition only. Although this experiment didn’t measure participants’ metaphoric style, it shows that being encouraged to adopt this style is more effective in alleviating negative feelings on troubling topics.

From an experimenter’s perspective, it’s interesting to note that in the font-colour study, participants who were well below average in metaphor usage didn’t show any significant preference for white words: those transfer effects don’t work on me, Jedi. In fact, if the researchers had just looked at the average scores for the participants as a whole, the metaphor effect would have been undetectable. This suggests the new measure of metaphorical thinking style can help us to investigate meaning-related effects that might be elusive. For example, it might have value in pinning down findings in the contested area of social priming, helping to identity those people likely to be influenced by such effects. Furthermore, we’ve seen that a metaphorical thinking style has emotional benefits, but could it also be useful in non-emotional domains, for instance in the extent to which fishy smells activate sceptical thinking?

One thing’s for sure – whether we prefer a crystal-clear monochrome take on the world, or to ladle on the technicolour, it’s clear that metaphor usage filters how we take in the world, for good and ill. AF

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First brain scan study to feature that dress In Cortex Earlier this year a dress nearly broke the internet. A photo of the striped frock (which is actually blue and black) was posted on Tumblr and it quickly became apparent that it looked very different to different people, spawning furious arguments and lively scientific commentary.

Specifically, people disagreed vehemently over whether it was white and gold or blue and black. Now, writing in the journal Cortex, researchers in Germany have published the first study to scan people’s brains while they look at the dress, and the neural findings appear to support earlier, psychological explanations of the phenomenon.

When the dress story went viral, psychologists were quick to explain that this dress provided a striking example of how our perception of the world arises from a combination of incoming sensory information and our interpretation of that information. In the case of colour perception, when light bounces off an object and hits your retina, its mix of wavelengths is determined by the colour of the object and the nature of the light source illuminating it. Your brain has to disentangle the two. Usually it does this very well allowing for something called ‘colour constancy’ – the way that objects of the same colour are perceived the same even under different illumination conditions.

However, the mental processing involved in colour perception does leave room for interpretation and ambiguity, especially when the nature of the background illumination is unclear as is the case with the photo of the dress.

For the new study, Lara Schlaffke and her colleagues scanned the brains of 28 people with normal vision while they looked at the photo of the dress. Fourteen of the participants see the dress as white and gold

and 14 see it as blue and black. The key finding is that the people who see the dress as white and gold showed extra activation in a raft of brain areas, including in frontal, parietal (near the crown of the head) and temporal (near the ears) regions. Yet, no group differences emerged in a control condition when the participants simply looked at large coloured squares that matched two of the colours that feature in the dress, but without any contextual information also visible.

These results are broadly consistent with the idea that the white/gold perceivers were engaged in more interpretative mental processing when looking at the dress. To oversimplify, their perceptual experience of the dress is based less purely on the ‘bottom-up’, raw sensory information arriving at their eyes, and is distorted more by their own assumptions and expectations about the background illumination. The extra activity in their brains during the dress viewing is likely, at least in part, to be a neural correlate of all this interpretative, ‘top-down’ processing.

What the new study can’t answer is whether this extra neural processing (or which aspects of it) in the white/gold group is the cause of their perceptual experience of the dress, or the consequence. However, the researchers describe some future approaches that could help address this quasi-philosophical conundrum: for example, by using transcranial magnetic stimulation (TMS) to temporarily disrupt the extra localised neural activity seen in the people who experience the dress as white and gold, we could ask: will they still experience the illusion? CJ

How jurors can be misled by emotional testimony and gruesome photos In Psychiatry, Psychology and Law As a juror in a criminal trial, you are meant to make a judgement of the defendant’s guilt or innocence based on the evidence and arguments presented before you. In many trials, however, alongside the facts of the case, material and statements are allowed that don’t in themselves speak to the culpability of the defendant. In a murder trial, for instance, a parent may take the stand and describe how their life has been destroyed by the loss of their child (the

The material in this section is taken from the Society’s Research Digest blog at www.bps.org.uk/digest, and is written by its editor Dr Christian Jarrett and contributor Dr Alex Fradera.

Visit the blog for full coverage, additional current reports, an archive, comment, our blog’s (now sold out) 10th birthday party, and the third episode of our ‘PsychCrunch’ podcast – how to win an argument!

Subscribe to the free fortnightly e-mail, friend, follow, advertise to our huge and international audience and more via www.bps.org.uk/digest

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victim in the case). Similarly, the prosecution may present disturbing crime scene photographs of the victim, which don’t say anything about the defendant’s culpability, but do exert an emotional effect in the courtroom.

Writing in Psychiatry, Psychology and Law, Kayo Matsuo and Yuji Itoh at Keio University in Japan describe how they tested the effects of these kinds of evidence on the decision making of 127 students (89 women) who were asked to play the role of juror in a fictional case. The students listened to a man read out a transcript of a murder trial, in which a homeless man stood accused of murdering a young female student so that he would be sent to jail and no longer be homeless. Factually speaking the prosecution’s case was weak, and while the defendant had confessed to the crime, he later recanted and pleaded innocence.

Among the students who heard a version of the trial transcript that featured no emotional testimony from the victim’s father, nor any photos of the victim’s body, 46 per cent of them said they thought the homeless man was guilty. Other students heard a version that did contain testimony from the victim’s father, in which he

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expressed his grief, described how kind and bright his daughter was, and how much anger he felt toward the defendant.

Although logically this testimony did not provide evidence of the defendant’s guilt, 71 per cent of the students who heard the father’s words said they thought the defendant was guilty, and this rose to 79 per cent if they were also shown photographs of the victim’s fatally wounded body.

The effect of the father’s emotional testimony appeared to be explained at least

in part by the negative emotions it aroused in the students, such as anger and disgust.

Among the students who rendered a guilty verdict those who heard the father’s emotional testimony also tended to support a harsher sentence for the defendant – 33 per cent said he should receive the death penalty compared with just 16 per cent of those who did not hear the father's testimony. It’s worth bearing in mind that the father’s emotional testimony was read out to students by the narrator in a neutral

voice – the psychological effects of this kind of testimony would likely be far greater in a real-life trial situation.

The researchers said their results showed that ‘emotional information upsets jurors and disturbs their legal decisions’.

They concluded that ‘in order to avoid false convictions and ensure a better trial system, psychological studies conducted in legal settings should explore the function of emotional evidence as well as the role of emotions’. CJ

People prefer food that comes in sexist packaging

LINK FEAST A Brief History of Our Desire to Peer into the Brain Our attempts to unlock the secrets of the mind range from the pseudoscience of ‘bumpology’ to the surprising part played by The Beatles, writes Melissa Hogenboom for BBC Future. www.bbc.com/future/story/20151028-a-brief-history-of-our-desireto-peer-into-the-brain Inside the Mind of God Punitive Big Brother; cosmic petty-thief-catcher; vigilant landlord.

Why is God so interested in bad behaviour? An Aeon essay by Benjamin Grant Purzycki. http://aeon.co/magazine/culture/why-does-god-care-only-aboutstuff-that-matters Can Neuroscience Explain Why People Are Sexist?

A Japanese study that Digest editor Christian Jarrett covered for New York's Science of Us claims to have found the brain-scan imprint of misogynistic views. http://nymag.com/scienceofus/2015/10/can-neuroscience-explainwhy-people-are-sexist.html How the Internet Has Changed Bullying Before the internet, bullying ended when you withdrew from whatever environment you were in, writes Mario Konnikova at the New Yorker.

But now, the bullying dynamic is harder to contain and harder to ignore. www.newyorker.com/science/maria-konnikova/how-the-internethas-changed-bullying The Life Scientific: Robert Plomin The behavioural geneticist is the latest guest on BBC Radio 4's show that profiles the lives of influential scientists (find his research featured in our archive via www.bps.org.uk/digest). www.bbc.co.uk/programmes/b06j1qts Teenage Mental Health (audio) BBC Radio 4’s All in the Mind is back with a new series and in the first episode Claudia Hammond is joined by a panel of experts to discuss teenage mental health. www.bbc.co.uk/programmes/b06kch0z

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In Social Psychology Putting unhealthy food in macho masculine packaging, or healthy food in feminine-themed packaging, makes it taste nicer, and people are willing to pay more for it. That’s according to a new study in Social Psychology.

Luke Zhu and his colleagues made their finding by asking participants (58 men and 82 women) at a local fair to tastetest a blueberry muffin. Every participant tasted the exact same kind of muffin, but it was packaged in different ways for different participants. When it was labelled as a ‘Mega Muffin’ (supposedly conveying an unhealthy variety) and its packaging was masculine (depicting men playing football) both men and women tended to rate the muffin as tastier, and they were willing to pay more for it, as compared with when the Mega Muffin was in stereotypically feminine packaging, with a woman ballet dancer depicted in the background. Similarly, participants’ ratings of the muffin were more positive if it was labelled as a Health Muffin and its packaging was feminine as opposed to masculine.

If you’re thinking that there’s something ridiculously retro about the implied sexism in these findings, you’ll be heartened to know that in another experiment the researchers showed that if the gendered packaging was taken too far, the results actually switched. With the Mega Muffin labelled as ‘The Muffin For Real Men’ alongside the same football imagery used previously, participants were on

average willing to pay less for it than when the packaging contained the football imagery only.

In another experiment, Zhu and his team changed tack to look at whether reminders of gender could affect people’s food preferences in line with the gender stereotypes around food.

Participants completed a wordpuzzle task that involved descrambling seven lists of words into coherent sentences.

When the word lists each contained a word pertaining to masculinity (such as men or hunting) male and female participants subsequently expressed food preferences that were more stereotypically male (for example, they said they’d prefer fried chicken over baked chicken) and said that they had weaker intentions to eat more healthily in the future. When the word lists contained a femininerelated word, the effects worked in the other direction, prompting a preference for healthy food and plans to eat more healthily in the future.

The researchers said they had shown the ‘power of cultural stereotypes to implicitly shape food preferences’ and they believe their findings have implications for public health policy. The idea of pandering to gender stereotypes may make some people uncomfortable, but if these effects can be replicated in future research, the implication, at least in the short term, is that healthy food products are likely to appeal to more people, whether male or female, if they are packaged in a ‘feminine’ way. CJ

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Survey that revealed iffy practices was itself iffy In Social Psychological and Personality Science Four years ago we were the first to break the disconcerting news that a survey of thousands of US psychologists had found their use of ‘questionable research practices’ was commonplace: that is, their tendency to do things like failing to report all the measures they had taken, or collecting more data after looking to see if their results were significant.

The story went viral, further aggravating the storm cloud sitting over the discipline at that time (it was shortly after the Diederik Stapel fraud case). But now in an ironic development, two leading psychologists have published a damning critique of the ‘questionable research practices’ survey, raising concerns about the methods that were used and the way the findings were interpreted.

‘Claims about violations of the standards of good science deserve to be held to the high standards they endorse,’ they write, ‘not the least in light of the damage that misleading inferences can cause.’

Klaus Fiedler at the University of Heidelberg and Norbert Schwarz at the University of Southern California, Los Angeles, point out that many of the survey items were hopelessly vague and ambiguous. For example, the survey asked whether respondents had ‘failed to report all of a study’s dependent measures’. Fiedler and Schwarz say it would be unrealistic for any psychologist to always report every single thing they measure. Really, they argue, the question should ask whether respondents had failed to report all of a study’s measures that were relevant for a particular finding.

The pair highlight similar concerns with other items in the survey.

Another issue they highlight is that for a respondent to demonstrate 100 per cent innocence they would need to answer ‘No’ repeatedly to all 10 items on the survey. When people complete surveys, they tend to show an aversion to always providing the same answer, so really a survey should be compiled such that scores toward a given construct or characteristic are based on a mix of ‘Yes’ and ‘No’ answers. The original survey also asked if respondents ‘had ever’ conducted any of the questionable practices in question, which speaks to the proportion of the sample who’d ever committed a given research ‘sin’, but the authors and media went beyond this, to make assumptions about the prevalence of these behaviours. Fiedler and Schwarz liken this logical error to making inferences about church attendance based on the proportion of people who have ever entered a church.

Fiedler and Schwarz go on to report the findings of their own ‘questionable research practices’ survey, which they gave to 1138 members of the German Psychological Association. Their survey contained the same 10 items that were used in the original 2011 survey, but with less ambiguous wording. They also asked their respondents not only if they’d ever committed the dubious practices but also in what proportion of their published work they’d done so.

The new survey finds firstly that admission rates for ever having committed questionable practices were lower than in the 2011 survey – this could be because of the tightened wording, or because this was a sample of psychologists from a different culture. Secondly and more importantly, argue Fiedler and Schwarz, is that combining the information they collected about prevalence leads to a big fall in survey outcomes. For example, the new survey found that 47 per cent of respondents admitted to at least once claiming to have predicted an unexpected finding. Yet the average prevalence figure for this practice was just 10 per cent (i.e. respondents on average said they did this for 10 per cent of their published work).

Fiedler and Schwarz agree it is important to address issues of scientific misconduct, but they worry that the misinterpretation of a poorly executed survey risks spreading a harmful message – that questionable research practices are rife, encouraging more people to think ‘everybody else is doing it, why shouldn’t I?’. CJ

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DIGEST DIGESTED Full reports are available at www.bps.org.uk/digest A study of hundreds of pairs of twins has helped to pick apart the root causes of procrastination. The data suggest the tendency to procrastinate is at least partly inherited, and that many of the genes that influence procrastination are also involved in executive function and goal management. Journal of Experimental Psychology: General When we’re anticipating a task, we tend to focus on its extrinsic benefits, such as what we’ll get paid. However, once we get going, we’re much more interested in what the experience is actually like – that is, in its intrinsic rewards. Researchers demonstrated this by asking participants to predict how long they’d persist with a task that involved judging jokes or dull computer manuals. Journal of Personality and Social Psychology Modern social psychology textbooks in the US present a biased version of Milgram’s so-called obedience experiments. A new analysis found that the market-leading books failed to mention any contemporary criticisms of Milgram’s studies. Coverage of traditional criticisms wasn’t much better. Teaching of Psychology People who were raised in adversity tend to perform better on a measure of mental flexibility (the ability to switch goals) than their peers who had more stable childhoods. The finding is consistent with the idea that people aren’t passively victimised by their circumstances but that they adapt to them. Journal of Personality and Social Psychology In can be taxing spending your life feeling like all mishaps are somehow your fault. However, there may be an upside to such ‘guilt-proneness’ – a new study finds that people with this trait are better than average at recognising other people’s emotions from their facial expressions. Cognition and Emotion The stereotype is that skilled computer programmers are awkward and unfriendly. A new meta-analysis finds that introversion is correlated with programming ability, but agreeableness and neuroticism are not. And the strongest personality correlate of programming ability was openness to experience. Journal of Research in Personality Sitting in a car affects people’s perceptions of distance, perhaps helping to explain why drivers often make misjudgements at traffic lights. Participants judged how far away a cone was as they sat in a car, or on a chair, or on a chair but behind a ‘windscreen’. Those in the car underestimated by more than those in the comparison conditions; even more so after they had spent a few minutes driving the car. Psychonomic Bulletin and Review

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their own. Could it be time for psychologists to fill a gap in an area that is literally ‘life and death’?

A matter of life and death Celia Kitzinger and Sue Wilkinson argue there’s a role for psychologists in helping people with their Advance Decisions

How can psychologists help people plan ahead for their future medical treatment?

resources

How do Advance Decisions address people’s concerns with quality vs.quantity of life?

ADA (Advance Decisions Assistance) is a small charity, set up in June 2015, to: raise awareness of ADs and help people to write them (including simple examples and one-to-one support); provide training for GPs, psychologists and other healthcare professionals; conduct and support research into ADs: www.ADassistance.org.uk E-mail: info@ADassistance.org.uk Tel: 01757 289453

Castillo, L.S., Williams, B.A., Hooper, S.M. et al. (2011). Lost in translation: The unintended consequences of advance directive law on clinical care. Annals of Internal Medicine, 154(2), 121–128.

Ditto, P.H. & Hawkins, A.H. (2005).

Advance Directives and cancer decision making near the end of life.

Health Psychology, 24(4), S63–S70.

Ditto, P.H., Hawkins, N.A. & Pizarro, D.A.

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ll of us are at risk of a sudden loss of capacity to make our own medical decisions – for example through a car accident or sporting injury that causes severe brain injuries. Older people are at additional risk of losing capacity due to brain injuries caused by falls (the leading cause of traumatic brain injury among people over 65: Tromp et al., 2001), or by age-related medical conditions that can strike suddenly (like a stroke) or cause gradual loss of capacity (such as dementia). Many of us will lose the capacity to make our own decisions towards the end of life.

When someone is unable to give consent, the default position is that clinicians provide medical treatments that they believe to be in the person’s best interests. These treatments may well be what we would have wanted if we could have chosen for ourselves. But sometimes they are not. Some people have religious reasons for wanting to refuse particular treatments – like a Jehovah’s Witness who refuses blood transfusion. Other treatments may be unwanted because they are experienced not as saving life but as prolonging the dying process, or as maintaining a quality of life that the person would not consider worthwhile.

Person-centred care, at any age, is important to the profession of psychology.

Advance Decisions (ADs) are a vital tool for protecting people’s rights not to receive medical treatments that they do not want – a right that may be under threat simply because they have become unable to make or communicate their decision. Yet very few people have written

A

references

questions

Many of us will lose the capacity to make our own decisions at some point in our life, and we may then receive medical treatment we would not have chosen for ourselves. Through the ‘Advance Decision’ (AD), the law provides the opportunity to refuse such treatments in advance. We argue that psychologists have a key role to play in raising awareness of ADs and helping people to write them.

(2005). Imagining the end of life: On the psychology of advance medical decision making. Motivation and Emotion, 29(4), 481–502.

Dresser, R. (1995). Dworkin on dementia: Elegant theory, questionable policy.

Hastings Centre Report, 25(6), 32–38.

Dworkin, R. (1993). Life’s dominion. New York: Knopf-Doubleday.

Fagerlin, A., Ditto, P.H., Danks, J.H. et al.

(2001). Projection in surrogate

Refusing treatment People’s views about quality of life differ widely, and may change over time.

Psychological adaptation to chronic illness and disability has been extensively studied from a wide range of perspectives (e.g. Livneh & Parker, 2005; Smith & Sparkes, 2005). Many people adapt, finding meaning and value in a life they would previously have considered unbearable (Kampman et al., 2015).

Others do not – especially when maintaining their lives requires ongoing treatments they experience as burdensome. Patients with decisionmaking capacity may refuse further cancer treatments, prioritising ‘quality’ over ‘quantity’ of life, or request the withdrawal of ventilation with the consequence that they die (Phelps et al., 2015).

In an important court case in 2002 that set the precedent for later judgments, a 43-year-old former senior social worker who was paralysed from the neck down after a bleed in her spinal cord decided that life as a quadriplegic on a ventilator was intolerable to her. She asked the doctors to remove the ventilator and took them to court when they refused.

Granting her request, the judge made it clear that ‘a mentally competent patient has an absolute right to refuse to consent to treatment for any reason, rational or irrational, or for no reason at all, even where that decision may lead to his or her own death’ (Ms B v. An NHS Hospital Trust [2002] EWHC 429 (Fam)).

When people have the mental capacity to refuse treatments their refusals are binding. Through the mechanism of the AD, the law provides the opportunity for us to refuse in advance treatments that might otherwise be provided for us once we lose capacity. We can use an AD to say, for example, ‘I refuse a feeding tube if I have dementia’ or ‘I refuse a feeding

decisions about life-sustaining medical treatments. Health Psychology, 20(3), 166–175.

Gwande, A. (2014). Being mortal. New York: Metropolitan Books.

Henry, C. & Seymour, J. (2008). Advance care planning: A guide for health and social care staff. London: Department of Health. Available at: www.ncpc.org.uk/sites/default/files/A dvanceCarePlanning.pdf

Hickman, S.E. (2002). Improving communication near the end of life.

American Behavioral Scientist, 46(2), 252–267.

Hirschman, K.B., Kapo, J.M. & Karlawish, J.H.T. (2008). Identifying the factors that facilitate or hinder advance planning by persons with dementia. Alzheimer Disease and Associated Disorders, 22(3), 293–298.

Kampman, H., Hefferon, K., Wilson, M. et

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advance decisions

‘I do not consent to be kept alive…

I should like to die in my own bed’ We have personal experience in our family of the way in which an AD can work to support an older person’s wishes at the end of life. Sheila Kitzinger (Celia’s mother, pictured) campaigned for autonomy and choice in childbirth, challenging its medicalisation. She expressed the same values around dying, making her own choices to refuse treatment when she had capacity, and writing an AD to refuse treatments for when she might lack capacity. At 86 she had cancer and many other diseases of old age and reached a point where she declined further investigations or interventions. Her AD (signed and witnessed in accordance with the requirements) stated: If the time comes when I can no longer take part in decisions for my own future, I want to receive whatever quantity of drugs can keep me free from pain or distress, even if death is hastened. If there is no reasonable prospect of recovery I do not consent to be kept alive by artificial means. I do not wish to be transferred to hospital and should like to die in my own bed.

When her GP surgery tried to insist, a few weeks before she died, that Sheila should be transferred to hospital after a ‘mini-stroke’, she said no. The GP questioned her mental capacity to refuse hospitalisation. We read out her AD and she stayed home. Later the AD empowered both us, as family members, and also her healthcare providers, to provide ‘person-centred care’ with confidence that we knew what Sheila’s wishes were. (For more details see Kitzinger & Kitzinger, 2015.)

tube, ventilator, CPR and life-prolonging antibiotics if I am in a continuing vegetative state’. One man with motor neurone disease dictated an AD (using eye movement on his alphabet board) refusing all life-prolonging treatment (including ventilator and tube feeding) ‘in the event that my disease progresses to a stage where I am unable to communicate my needs and lose the ability to have any control over my decisions of my care and management’ (X Primary Care Trust v. XB and YB [2012] EWHC 1390 (Fam)) – a decision supported by the court. Provided the AD is properly completed and applicable to the situation the person is in, then these refusals are legally binding in the same way as a contemporaneous decision by someone with mental capacity.

ADs have a long history in common law (as ‘living wills’) and were given statutory force in England and Wales by the Mental Capacity Act 2005. (In Scotland the relevant legislation is the

al. (2015). ‘I can do things now that people thought were impossible, actually things that I thought were impossible’: A meta-synthesis of the qualitative findings on posttraumatic growth and severe physical injury.

Canadian Psychology – Psychologie Canadienne, 56(3), 283–294.

Kitzinger, C. (2014). Advance Decisions: Do they work in practice? Elder Law Journal, 4(2), 198–204.

Adults with Incapacity (Scotland) Act 2000, under which ADs are ‘potentially binding’; Northern Ireland has no comparable legislation at present.)

Various similar legally binding arrangements are available internationally (Negri, 2011). A valid Advance Decision that refuses life-prolonging treatment, according to the Mental Capacity Act 2005, must: I be a written document specifying which treatments are refused under what circumstances; I state that the decisions apply even if your life is shortened as a result; I be from a person over 18 and with the mental capacity to make these decisions (capacity is decision-specific and must be presumed unless there is evidence to the contrary); and I be signed in the presence of a witness who also signs it.

An AD offers a legal mechanism for ensuring that a person’s life is not

Kitzinger, C. & Kitzinger, J. (2015, 19 June). How to plan for a good death.

The Guardian. tinyurl.com/oj5qyxj Livneh, H. & Parker, R.M. (2005).

Psychological adaptation to disability, Rehabilitation Counseling Bulletin, 49, 17–28.

Marsh, H. (2014). Do no harm. London: Phoenix.

Morrison, R.S., Morrison, E.W. & Glickman, D.F. (1994). Physician

read discuss contribute at www.thepsychologist.org.uk

extended with medical technologies against their – capacitous – wishes (Wilkinson, 2014b). An Advance Decision is not the same as Advance Care Planning and/or writing Advance Statements laying out wishes for endof-life care (Henry & Seymour, 2008).

Such planning tools are very helpful in providing a guide to carers, and they can cover a range of non-medical issues, such as preferences in food, music, TV programmes and clothing. Advance Statements must be considered by the people providing treatment when they determine what is in a person’s best interests, but carers are not legally bound to follow them. This makes them very different from an AD, which is legally binding. If someone administers treatment knowing that the patient has refused it in a valid and applicable AD they could be charged with a criminal offence. Not everyone feels so strongly about treatment refusal that they want to ensure that it is legally binding – but for

reluctance to discuss advance directives: An empiric investigation of potential barriers. Archives of Internal Medicine, 154(20), 2311–2318.

Negri, S. (Ed.) (2011). Self-determination, dignity and end-of-life care. Leiden: Martinus Nijhoff.

Phelps, K., Regen, E., Oliver, D. et al.

Withdrawal of ventilation at the patient's request in MND: A retrospective exploration of the

ethical and legal issues that have arisen for doctors in the UK. BMJ Supportive & Palliative Care [Advance online publication]. doi:10.1136/bmjspcare-2014- 000826 Pyszczynski, T., Greenberg, J., Solomon, S. & Maxfield, M. (2006). On the unique psychological import of the human awareness of mortality.

Psychological Inquiry, 17, 328–356.

Sachs, G.A., Stocking, C.B. & Miles, S.H.

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those who do, ADs (and not Advance Statements) are the appropriate mechanism.

Advance Decisions are for those who are confident that they are personally and ethically committed to prospective autonomy (i.e. to making decisions now about an unknown future). For those who are less sure, there is the alternative of granting a Lasting Power of Attorney for Health and Welfare (see box). A person granted this power would be able to make decisions for them (once their own capacity to do so is lost) that take into account the quality of life they are apparently experiencing at the time.

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Do Advance Decisions work?

To be effective in practice an AD must do the following (see Kitzinger, 2014): I Reflect the person’s wishes. In reviewing draft and existing ADs, we have found that this is not always the case,

especially for those prepared by solicitors from a template or downloaded by the person from an internet source. Sometimes people have misunderstood terminology or have not been offered the opportunity to think through the various options and reflect on alternative scenarios.

Be available when needed. There is no national register (such as the organ donation register) where ADs can be lodged. As a minimum, an AD needs to be lodged with a GP and put on the individual’s medical record; copies should also be given to other relevant healthcare providers, and to trusted family members and/or friends.

Meet with compliance by health care providers (or, if necessary, the courts).

Healthcare providers can be very anxious about withholding or withdrawing treatment – even when a capacitous person refuses it, and still more when they are dependent on a

An alternative: Lasting Power of Attorney for Health and Welfare Creating a Lasting Power of Attorney for Health and Welfare (LPA(H&W)) is an alternative way of taking primary responsibility for medical decision making out of the hands of clinicians. With an AD the person retains decision-making rights and exercises them prospectively, documenting their decisions in advance of losing mental capacity. With an LPA(H&W), the person appoints a trusted other (relative, friend or professional) to make decisions on their behalf, once they have lost mental capacity.

But not everyone has someone they trust to act as an LPA(H&W), and even if they do, many people worry about the burden it might impose on a loved one who is then charged with making difficult decisions on their behalf, or wonder whether the person would have the ‘courage’ to make a decision that allowed death in a situation where that might be their preferred outcome. There is also an important distinction between the basis for decision making, which can be ethically and practically consequential: an AD is based on what the person wants for themselves, whereas an LPA(H&W) authorises decisions based on the criterion of ‘best interests’.

It is possible to have both an AD and an LPA(H&W) by drawing them up to cover nonoverlapping decisions (this takes considerable care to get right).

For more information on LPAs – and application forms – visit www.gov.uk/power-ofattorney/overview

(1992). Empowerment of the older patient: A randomized, controlled trial to increase discussion and use of advance directives. Journal of the American Geriatrics Society, 40(3), 269–273.

Schiff, R., Rajkumar, C. & Bulpitt, C. (2000). Views of elderly people on living wills: Interview study. British Medical Journal, 320, 1639–1640.

Sharman, S.J., Garry, M., Jacobsen, J.A.

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et al. (2008). False memories for endof-life decisions. Health Psychology, 27(2), 291–296.

Smith, B. & Sparkes, A.C. (2005). Men, sport, spinal cord injury, and narratives of hope. Social Science & Medicine, 61, 1095–1105.

Tromp A.M., Pluijm S.M.F., Smit J.H. et al. (2001). Fall-risk screening test: A prospective study on predictors for falls in community-dwelling elderly.

written document for the refusal.

Nonetheless there is evidence that refusals will be respected, especially where family or friends support the AD. Several cases have now reached court and valid and applicable ADs have always been upheld.

Supporting people in writing Advance Decisions A YouGov poll (see tinyurl.com/ppaaze3) revealed that 82 per cent of people in Britain have strong views about their end-of-life care, yet only 4 per cent report having written an AD. (Only healthy adults living in the community were polled – the figures are likely to be higher for older people with poorer health, often living in institutions, and/or those specifically planning for end-of-life.) This is partly because many people are still unaware that it is possible to make a legally binding decision about treatment in advance of losing capacity (Schiff et al., 2000) and partly because many people believe – wrongly – that ‘next of kin’ will be able to make end-of-life decisions on their behalf. In fact, family members (as such) have no decision-making power for adults in English law – and, in any case, surrogate decision making is notoriously inaccurate (Fagerlin et al., 2001).

Other reasons for the lack of uptake of ADs are avoidance and procrastination in talking about death and dying (Hirschman et al., 2008; Sachs et al., 1992) and the difficulties medical practitioners experience initiating end-oflife discussions (Morrison et al., 1994).

There are also ‘practical roadblocks’, such as difficulties understanding the law, unclear procedures and complex paperwork (Castillo et al., 2011).

There is very little professional support for people wanting to write ADs. Although Advance Care Plans sometimes (not always) include information about ADs, it seems that they are rarely completed via this route. People often turn to doctors (primarily GPs) or solicitors for help with writing an AD,

Journal of Clinical Epidemiology, 54(8), 837–844.

Wilkinson, S. (2014a). An analysis of calls to the Compassion in Dying information line (2013). Available via tinyurl.com/pwaq78t Wilkinson, S. (2014b). Dementia and Advance Decisions. Available at tinyurl.com/nulb54b.

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Psychologists have the right expertise base to provide support for people wanting to write ADs

but neither GPs nor solicitors can offer sufficient time or expertise – and they often lack the knowledge and communication skills required (Kitzinger, 2014; Wilkinson, 2014a). The main providers of help for people who want ADs are charities such as Compassion in Dying, Age UK, the Alzheimer’s Society, the Motor Neurone Disease Association, and our own charity, ADA (Advance Decisions Assistance).

So what role for psychologists?

Psychologists have the right expertise base to provide support for people wanting to write ADs, bringing professional skills in communication and counselling, and academic and professional knowledge in areas such as information processing, decision making, and mental health. But so far psychologists have been very little involved in this domain. Most research on ADs comes from disciplines other than psychology – medicine, nursing, medical ethics, philosophy and the law. There is some research from the US that explores psychological theory and empirical evidence relating to ADs – including psychological barriers to thinking about and planning for death (Pyszczynski et

al., 2006); communication problems in end-of-life conversations (Hickman, 2002); variable stability of treatment preferences (Ditto et al., 2005); ‘false memories’ for treatment decisions (Sharman et al., 2008); and failures in predictive capacity for end-of-life preferences (Ditto & Hawkins, 2005).

However, there is very little research on – or practice-based evidence of – psychologists working with clients to explore their end-of-life wishes in a way that supports them in writing an AD. The charity we have set up is designed to fill this gap.

Our expertise on ADs was developed through our work in the Coma and Disorders of Consciousness Research Centre (cdoc.org.uk; see also the multimedia resource at www.tinyurl.com/vandmcs); through an ESRC-funded seminar series on ADs; and through collaborative research with the charity Compassion in Dying to evaluate their services in relation to end-of-life issues (Wilkinson, 2014a).

We provide CPD training to professional groups including care home staff, neurologists, independent mental capacity advocates and GPs. None of these groups is as well placed to offer individual, personalised support for ADs as are – at least potentially – psychologists.

Psychologists taking on this role would need training in order to develop a sound understanding of the specific legal, ethical and medical issues, as well as some of the psychological and practical issues involved in hands-on work – for example, managing uncertain or fluctuating capacity and supporting assisted decision making, understanding different attitudes to risk and uncertainty, and supporting clients in conflict with family members or medical practitioners.

Debate and opportunity Advance Decisions have attracted significant philosophical and ethical debate. Ethicists have wrestled with the problem of whether the newly diagnosed dementia patient who writes an AD

Advance Decisions Part 1 Tues 10 May 2016 Advance Decisions Part 2 Weds 28 September 2016 (with Part 1 as a prerequisite) Prof. Celia Kitzinger CPsychol, FBPsS and Prof. Sue Wilkinson CPsychol, FBPsS British Psychological Society London office, Tabernacle Street Save the dates and book from the end of January via www.bps.org.uk/events/search

read discuss contribute at www.thepsychologist.org.uk

ADs for all?

It is not just those who are approaching their later years who may wish to write an Advance Decision. When we began discussing this article with the Editor of The Psychologist, Dr Jon Sutton, he enlisted our help to write his own. You can read his draft with the online version of this article, via http://thepsychologist.bps.org.uk. He said: ‘I firmly believe that attitudes towards death and dying will be the major area of social change over the next 50 years. Loss of mental capacity scares me more than death, and I don’t want to leave all the risk assessment to medical professionals.

Writing my AD, with Celia and Sue, has been a learning curve and for now it remains a work in progress… I think I would find it valuable to hear readers’ views.’

directing (for example) that she should not be given life-prolonging treatment for serious illnesses or not given a feeding tube if she stops eating, should have the moral right to determine what happens to the person she becomes in the future – especially if it turns out that this future person seems to the observer to be happy or content (Dresser, 1995; Dworkin, 1993). There are strongly opposing views and no consensus on this issue. But at a time when medical advances can now extend the lifespan beyond what many people desire (Gwande, 2014; Marsh, 2014), and when the British Medical Journal has launched a ‘Too Much Medicine’ campaign, there is no doubt that ADs are of renewed interest to governments and policy makers. For psychologists, this offers an opportunity to extend our skills into this new area and to make a positive contribution to supporting people’s rights and choices in relation to their lives and to their deaths.

Celia Kitzinger is Co-Director of the Coma and Disorders of Consciousness Research Centre, University of York celia.kitzinger@york.ac.uk Sue Wilkinson is Honorary Professor in the Department of Sociology, University of York and Director of the charity ADA sue.wilkinson@york.ac.uk

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The uncensored truth about morality Chelsea Schein, Amelia Goranson and Kurt Gray consider why immoral acts always seem to be those that cause harm – especially to children

Why do people morally condemn ostensibly ‘harmless’ violations?

resources

Do liberals and conservatives have fundamentally different moral minds?

Wegner, D.M. & Gray, K. (2016). The mind club: Who thinks, what feels, and why it matters. New York: Viking.

The Mind Perception and Morality Lab: www.mpmlab.org

Baron-Cohen, S. (2011). The science of evil: On empathy and the origins of cruelty. New York: Basic Books.

Cameron, C.D., Lindquist, K.A. & Gray, K. (2015). A constructionist review of morality and emotions: No evidence for specific links between moral content and discrete emotions.

Personality and Social Psychology Review [Advance online publication]. doi:10.1177/1088868314566683

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n December 2014 the British Board of Film Censors (BBFC) banned pornographic materials depicting acts such as consensual spanking, facesitting, urolagnia, and female ejaculation.

According to a spokesman for the organisation, the ‘BBFC classification regime is a tried and tested system of what content is regarded as harmful for minors’ and the legislation was aimed at ‘safeguarding children’ (Quinn, 2014).

However, critics of the move quickly pointed out that this list is not only ‘arbitrary’, but includes only harmless acts between consenting adults. The BBFC and its critics seem to see the world in two very different ways – one in which pornography is both immoral and harmful to children, and one in which pornography is neither immoral nor harmful. This alignment of perceived immorality and perceived harm is not coincidental, but instead reflects the central role of harm in moral cognition.

The power of harm within morality is intuitive, as many of the gravest moral violations are those that directly cause harm – murder, assault, theft, rape and abuse are acts that are both harmful and universally viewed as immoral. Harm is also central to rhetoric about immorality, as the issue of censorship clearly illustrates. When people want to argue that an act is wrong, they reference its harmfulness, often to children. However, some recent theories of morality (e.g. moral foundations theory: Haidt, 2012) have suggested that this harm-based rhetoric is just that – mere rhetoric. These theories claim that questions of harm are

I

references

questions

Moral disagreement is ubiquitous.

People argue about the morality of abortion, taxation, immigration, pornography and censorship. But everyone agrees that morality is about harm. Not only do harmful acts seem immoral, but immoral acts seem harmful. Building on this fact, our article outlines a new harm-based theory of morality called ‘dyadic morality’. This theory explains many quirks of moral judgement, such as why pleas of ‘think of the children!’ feature so prominently in moral disagreement.

Dyadic morality is supported by experiments in moral psychology, and challenges other popular theories of morality. It also suggests that people – of all political hues and nationalities – have fundamentally the same moral mind, but moral disagreement occurs when people disagree about which acts are harmful.

Cheng, J.S., Ottati, V.C. & Price, E.D. (2013). The arousal model of moral condemnation. Journal of Experimental Social Psychology, 49(6), 1012–1018.

Gray, K. & Keeney, J.E. (2015). Impure, or just weird? Scenario sampling bias raises questions about the foundation of moral cognition. Social Psychological and Personality Science [Advance online publication].

relevant to only a fraction of moral judgements, and that arguments about harm reflect only convenient post-hoc justifications (Haidt, 2012).

However, the new theory of ‘dyadic morality’ pulls harm from the shadows back into the spotlight (Gray et al., 2012). Dyadic morality suggests that harm is not only the most important factor in moral judgment, but the very core of a universal moral template – a template that both detects harm in diverse moral transgressions (Schein & Gray, 2015) and fills it in when apparently absent (Gray et al., 2014).

In this article, we first describe dyadic morality before addressing three apparent challenges to this theory: the intuitive nature of morality (intuitionism); the moralisation of ‘harmless’ transgressions in other cultures (pluralism); and cognitive differences across moral content (modularity).

Categorisation and the moral dyad In essence, moral judgement is simply about categorisation. The question ‘Is X immoral?’ can be reworded as ‘Does X belong to the category of immorality?’.

As decades of research in cognitive psychology suggest, stimuli are categorised by automatically comparing them to a category’s prototype (Murphy, 2004). This prototype (or ‘cognitive template’) emerges from the most common, salient, and important features of the category. For example, the template of ‘bird’ is something small, winged, seed eating and capable of flight. The better a stimulus matches the template, the more robustly it is categorised as part of that group, explaining why sparrows are judged to be birds faster than ostriches.

What is the template of immorality?

It is based upon acts that are the most universally condemned, the most evolutionary important, and the most emotionally evocative. Harm fulfills all these criteria. Harmful acts such as murder and assault are condemned across

doi:10.1177/1948550615592241 Gray, K., Schein, C. & Ward, A.F. (2014).

The myth of harmless wrongs in moral cognition: Automatic dyadic completion from sin to suffering.

Journal of Experimental Psychology: General, 143(4), 1600–1615.

Gray, K., Waytz, A. & Young, L. (2012). The moral dyad: A fundamental template unifying moral judgment.

Psychological Inquiry, 23, 206–215.

Greene, J.D. (2013). Moral tribes: Emotion, reason, and the gap between us and them. New York: Penguin.

Haidt, J. (2001). The emotional dog and its rational tail: A social intuitionist approach to moral judgment.

Psychological Review, 108(4), 814–834.

Haidt, J. (2012). The righteous mind: Why good people are divided by politics and religion. New York: Pantheon Books.

Kohlberg, L. (1969). Stage and sequence:

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cultures, strongly impair genetic survival, and consistently evoke powerful negative emotion (Baron-Cohen, 2011). Of course, many harmful acts (e.g. car accidents) are not immoral, so our moral template must have some additional features.

Research finds that our moral template involves two interacting minds – an intentional agent (i.e. perpetrator) harming a suffering patient (i.e. victim; Gray et al., 2012). In other words, the essence of immorality isn’t merely ‘harm’ but ‘harm caused by an agent’. This agent can be another person, a corporation, or a government, but it must be an entity perceived to be mentally capable of intention and action. Conversely, the

The BBFC and its critics seem to see the world in two very different ways

patient who receives the harm must be mentally capable of feeling pain and suffering, such as children, or puppies, or the elderly.

The cognitive-developmental approach to socialization. In T. Mischel (Ed.) Cognitive development and epistemology (pp.151–235). New York: Academic Press.

Murphy, G.L. (2004). The big book of concepts. Cambridge, MA: MIT Press.

Quinn, B. (2014, 2 December).

Pornography law bans list of sexual acts from UK-made online films. The Guardian. Retrieved 16 June 2015

The combination of ‘intentional agent and suffering patient’ – or even more simply ‘thinking doer and vulnerable feeler’ – gives us a simple formula for understanding the moral world. People are most morally incensed when powerful thinking doers harm powerless vulnerable feelers (e.g. a CEO kicks a baby). This is exactly the combination of minds seen by the BBFC censors, who believed that profit-driven movie producers were harming children. Conversely, people are least morally incensed when powerless vulnerable feelers harm powerful thinking doers (e.g. a baby bites a CEO).

With this formula of ‘thinking doer and vulnerable feeler,’ we can predict people’s moral outrage to any infraction with two questions: How much does the patient/victim suffer? How much does the agent/ perpetrator intend the harm? We can also predicts a situation’s potential for moral outrage by considering the patient’s potential for suffering and the agent’s potential for thought and action.

Because this moral template involves two interacting minds, it is called the dyadic template, from the Greek work dyo, meaning two.

Unlike the template for birds (or dogs or furniture), the moral template is a matter of perception.

Whether a bird can fly is a matter of fact, but less certain is whether a perpetrator is capable of intentional thought, or a victim is capable of suffering. The inherent ambiguity of other minds means that good people can nevertheless have moral disagreement, because they see different mental capacities in potential perpetrators and victims.

Debates about whether children who kill should go to adult prison hinge on whether they are fully capable of thought and action – an issue of perception as much as fact. Likewise, debates about abortion hinge on whether fetuses are capable of feeling pain – which is also largely a matter of perception. Where

from tinyurl.com/noquu7q Schein, C. & Gray, K. (2015). The unifying moral dyad: Liberals and conservatives share the same harmbased moral template. Personality & Social Psychology Bulletin, 41(8), 1147–1163.

Shweder, R.A. (2012). Relativism and universalism. In D. Fassin (Ed.) A companion to moral anthropology (pp.85–102). Chichester: Wiley-

read discuss contribute at www.thepsychologist.org.uk

people perceive minds, they perceive the potential for evil.

Moral universals The dyadic template not only allows for moral differences between people, but also suggests two powerful moral universals. The first is what is harmful seems wrong (Schein & Gray, 2015).

As the moral template is rooted in perceptions of harm, the more apparently harmful an act, the more it is judged as immoral: first-degree murder (obviously intentional and harmful) is universally condemned, whereas pornography (ambiguous intention and harm) is less universally condemned, and hence a matter of debate.

Our lab tested the centrality of harm for determining whether or not something is immoral in a number of studies (Schein & Gray, 2015). One asked participants to volunteer the first immoral act that came to mind. If harm is central to moral judgement, people should volunteer something obviously harmful, which is exactly what they did. Over 90 per cent of the acts recalled were dyadic in nature, such as murder, abuse, theft and adultery. Another test asked people to rate the immorality of acts that violated different kinds of norms, for example those that were harmful, unfair, disloyal, disrespectful, or gross. Consistent with a dyadic template, harmful acts were seen as the most immoral. The importance of harm was also observed in automatic judgements, as reaction times to categorise an action as ‘immoral’ almost perfectly predicted reactions times to categorise an action as ‘harmful’. Whether an act is immoral seems best predicted by its perceived harmfulness.

The second moral universal predicted by dyadic morality is what is wrong seems harmful (Gray et al., 2014).

Imagine you knew nothing about an action beyond that people believed it to be truly evil. You would assume that this action was harmful – or at least that these people perceived it to be harmful. This

Blackwell.

Turiel, E. (1983). The development of social knowledge: Morality and convention.

Cambridge: Cambridge University Press.

Young, L. & Saxe, R. (2011). When ignorance is no excuse: Different roles for intent across moral domains. Cognition, 120(2), 202–214.

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perceived harm is an inevitable incidental emotions, and can sometimes consequence of a dyadic moral seem contradictory (Greene, 2013). As template, which not only determines dyadic morality embraces the power of how stimuli are categorised, but also harm, some have assumed that it also shapes how stimuli are perceived after embraces the reign of reason. Nothing categorisation. Like any lens through could be further from the truth. The role which we view the world, schemas of templates in categorisation – whether powerfully shape our perceptions, moral or non-moral – progresses often without our knowledge. intuitively and automatically. When Consider again the template of people think about birds, they need not birds. Because the concept of flying consciously ponder about the importance is central to birds, you will of flight as they categorise sparrows and automatically assume that something ostriches. Instead, key template features labelled ‘bird’ can fly. Because the are used automatically and effortlessly in While it is true that liberals and conservatives concept of ‘harm’ is central to categorisation. often morally disagree, they share similar immorality, you will automatically As we reviewed above, studies reveal harm-based moral judgements assume that something labelled that the role of harm in moral judgement ‘immoral’ is harmful. Of course, with is both intuitive and automatic – birds, you can objectively learn that some judgement (Turiel, 1983), it conflicts with consistent with a dyadic moral template. birds cannot fly. But because harm is one popular theory of morality – moral People rapidly see harm in moral subjective, people can seldom ‘objectively’ foundations theory (MFT: Haidt, 2012). violations, automatically use this learn that something they see as evil is Moral foundations theory argues against perceived harm in forming their moral also harmless. Returning to the example the overarching role of harm, instead judgements, and effortlessly perceive of censorship, no amount of cajoling advocating for distinct moral modules, harm in response to immorality (Gray about the harmlessness of consensual each corresponding to different kinds of et al., 2014; Schein & Gray, 2015). spanking or facesitting is going to change moral content, such as ‘purity’ or Of course, people can (and often do) use perceptions of those who already perceive ‘fairness’. In these theories, harm is considerations of harm in subsequent it as harmful (and wrong). No one ever merely one ‘little switch’ of the moral deliberative moral reasoning, but initial says ‘It’s harmless and wrong’. mind, and not a global template. perceptions of harm are automatic.

This link from wrong to harm (and Advocates of MFT have challenged dyadic back) isn’t just rhetoric, but automatic morality primarily along three lines: Moral pluralism and intuitive. In one study from our lab, intuitionism, moral pluralism, and Anthropologists have long recognised that people read about acts that seemed wrong content differences. We summarise and different cultures have different morals. In despite causing no directly physical harm, address these challenges here, using them the West, there are no clear prohibitions such as masturbating to a picture of your as an opportunity to correct common about what you can eat after a loved one’s dead sister (yes, we know it’s bizarre – misconceptions about the theory of death. On the other hand, in India, Oriya blame our reviewers). Consistent with a dyadic morality.

Hindu Brahmans believe it to be immoral dyadic template, participants nevertheless for the eldest son to eat labelled these ‘objectively harmless’ Intuitionism chicken after his father’s misdeeds as harmful. Were these Historic accounts of moral death (Shweder, 2012). “…moral judgement perceptions mere effortful justification? judgement emphasised the To account for these reflects emotionNo. In fact, people were especially likely importance of harm, and differences, theories such based intuitions” to see harm when we impaired their also of moral reasoning. as MFT suggest that our ability to reason by forcing them to These theories – such as basis for morality must extend answer quickly.

Kohlberg’s stage model beyond harm to considerations Other studies reveal that these (1969) – suggested that moral judgement of spiritual purity (Haidt, 2012). This perceptions of harm even creep into other relied upon careful deliberation and perspective is called moral pluralism, judgements. After reading about ‘harmless conscious reflection. Reacting against because it advocates for a plurality of immoral acts’, people were more likely to this ‘rule of reason’, more recent accounts moral concerns. On the surface, moral see sad expressions in the faces of have claimed that morality is typically pluralism seems to argue against the a matter of intuitive judgements and children – an experimental demonstration harm-centric dyadic morality. However, affective reactions (Haidt, 2001). When of why those against pornography a closer inspection suggest that dyadic people denounce (or fail to denounce) inevitably see it as harming children. morality is actually more consistent with pornography, it is rarely because they moral pluralism than is MFT. Importantly, perceptions of harm weren’t have rationally considered the issue.

Although MFT embraces nondriven by general feelings of ‘badness,’ as Instead, their moral judgement reflects Western conceptions of morality, it fails other judgements about these children emotion-based intuitions. As one analogy to embrace non-Western notions of harm, were not more negative. Perceived harm suggests, our faculty of moral judgement rigidly defining it as only direct physical leads to judgements of evil, and is not an impartial judge weighing the suffering. In contrast, dyadic morality judgements of evil lead specifically to evidence, but rather, it is an impassioned suggests that harm is in the eye of the perceived harm. lawyer arguing in favour of its original beholder, which means that even position (Haidt, 2012). violations of spiritual purity can actually Questions for dyadic morality Significant evidence supports the be grounded in concerns about harm.

Although dyadic morality aligns with power of intuition in determining our Consider the example of the Brahman son decades of research on categorisation and moral judgement. Moral judgements are eating chicken – Hindus believe that the historical harm-centric accounts of moral formed quickly, are influenced by eldest son is responsible for processing

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the father’s ‘death pollution’ by eating a vegetarian diet (Shweder, 2012). By eating chicken, the son is thereby condemning the father’s soul to eternal suffering. In other words, what superficially seems to be just about ‘purity’ is actually about harm. This idea is also supported by research from our lab, which finds that violations of ‘purity’ are judged to be simply a certain kind of perceived harm (Gray & Keeney, 2015).

Our research also finds little support for another oft-discussed ‘cultural’ difference in morality – MFT has suggested that US liberals and conservatives have different ‘foundations’ (Haidt, 2012). While it is true that liberals and conservatives often morally disagree, they share similar harm-based moral judgements, as revealed by studies in our lab. Conservatives oppose gay marriage not because it seems ‘impure’, but because they see it as harmful. One notable anti-gay activist believed that allowing gay rights would destroy the American family, throw society into chaos and – of course – harm children. As with the Hindu Brahmans, MFT dismisses these perceptions of harm as illegitimate, whereas dyadic morality embraces ‘harm pluralism’ – the diversity of perceived harm. With its embrace of both moral and harm pluralism, dyadic morality better embodies the anthropological tradition that MFT seeks to claim for itself.

Content differences Dyadic morality suggests that – consistent with other forms of judgement – moral judgement is based upon comparison to an overarching template. In contrast, MFT believes that moral judgement is underlain by cognitive modules or ‘little switches in the brain’ (Haidt, 2012, p.123), each of which has fundamentally ‘distinct cognitive computations’ (Young & Saxe, 2011, p.203). This module view suggests that violations of one ‘content’ area (e.g. harmful acts like murder) are processed differently from those of another (e.g. purity acts like facesitting).

The module view also suggests that different kinds of moral content are linked to different emotions, such that harm (e.g. murder) is linked to anger, and purity (e.g. facesitting) is linked to disgust.

Despite the common acceptance of these claims in our field (Haidt, 2012), our lab wondered if all was not as it seemed. We examined the research arguing for unique cognition and unique emotions in the content area of ‘purity’, and found no support for either claim.

First, uniqueness requires distinctness,

and judgements of ‘harm’ and ‘purity’ are highly correlated (r = .87: Gray & Keeney, 2015). Second, previous studies had clear confounds – unaccounted-for third variables – which we suspected gave only the illusion that purity was special.

Studies arguing for unique cognition all used a specific set of scenarios. These scenarios represented harm through acts such as murder and child abuse, and represented purity through acts such as masturbating with a dead chicken or getting a tail via plastic surgery. The savvy reader will recognise that these scenarios differ not only in moral ‘content’ but also in severity and weirdness. The harm scenarios are punishable by decades in prison, unlike the purity scenarios. The harm scenarios are also much less weird (i.e. atypical) than the purity scenarios.

We read about murder everyday in the paper, and can easily imagine motivations for killing another person. Conversely, we seldom read about tail-plastic-surgery, and have difficulty imagining why someone would do this. Our studies reveal that these differences in severity and weirdness account for the apparent uniqueness of purity. With careful experimental controls, the specialness of purity disappears altogether (Gray & Keeney, 2015).

Careful experimental controls also cause the apparent link between purity and disgust to vanish. Previous studies linking these concepts fail to include control conditions with other similar emotions (e.g. anger, fear), or use improper statistical techniques that inflate the appearance of specialness (Cameron et al., 2015). In our comprehensive review, we found only one study that met the threshold for experimental controls, and it found no evidence for a special disgust–purity link (Cheng et al., 2013) – consistent with an overarching dyadic template.

largely abandoned harm. Inspired by classic research on categorisation (Murphy, 2004), anthropological pluralism (Shweder, 2012), and modern accounts of cognition (Cameron et al., 2015), dyadic morality has reinstalled harm to its rightful place.

A flurry of recent research reveals that harm is both central to moral judgements (Schein & Gray, 2015), and also shapes our perception of the moral world (Gray et al., 2014). This same research also reveals that moral differences between people do not reflect deep cognitive differences: Whether British or Indian, liberal or conservative, people have the same harm-based template based upon the perception of two minds – and it is these perceptions that drive moral debate.

Whether people are pro-life or pro-choice, or for or against gay rights, depends upon the same simple (but ambiguous) question: Do they perceive a mind being harmed?

The perception of harm may be subjective, but it has the hot truth of reality to those who see it. The ‘truthiness’ of these perceptions suggests that arguing about perceived harm may be as difficult as arguing about the sexiness of fetishes. Depending on whom you ask, watching consenting adults spanking, screaming, and biting each other may be arousing or morally repugnant. As the British Board of Film Censors (BBFC) suggests, the issue of censorship does indeed depend on the question of whether children are harmed.

But answers to the question of harm – like those of sexiness – are in the eye of the beholder.

Chelsea Schein is at the University of North Carolina, Chapel Hill chelsea.schein@unc.edu

The evolution of moral theory Our morals change over time. Smoking used to be a matter of personal preference, but now seems morally tinged. Pre-marriage cohabitation used to be deeply sinful, but now seems like a prudent choice before lifelong commitment. Likewise, the scientific understanding of morality changes over time. How people divide norm violations into ‘inappropriate’ versus ‘immoral’ was once thought to be a matter of both harm and rational reason. Years later, it was discovered that moral judgement was driven by intuitions and emotion (Haidt, 2001). However, in their rush to abandon reason, these intuitive theories also

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Amelia Goranson is at the University of North Carolina, Chapel Hill agoranso@live.unc.edu

Kurt Gray is at the University of North Carolina, Chapel Hill kurtgray@unc.edu

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Annual Conference 2016 East Midlands Conference Centre, Nottingham 26–28 April Themes:

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BIG PICTURE

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Jennie Jewitt-Harris, a psychologist and medical doctor, uses drawing, collage, and 3D stereo photography to consider the psychology relating to how our memories and opinions are shaped.

During her time as Artist in Residence at Watts Gallery in Compton, Surrey, she is exploring, through her artwork, the theories relating to memory Image by Jennie Jewitt-Harris triggers, flashbulb memories, and déjà vu relating to places.

‘I use weathered objects and Fine Art PhD to investigate what influences the driftwood as a physical metaphor for the passage specific reluctance of many people to refuse of time. Each anonymous discarded object also consent to transplant corneas from eyes of physically shows its own individual long complex deceased donors. She has worked in the field of history. Collected objects are woven into the organ donation for many years, currently as CEO collages, as triggers of memories of a time or of the Transplant Links charity, and is intrigued place, such as music, books, photos, stamps and by the special relationship we have with our eyes. maps, which I think of as the flotsam and jetsam ‘Our relationship with our eyes seems very of life.’ The work also considers time relating to different to that with other organs, and mortality and our desire to ‘live in the moment’, researching this through interviews and making contradicting a competing desire to capture and art will be fascinating.’ hold on to memories.

For details of Jennie’s exhibition and artwork Jennie, a member of the British Psychological go to www.jenniejh.co.uk.

Society, is extending this thinking through her

The flotsam and jetsam of life

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INTERVIEW

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‘I took the plunge and chose the risky option’ Lance Workman meets Gerd Gigerenzer, Director of the Max Planck Institute for Human Development and the Harding Center for Risk Literacy in Berlin

interested to learn about Ican’myourIvery work on decision making, but start by going back to a former life. I gather you started out playing a banjo as a Dixieland jazz band – how did that come about?

I always loved music, and being a musician helped me become financially independent from my parents at the age of 17. My first instrument was the accordion, then guitar and banjo.

situations in which all of this is known.

We try to open decision making up by developing and studying models of heuristics that can be superior to so-called rational models in the real world where uncertainty reigns.

The ABC contains a very wide range of academics – do you ever find you speak

How did you make the transition from successful jazz musician to academic psychologist?

After getting my PhD, I had to decide – should I continue playing music on stage or leave that behind me and aim for an academic career? As a musician, I was raking in good money, much more than an assistant professor earns.

Music was the safe option for me, and academics the risky one. At that point it was anyone’s guess whether I would ever get a professorship. But I took the plunge and chose the risky option.

I’m glad to see the risky option paid off. You’re currently director of the interdisciplinary Center for Adaptive Behavior and Cognition (ABC) at the Max Planck Institute. What sort of questions does this group seek to answer?

We study decision making under uncertainty, that is, in situations where it is impossible to know all options, consequences and probabilities in advance – just like my decision between the world of music and academia. Most psychologists, and almost all behavioural economists, restrict their research to

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a number of different scientific languages and come at things from really quite different angles?

The very idea – and the success – of the ABC Research Group is to bring together young, adventurous scientists from different disciplines to work on the same topic. The group currently consists of about 35 researchers who come from about 10 disciplines. Because everyone looks at the same issue from different angles, we learn from one another and can approach the study of heuristics and rationality with a wide range of useful

methodological tools. And last but not least, I learn something new almost every day from my researchers, so I am never bored.

When I interviewed Daniel Kahneman he explained how he sees human heuristics as having various irrational cognitive biases and weaknesses. You have a different view?

I do. Kahneman studies the deviations of human judgement from rational choice models or logic. In his view, when there is a discrepancy, it’s we who should be blamed and never the rational choice model. I make a distinction between situations of ‘risk’ where we can calculate the best option with certainty (as in monetary gambles) and situations of ‘uncertainty’, where we do not know all alternatives, consequences and probabilities – such as how to invest your money and whom to trust. In uncertain situations, it is an illusion to believe that the standard models of logic, probability or rational choice can define what a good decision is.

What I have shown is that under uncertainty, simple heuristics can make better predictions than complex statistical models such as multiple regression or other complex ‘rational’ models. That clashes with Kahneman’s belief that heuristics are always second-best. Whereas the heuristics-and-biases programme relied on labels such as ‘availability’ or ‘affect’ heuristics, or the nearempty notion of ‘System 1 and 2’, we used formal models of heuristics to show the effectiveness of simplicity, so-called less-is-more effects. Without such scientifically precise models, the older research programme was not equipped to find these exciting results, nor could it develop a study of ecological rationality that specifies the conditions under which a given heuristic succeeds or fails. After all, we humans are not as dim-witted as the heuristics-and-biases research makes us appear.

You relate the current problems we have with handling probabilities to our evolutionary past when we faced quite different challenges?

That is one aspect. But it is too general for making precise predictions. We have derived a number of quite precise insights. For instance, many experiments by others used single-event probabilities to demonstrate human cognitive fallacies, such as the question ‘Is Linda more likely to be (1) a bank teller or (2) a bank teller and active in the feminist movement?’.

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the last financial crisis, the results would not have been as devastating. Simple rules can be much more effective than rating agencies’ complex and misleading risk calculations and banks’ value-at-risk calculations. These calculations border on astrology. I am currently working with the Bank of England on a project, ‘simple heuristics for a safer world of finance’.

I’ll certainly look out for that! You have conducted a great deal of research in decision making and in cognitive psychology in general, you have published a great deal and you have headed a number of research centres.

I’m wondering if you have any unfulfilled ambitions?

Oh yes, dozens of them. I want to better understand the heuristics in the ‘adaptive toolbox’ of experts and laypeople, and how they develop in the course of a lifetime and training, and I also want to better understand the ecological rationality of heuristics, that is to describe the environmental conditions in which a heuristic is better than, say, a complex calculation, and vice versa. This requires a formal study of models of heuristics and environments. And finally, there is a larger dream. I would like to help create a society where most people are risk savvy and can make intelligent choices on their own. We do not need more ‘nudging’ or blaming… we should instead help people to take their lives into their own hands.

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Most people choose (2), which Tversky understand, say, what the chances are and Kahneman attribute to not that a woman has breast cancer if she understanding the basics of probability has a positive screening mammogram. theory (the so-called conjunction fallacy).

For instance, in one study with 160 Yet in statistics proper there is a debate gynecologists, only 21 per cent whether single-event probabilities belong understood that the probability that to the domain of probability theory. a woman has breast cancer if she has Whatever the answer, one should not a positive screening mammogram is immediately put the blame on people only about 1 in 10. Most believed it is without questioning a controversial norm. between 80 per cent and 90 per cent!

Ralph Hertwig and I (1999, Journal of As mentioned, the problem is not simply Behavioral Decision Making) turned the in some biases in doctors’ minds, but in single-event question into a the widespread frequency question (‘Think of use of conditional 100 people like Linda: How probabilities to “I would like to help create many are (1) bank tellers? communicate risk. a society where most How many are (2) bank tellers So we taught people are risk savvy ” and active in the feminist doctors how to movement?’), which made the translate conditional so-called fallacy more or less probabilities into disappear. Thus, the problem is not that natural frequencies. With the help of people fail to understand the conjunction natural frequencies, 87 per cent of the rule of probability, but rather that doctors finally understood the correct researchers fail to critically think about numbers. norms of reasoning. We have documented You published a book recently called that many of the so-called biases reflect Risk Savvy: How to Make Good Decisions careless thinking on the part of in which you claim anyone can learn to researchers. make better decisions for their health, One area you have tried to improve finances, family and business without is the way that medical doctors needing to consult an expert. If you understand natural frequencies in test could give me just one tip to improve results. Why do you think these highly decision making what would it be?

Don’t buy financial products you don’t trained professionals get things wrong understand. If everyone on both sides of and how can they learn to improve the Atlantic had followed this rule before this?

In the good old days (and even in some backward textbooks today) the message was spread that people cannot think the Bayesian way. Many otherwise competent doctors have considered themselves mathematical duds and avoided statistics when they could. In a 1995 Psychological Review article, Ulrich Hoffrage and I report the results of our experiments that showed for the first time that the problem is not simply in the minds of people but in the way the information is framed. That is, misunderstandings arise through the use of conditional probabilities.

When we replaced these by what we termed ‘natural frequencies’, much of the confusion evaporated.

And we could identify the reason – natural frequencies facilitate Bayesian computations, being a format that corresponds to the way people learned information before the invention of books and probability theory.

We then applied these findings to the medical field, where confusion can have critical effects. First, we showed that most doctors do not

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REVIEWS

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A life less ordinary Hanya Yanagihara’s first novel (The People in the Trees) took her years to write, and although well received, sank without trace. Her second, A Little Life, was written in an astonishing 18 months (it’s over 700 pages long). Critically acclaimed and becoming a best seller, it was shortlisted for the Man Booker Prize and had been expected to win. Its popular success is all the more remarkable when you consider that it has been described as ‘harrowing’ and ‘unrelenting’, and many reviews have discussed how upset the book made them. I was in two minds about whether or not I could face reading it. I’m not drawn to misery memoirs or fictionalised ‘misery-lit’, where any amount of ghoulishness is justified on the basis that it supposedly reveals some inner truth. I did pick it up though. And, cliché though it is, I couldn’t put it down.

A Little Life starts gently, as we are introduced to the four main characters – Jude, Willem, Malcolm and JB. They first meet each other at a college much like Harvard, and become each other’s firmest and best friends. Jude and Willem are especially close.

They graduate, and start to face up to the usual challenges of finding work, accommodation, relationships. So far, so conventional. Others have mentioned the similarities to Mary McCarthy’s The Group, which followed a larger group of graduate friends. Any resonance with this story arc is no doubt entirely deliberate, and one of Yanagihara’s many strengths is her ability to play with convention.

This comfortable middle-class world shifts at about 70 pages in, when we are faced with a dramatic turning point. Jude awakens his roommate Willem to tell him there’s been an accident, and is bleeding profusely from his arm. We have been subtly alerted to something about Jude which is different from the other three. Not just his orphan status (Willem too is an orphan), but how reserved he is, and how uncomfortable he is with his body – he walks with a limp, and keeps himself covered up. The bleeding arm is of course A Little Life a self-harming incident that has gone wrong. It is the first of many, Hanya Yanagihara many incidents of self-harm in the book. The descriptions of selfharm are so visceral that they are at times almost impossible to read. Yet they did not seem to me to be ghoulish. Yanagihara is willing to stare right at the source of pain, both physical and mental, and will not turn away.

It is no surprise that behind this self-harm is something truly appalling, although perhaps in a world post-Catholic Church scandal, post-Savile and post-Rotherham, not as difficult to believe as it might once have been. Yanagihara leads us deeper and deeper into this world. We don’t want to go there, but we know we must. What I found so remarkable was that I simultaneously dreaded, and was desperate to know, what would come next.

There is much that seems to be wrong with how this book is written. It has an extremely narrow focus, where it’s only the lives of the characters we hear about, and there are no contemporaneous references. It’s hard to believe there could be a novel largely set in Manhattan that passes through 2001 without a single person mentioning 9/11. But this is that book. It can only be a deliberate choice by the author, and it should detract from believability. The characters also shouldn’t work.

Although written by a woman, it is almost entirely populated by men, most of whom are gay: another challenge to credibility. Some characters are pushed to the background and only allowed back in to further a plot point. Others, such as Willem, are too good to be true. The effect is a form of heightened reality. Yet given the subject matter, hyper-reality seems completely appropriate.

Perhaps the most challenging aspect of this novel for a psychologist is having to consider the limitations of what we can do to fix a broken mind. As Jude’s story unfolds, we have to stand watching on the sidelines, desperate to help. We share the frustration and occasional anger of Jude’s friends, who also feel powerless. The question is whether we would be able to help in the real world.

This is, without a shadow of a doubt, a deeply upsetting book, and it is not for everyone. But if you feel up to it, and want to read a novel about love, hate, compassion, cruelty, friendship and survival, it is unmissable.

I Picador; 2015; Hb £16.99 Reviewed by Kate Johnstone who is Associate Editor (Reviews)

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Fear the pseudo-science The Fear-Free Organization Paul Brown, Joan Kingsley & Sue Paterson This book annoyed me from page 1. Had I picked it up in a bookshop I would have frowned and put it down. I persevered, because the title promised much, those ‘vital insights from neuroscience’ that I could use with my clients to ‘transform business culture’.

I hope that most of you would not recognise the bleak picture painted of corporate culture here. They present numerous case studies of dysfunctional people and relationships, all trying to demonstrate their fundamental premise that ‘[f]ear…is what an overwhelming majority of bosses use, deliberately or mindlessly, to keep order’.

I would not want to pretend that all is sweetness and light where I work, or in the client organisations I support, but their negative tone, and description of ‘greedy, performance-driven models’ was off-putting for me.

And what of the ‘neuroscience’ offered? An introduction to the limbic system, amygdala, oxytocin, and an updated Hebbian learning theory to say ‘the cells that flow together, grow together’. How do these findings relate to the business world? The authors then rely on the work of others – David Rock’s popular SCARF model and Daniel Goleman’s work on emotional intelligence.

I did not feel that the authors’ 10-point plan for a fear-free organisation would have much credibility with my clients – the first point suggests that we must ‘have a leader who is good-hearted’. I cannot disagree with this point, but I don’t think this book offered me any ‘vital insights’ into shaping such leaders or transforming business culture.

I Kogan Page; 2015; Pb £26.99 Reviewed by Alison Gregory, who is a management consultant

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Into the future Ai Weiwei Royal Academy of Arts his time writing blogs and micro-blogs.

Ai WeiWei: is he an artist, a political activist, a celebrity or a self-publicist? Or perhaps he Although his dissent was mostly online rather than offline activity, unsurprisingly is all of these? the CCP did not like his activities and he Ai Weiwei’s artistic family background was placed under arrest. When he became and early negative experiences with the aware that he was being watched by the Chinese Communist Party (CCP) shaped authorities who had surveillance cameras him into the artist he is today. In China, all around the outside of his home, in given names are created by parents who a clever and witty response, he set up web often choose words that are significant or cams in every room and broadcast his own aspirational for them. Wei means 'future'. reality show 24/7, until he was told to close When growing up, how salient was his name the site down. Several of the installations in in making him want to change the future or the exhibition refer leave a mark on the future of art to this, such as the or the politics of China? carved marble CCTV Ai’s view of art is that it is camera, and the a means of awakening people to peep show boxes the need for change rather than showing his to beauty. He wants to use art to imprisonment. make his fellow Chinese citizens (I dare say all this aware of their lack of freedom, takes place under particularly freedom of speech, the surveillance of though he knows that many cameras at the Chinese people would rather Free Speech Puzzle, 2014 Royal Academy for concentrate on earning money, our ‘safety’ as the trains and stations put it.) buying a house and a car, and getting a good Ai uses a range of materials to put education for their children. Ai demands across his message – timber, glass, marble, transparency and accountability from the tea, sand, bones and metal. Some other state. He makes great use of the web and Chinese artists think he wastes materials, social media, particularly Twitter, to call for such as the lovely antique tables he has this. Chinese characters are more like sawn up and the old pottery jars he has words than letters, so with 140 it is possible overpainted, but as he grew up he must to say quite a lot. Twitter and Facebook are have seen the Red Guards destroying every theoretically banned in China but many traditional Chinese art object they could find people can get round this. during the Cultural Revolution. Some artists At one point, Ai was spending most of

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admire the vast size of his installations, reminiscent of ancient installations like the Terracotta Army. For example, one hall is filled with rusty iron rods removed from the rubble after the Sichuan earthquake in Wenchuan in 2008. China has a history of terrible tragedies. In the past the government tried to keep them quiet in a way that is no longer possible with modern communication technology. After the earthquake many volunteers poured in to help, including Ai WeiWei and his team, who wanted to highlight the poor building practices and corruption that made many of the buildings unsafe. They collected the twisted iron bars from the substandard buildings, straightened them and laid them out in a pattern. They also made lists of the names of all the thousands of children killed in the earthquake and these have been placed on the surrounding walls.

In one area is a huge jumbled up pile of ceramic crabs (or he xie which is a homophone for ‘harmonious’). The CCP is always exhorting a harmonious society. In the corner, one single crab seems to be starting to climb alone up the wall. I wonder, does Ai see himself as this crab leading the harmonious masses into a freer future?

I The exhibition runs until 13 December at the Royal Academy of Arts Reviewed by Louise T. Higgins who is Emeritus Professor of Psychology, University of Chester

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Heed these words Mental – the vacuum cleaner Freud Museum, London The Metropolitan Police call him a Domestic Extremist. The NHS have described him as ‘highly disturbed’ and labelled him with Borderline Personality Disorder. ‘A real and present threat to the safe running of our lawful business’ is how E.ON described him at the Royal Courts of Justice.

He prefers the term Mental.

After 10 years of being an outlaw and inpatient, artist activist ‘the vacuum cleaner’ presents an autobiographical performance told through his psychiatric records, police intelligence files and corporate injunctions collected through the Data Protection Act. (from www.thevacuumcleaner.co.uk) There we sat, around 25 of us on Sigmund Freud's bedroom floor with ‘the vacuum cleaner’ – aka James Leadbitter – who lay deep under his duvet in our midst. Surrounded by piles of case notes, his medical records, so many they seemed to swallow him as much as the duvet did. Freud, in shadow across the screen, cast across the bedroom walls, observing from a distance.

On the occasion of the Philadelphia Association’s 50th anniversary we revisited the radical ideas of Ronnie D. Laing and colleagues: in short to listen to and talk to people in distress. Hardly radical and yet in our time-poor, CBT yourself back to work in just six sessions, slap on a label and medicate it, production-line era, this message was an ironic reminder of the fundamental importance of person-centred care and how it seems to have been forgotten in the mental health system being cut in the name of efficiencies.

I, a former mental health professional, experienced toe-curling culpability as I witnessed the vacuum cleaner’s patient and personal testimony. He rose up from under the duvet and illustrated using his case notes on OHP, the (important) points highlighted – many sweeping and generalised attempts at diagnosis, and often contradictory reports. Such is the difficulty with prescriptive accounts of mental distress. Yet all the agents involved – police, doctors, nurses, security services and therapists, conspired to monitor, contain and categorise the man lying before us on the bed.

He was a person to us, but a domestic terrorist to the authorities.

He was variously described as: a diagnosis unstable PD, schizophrenic, high scorer on the GHQ, anxious, suicidal, selfharming, manipulative and dangerous. On and on it went. Personal trauma, absurdity and cruelty enacted.

The performance evoked powerful bodily surges of empathy.

His pain that words can’t describe hung heavy in the intimate space as the audience sat in stillness and silence. I winced as the vacuum cleaner described various failed suicide attempts. When it began to feel unbearable, and visitors were advised at the outset that it was OK to walk out, the vacuum cleaner played his favourite tunes on vinyl and introduced the purest black humour. On his attempt to hang himself the flex broke, ahhh, this is not my method he wryly concluded. The stocky ICD 1 male referred to in a police report: I call him Gavin. Towards the end he emptied a large cardboard box onto his bed. Out came hundreds of boxes of psychotropic and other mood stabilising drugs, plus drugs to counteract the drugs, etc., etc.

The weight of the treatment regime left physical and metaphorical scars. On his back, scratched deep into his skin, a message to his tormentors.

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This was an important albeit hard to swallow performance. The simple truths of Maslow’s hierarchy shone through. We all require our basic needs to be met in order to grow. We need shelter, safety, food and relationships to sustain us. Only then we can heal and recover. All those concerned about the care of those who experience mental distress should heed the words of the vacuum cleaner and the Philadelphia Association: especially those responsible for cutting mental health services.

I Reviewed by Victoria Tischler PhD CPsychol who is an independent research consultant

Fascinating and salutory Love and Mercy Bill Pohlid (Director) Those of us of a certain age were lucky enough to live out our adolescence in the 1960s against a backdrop of some of the most exciting and creative periods of modern music. The Beatles, Rolling Stones, Kinks, the Who and from America the Beach Boys provided us with a never-ending stream of what proved to be classic pop. The Beach Boys originally emerged singing jolly ditties about surf sunshine and girls in distinctive high falsetto harmonies, but in 1969 they changed tack and produced a much more serious collection of songs in a ground-braking album, Pet Sounds. The record was critically acclaimed sold well in the UK but failed to sell in the USA. This film is an account of the life of the creative force behind the group, Brian Wilson. It is set in two periods of his life. First around the

time of the making of Pet Sounds when the part of Brian is played by Paul Deno and 20 years later when his life is changed by meeting the woman who was to become his wife, when the part is played by John Cusack. It is this second period that forms the core of the film. After the lukewarm sales of Pet Sounds and despite the success of their greatest hit ‘Good Vibrations’ Brian Wilson spent more and more time isolated in the studio trying to produce a follow-up record ‘Smile’.

By this time he has become increasingly dependent on the drugs readily available in California at the time and reached a state when he had an inevitable mental breakdown to the extent that his paranoia led him to destroy the tapes of ‘Smile’.

We meet him again in the 1980s when he is a pale

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Creative ways to be less sad How to Be Happy (or At Least Less Sad) Lee Crutchley You have to be severely myopic to have missed people’s current insatiable appetite for wanting to feel good. People are hungry for happiness, ravenous in fact. It is no coincidence that rates of depression and general dissatisfaction with life are going through the proverbial roof. So, another self-help book that claims in the title to show us all how to be happy may be greeted with rolled eyes. However, Crutchley, an artist and author, has developed this ‘creative workbook’ not to be more happy, but rather less sad.

The book is a practical, light-hearted, fill-in-the-gaps approach, which does not overwhelm at first glance. He includes many common CBT, mindfulness and values-based exercises within the number-less pages (encouraging us to deal with uncertainty perhaps?), and bite-size chapters introduced by his own personal experiences of depression. The sparkle of this book comes from its being

shadow of his former self, heavily dependent on medication provided for him by his personal psychologist Dr Eugene Landy, played by Paul Giamatti. Dr Landy it appears controls all aspects of his life, provides him with bodyguards who monitor all aspects of his life, even to extent of vetting and ultimately intimidating the young woman, Malinda Ledbetter played by

peppered with unique, rather humorous exercises, challenging people to switch off the internet for the day and find analog versions of websites/apps e.g.

Google = go to the library, do something spontaneous by only turning left on a walk, listen to an album you hate all day and find something that resonates with you.

Overall, this book brings a unique and creative angle on established techniques that may even inspire the most experienced clinician. However, this book leans more towards the internet generation, and as with any self-help book, it requires a level of self-motivation in order to ‘dive in’. Nonetheless, it is a nice light twist to support people out of a seemingly dark hole.

I Ebury Press; 2015; Pb £8.99 Reviewed by Eleanor Parker who is a clinical psychologist with Barnet, Enfield and Haringey Mental Health NHS Trust

Elizabeth Banks who he meets while buying a car. She immediately recognises that Brian is totally dependent upon and controlled by Landy. The film is essentially about their relationship and how she attempts to release Brian from the all-pervading influence of Landy whose role as psychologist appears to encompass, manager, financial

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Sample titles just in: Nostalgia: A Psychological Resource Clay Routledge The Science Inside the Child Sara Meadows Play and the Human Condition Thomas S. Hendricks Art, Aesthetics and the Brain Joseph P. Huston, Marcos Nadal, Francisco Mora et al. (Eds.) Children in Society: Politics, Policies and Interventions Craig Newnes (Ed.) Psychology for Sustainability Britain A. Scott et al (Eds.) Murdered Father, Dead Father: Revisiting the Oedipus Complex Rosine Jozef Perelberg For a full list of books 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 ‘Reviews’ now covers much more than books: if you see a film, play, exhibition, app, TV programme, radio show etc that you would like to review for us, get in touch on jon.sutton@bps.org.uk or on Twitter @psychmag

adviser and record producer.

The film successfully captures the hedonistic nature of the 1960s. The sequences recreating the recording of the music are fascinating and sound every bit as good as the original.

In fact some of the scenes of the recording of Pet Sounds were filmed in the original studio.

To put it mildly, psychology does not come out of this film well. Dr Landy is portrayed as an evil genius who went to almost any length to manipulate and control his client. He appears motivated by shear greed, be devoid of any ethical or professional standards whatsoever and was only exposed when he changed his client’s will in his favour. We find out at the end of the film that Landy lost his licence to

practise as a psychologist in California once he was exposed.

After seeing the film one wonders how on earth he continued to practise anywhere in the world, but apparently he did continue to work in New Mexico and Hawaii.

Films in which psychologists are depicted in a positive light are many: Sixth Sense (1999) and Good Will Hunting (1997) come to mind. It is rare to see our profession portrayed as such an evil influence as Landy. What makes it even more shocking is of course that the film is biographical. Dr Landy is not a monster created by Hammer House of Horror, but a real-life psychologist like you and me.

It is salutary for us to acknowledge that for all the good that we perceive that we may bring to our work with clients young and old, members of our profession are capable of using their psychological skills for such evil means.

I Reviewed by Dr Jeremy Swinson who is an Educational Psychologist from Liverpool

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Generous, genuine humour The Brain Show Robert Newman You might remember Robert Newman as one quarter of The Mary Whitehouse Experience in the 1980s, or one half of Baddiel & Newman in the 90s – the first stand-up act to pack Wembley Stadium when comedy became the new rock’n’roll. He has been out of the limelight for a while, writing novels and becoming politically active in publicising concerns over climate change.

Now he’s back on Radio 4 with Robert Newman’s Entirely Accurate Encyclopaedia of Evolution. The similarly titled book, The Entirely Accurate Encyclopaedia of Evolution, is published by Freight. He is currently touring his one man performance, The Brain Show.

A fast and furious journey, The Brain Show opens with an account of Robert Newman’s experience as a research subject at University College London. He posits that the failure of the genome project to find direct correlates of human behaviour in our DNA has resulted in a shift of focus in this century, to bridging the gap between the physical wetware of the brain and the subjective experiences of our conscious mind. He skilfully takes apart the outlandish claims of researchers, for example, to have discovered particular

gender biases in macaques, and intelligently questions the experimental paradigms of neuroscience, appropriately sceptical about whether neuroimaging data can accurately correlate with subjective experiences such as love, guilt or wisdom.

A mesmerising storyteller, the point at which factual reporting blends into funny fairytale fiction is not always clear. His erudite and splenetic critiques of key neuroscientific papers had the audience spellbound in silence, until, acutely aware of the need to navigate away from the dangerous rocks of pomposity, he burst his own balloon with a self-deprecating punchline, a song, or a delightfully silly prop.

Robert Newman would definitely jump on the clumsily mixed metaphors of this paragraph, and find a joke lurking there.

Riffing on Ramachandran and Baudelaire, we meet many of ‘the greats’ in this show – a thoroughly researched reverence for Charles Darwin is matched by a hilarious satire on Richard Dawkins’s less charitable view of evolution.

We are regaled with wicked impersonations of a raft of

celebrities including Brian Cox, Paul McCartney and Winston Churchill; a story about Isaac Newton at the Fair; and a delightful set piece in which he personifies the Gulf Stream as an old girl getting pissed in a pub, grumbling about climate change. Even Sigmund Freud makes a brief cameo appearance, as do many wondrous creatures from the natural world, for example the Peruvian spider who fashions decoy spiders out of the debris of her prey.

A particularly rich seam was his retelling of the story of Phineas Gage, the case example beloved of many undergraduate psychologists. Shifting the perspective to Gage’s own point of view, Newman cleverly mocked the scientific establishment’s interpretation of his foul language as ensuing from frontal lobe damage, and constructed a much funnier, more down-to-earth, but equally plausible, version of why Gage behaved as he did. [Editor’s note: For another hilarious take on Phineas Gage’s day-to-day travails, see the chapter in comedian Rich Hall’s Things Snowball.]

The threads of all these and more are woven into the rich

texture of the first half of Newman’s set, which broadens out in the second half to concerns beyond the individual brain to critique the ideology of the selfish gene and make a case for cooperation and group selection. He pulls these torrents of ideas together with a couple of winsome songs accompanied by his ukulele, and a very funny personal anecdote for an encore.

Although the show is thick with complex ideas and wideranging references, the lucid delivery meant that my teenaged son enjoyed it as much as I did. Robert Newman strikes the perfect balance between scalpel-sharp analysis, romantic optimism and generous, genuine humour.

I The Brain Show is touring until mid-December 2015, plays at the Soho Theatre in London from 11 to 23 January 2016, and then tours again throughout February – see www.robnewman.com/live.html Reviewed by Jenny Doe who is a clinical psychologist with East London Foundation Trust. See the online version of this review (https://thepsychologist.bps. org.uk/scalpel-sharp-analysisbrain-and-more) for a Q+A with Robert Newman.

And we all lived happily ever after?

The Happiness Illusion: How the Media Sold Us a Fairytale Luke Hockley & Nadi Fadina (Eds.) This slim, but densely packed volume is a collection of articles from the fields of media studies and psychotherapy. The authors argue that the media has tried to sell us the illusion of gaining happiness by acquiring products reputed to transform our lives.

Yet in the West, antidepressant use is on the increase. The mass media have transformed the symbolism of fairytales into commodities to be sold. This has resulted in the loss of their ability to entertain and educate.

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And even ‘retail therapy’ no longer holds a spell over us.

Given this situation, the book explores what actual sources of happiness are, in our societies. Focusing on different fairytales and their common themes (e.g. Snow White, the ‘Happily Ever After’ endings), the chapters discuss topics such as age, gender, marriage, reality TV and therapy, and how these are portrayed in the media, particularly on television. The conclusion is that we should just

be ourselves – ‘warts and all’ – to be truly happy, and not fall under the allure of the fanciful promises of modern-day television and advertising.

The book was indeed interesting, but at times I struggled with the complexity of the flow of narrative, and the terminology used. The in-depth focus on symbolism in some chapters could also be overwhelming. This may be more the failing of the reader, than the writers, with my own

limited background in media studies and analysis. With this in mind, I would recommend the book to academics and students in media studies. Those with a background in psychotherapy may also find it of interest.

Overall, this is a very thoughtprovoking book, but perhaps not for those expecting a bit of a light read!

I Routledge; 2015; Pb £29.99 Reviewed by Dr Kate Sparks who is a Chartered Psychologist

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An informative detailed summary Geriatric Depression: A Clinical Guide Gary J. Kennedy When planning my review of this book I first asked myself what I would hope to gain from reading a book about geriatric depression.

I settled on: an improved understanding of what is different about the aetiology of depression, response to psychotherapeutic interventions and impact of living with depression in this client population compare to others. I have to say I got all this and more!

There is indeed a comprehensive chapter entitled ‘What Causes Depression in Late Life and What Makes It Difficult to Treat’, which as well as acknowledging for example that older people are more likely to be living with a chronic physical illness and loss, also emphasises the possible impact of agerelated changes to subcortical white matter that can both predispose an individual to depression in later life and make that depression harder to treat. Another chapter, ‘Effective Psychotherapies’, considers a range of therapies, provides a summary table of their distinguishing attributes and weighs the evidence supporting their use in an older adult population.

There is a comprehensive chapter entitled ‘Reducing the Risk of Suicide in Later Life’, which provides information about risk and

prevention of suicide. However, many studies quoted here are not restricted to a geriatric population and the emphasis on the use of firearms as a means is less pertinent to a UK population.

I found the ‘Diet, Supplements, and Exercise’ chapter particularly interesting; although psychologists do not traditionally provide advice on these topics, it includes some valuable information which could be usefully delivered as part of an understanding depression group to help participants consider the potential impact of these aspects of their lifestyle.

Regarding limitations of the book, the author is an American psychiatrist, so a chapter on ‘Pharmacotherapy’ is to be expected; this being of more relevance to prescribers than psychologists.

Some UK studies are quoted but the majority are from the USA and at times this may be unhelpful, as previously mentioned. However, overall this is an informative book that is easy to read and provides a detailed summary of current knowledge in this area.

I Guilford Press; 2015; Hb £26.99 Reviewed by Dr Claire Pond who is a clinical psychologist with South West London and St George’s Mental Health NHS Trust

See http://thepsychologist.bps.org.uk for more reviews, including Spectre; The Father; Professor Green’s BBC3 documentary Suicide and Me with Professor Rory O’Connor; and Professor Mary Aiken on how her work inspired the major series CSI:Cyber.

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Madness from the outside in Gail A. Hornstein considers artistic depictions of insanity

ince at least the 13th century, artists Diamond’s attempts in the 1850s to create have been fascinated by insanity. photographic ‘portraits of the insane’. Far There are literally hundreds of more than painting, photography seemed images, most stylised and stereotypic, capable of recording the succession of of ‘madness’ and ‘the madman’ (or woman). When asylums spread across 19th-century Europe, providing a captive population of mad people, artists began to use actual patients as models for their drawings and paintings. These images are often less extreme than earlier portraits, but their typically grotesque emotionality is just as dehumanising.

Patients are treated as specimens, devoid of any context, like tumour cells in a pathology manual. Even in the works of progressive physicians like Pinel or Esquirol, madness is depicted as brutality or as generalised deterioration. Esquirol’s particular interest in pathological types influenced the thinking of generations of psychiatrists and reduced the patient’s whole life to one main symptom (e.g. mania).

Of course, today we take this idea far more literally than Esquirol did in the 1830s – current images of madness don’t even show the person, just their hypothesised brain defect.

Among the most provocative examples of this way of knowing madness – that is, depicting it from Dementia – by Esquirol (1838) the outside – are Hugh Welch

references

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Brand-Claussen, B. (1996). The collection of works of art in the psychiatric clinic, Heidelberg, from the beginnings until 1945. In B. BrandClaussen, I. Jádi & C. Douglas (Eds.) Beyond reason: Art and psychosis. (pp.7–23). London: Hayward Gallery/Southbank Centre.

Burrows, A. & Schumacher, I. (1990).

Portraits of the insane: The case of Dr Diamond. London: Quartet Books.

Conolly, J. (1858, 6 March). The physiognomy of insanity: No. 4 – Melancholia passing on to mania.

Medical Times and Gazette, 37, 238–241.

Diamond, H.W. (1856). On the application of photography to the physiognomic and mental phenomena of insanity. Paper read to the Royal Society, April 1856.

Gilman, S.L. (1976). The face of madness: Hugh W. Diamond and the origins of psychiatric photography. New York:

minute variations in emotional expression that signalled, for example, the shift from mania to depression or from illness to recovery.

Diamond (1808–1886), chief psychiatrist at the Surrey County Lunatic Asylum, was quickly dubbed the ‘father of psychiatric photography’ (Gilman, 1976, p.5). In 1839, within three months of the announcement of commercially available materials and methods, Diamond made his first photograph (of a lace pattern).

He became fascinated by the medium, photographing houses of famous writers, a still life of hunting paraphernalia, as well as his friends, his wife, his fellow physicians and photographers, and, of course, the patients in his asylum.

Diamond’s most consuming interest was in depicting moments of madness – the slight elevation of the eyebrows that hinted at a feeling of suspicion, the vacant look in the eye of one who saw no purpose in living. By the early 1850s he was exhibiting grouped photographic portraits of his patients, with titles like ‘Phases of the Insane’.

Diamond wanted to show how mental states could be represented in external signs. Physiognomy had long dominated medical thinking: just as a pounding pulse could signal cardiac difficulties, a certain expression could, he argued, reveal mental turmoil. If you could capture the look on patients’ faces, you could diagnose them. And patients were, of course, the perfect photographic subjects – always available (the benefit of locked wards), and ideally suited to reveal, by their extremes of emotion, the core qualities of ‘internal derangement’, as Diamond called it. A series of photographs of the same patient might even ‘mark the progress and cure of a severe attack of Mental Aberration’ (Diamond, 1856).

In the original prints of Diamond’s photographs, patients’ conditions and their initials were printed under their portraits. However, as the photographs

Brunner/Mazel.

Hornstein, G.A. (2009). Agnes’s jacket: A psychologist’s search for the meanings of madness. Monmouth: PCCS Books.

Parker, R. (1996). The subversive stitch: Embroidery and the making of the feminine (Revised edn). London: Women’s Press.

Star, S.L. (1983). Simplification in scientific work. Social Studies of Science 13(2), 205–228.

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began to be reproduced and cited by other psychiatrists, the initials disappeared, illustrating one of the classic forms of simplification in scientific work that sociologist Leigh Star has articulated (Star, 1983). So, despite the sensitivity of Diamond’s portraits, which preserved the complexity of individual expression, patients again became defined in terms of their major symptom.

By ‘freezing the features’ of his patients, as historian Sander Gilman has put it (Gilman, 1976, p.9), Diamond sought to go beyond the standard ‘acute’ and ‘recovered’ images that physicians had long used to represent the stages of illness. In a paper read to the Royal Society in London in April 1856, Diamond said that the photographer was in a unique position to ‘listen to the silent but telling language of nature’. He could ‘catch in a moment the permanent cloud, or the passing storm, or sunshine of the soul’. The fuzzy language of emotion could be replaced by the ‘marked precision’ of photography, a crucial advance for psychiatry, Diamond argued (Burrows & Schumacher, 1990, p.153).

One of his most famous portraits, ‘Melancholy Passing into Mania’ (see right), shows a defiant woman in her late thirties who refuses to look at Diamond as he photographs her. Presumably, the woman in this portrait consented to sitting in the elegant wing chair on which Diamond has posed her, but her expression remains elusive, her mind clearly elsewhere.

John Conolly, the pre-eminent psychiatrist of Victorian England, later studied this photograph. In a famous clinical paper, he wrote: The eyes seem to discern some person or object which excites displeasure or suspicion… The lips are somewhat compressed, and the lower jaw indicates some half-formed determination. The corrugation of the frontal muscles is seen to have given way to transverse wrinkles, and a partial elevation of the eyebrows, the eye having at the same time assumed an active character; as if the patient was now beginning to understand some plot, and distinct ideas of revenge were beginning to excite her…. (Conolly, 1858, p.238)

The technology of picture-taking in those early years required that a subject sit still for an extended exposure period. These portraits could never have been made without a ‘spirit of friendly cooperation’, as Diamond put it, between physician and patient. As two historians of his work have recently written, ‘there could be no

scenes snapped in the ward, no secret portraits taken while a patient was unaware’ (Burrows & Schumacher, 1990, pp.48–49). This careful posing is evident in Diamond’s photographs as well as in those of his colleague at Bethlem Hospital, Henry Hering.

In his Royal Society paper, Diamond said that ‘photography presents a faithful record, free altogether from the painful caricaturing which so disfigures almost all published portraits of the Insane’.

He gives examples of patients thanking him for the opportunity to see portraits of themselves in disturbed states because it let them appreciate how much they had changed. By portraying his patients with the same calm formality as is evident in his portraits of friends and colleagues, Diamond saw himself as humanising madness and helping his patients to recover themselves.

But of course these are still essentially depictions of pathological types. For all their noble sentiment, photographers like Diamond and Hering were trying to find some external mark, some sign that could Melancholy Passing into Mania – by Diamond give a glimpse of the mad mind. It seemed never to have occurred to them to ask patients directly about their range of works that arrived in response feelings or the meanings of their unusual to his solicitations. states.

There were drawings in pencil and Hans Prinzhorn (1886–1933) took crayon and charcoal, on school the opposite attitude. Trained in both art notebooks, institutional stationery, orange history and psychiatry, Prinzhorn eagerly wrappers, torn envelopes, meal plans, collected works of art created by packing materials, wartime propaganda psychiatric patients. In 1919, when he pamphlets, and toilet paper. There were was appointed assistant psychiatrist at paintings on canvas, wood, tissue paper, the Psychiatric Clinic of the University and cardboard. Some of the wealthier of Heidelberg, Prinzhorn began writing patients had gotten access to oil paints; to the heads of asylums across Germany, the poor used tempera, sometimes mixed Austria and Switzerland asking them to with odd substances like cocoa, urine or look for ‘productions of pictorial art by blood. There were collages of painted or mental patients, which are not simply drawn images pasted to cutouts from copies of existing images or memories magazines and newspapers, a few of their days of health, but intended as adorned with unusual objects like pebbles expressions of their personal experience’ or pine needles. There were illustrated (Brand-Claussen, 1996, p.7). In less than books bound with a paste of flour and three years, he was able to assemble a water, their pages varnished or sewn collection more astonishing than any together. A few (of the richer) patients other, before or since, consisting of more had even worked in pigskin diaries. There than 5000 pieces by 500 artist-patients. were sculptures made from clay or wood Works arrived from dozens of or stale bread moistened with water. institutions and took every conceivable Embroideries and textiles were pieced form – paintings, drawings, sculptures, together from scraps of material or textiles, even installations. Their materials abandoned garments or woven from were varied and inventive, patients having thread unravelled from hospital uniforms apparently taken full advantage of any or bedclothes. Some of the works were substance, technique or surface they minuscule; others took up a whole room. could cadge or otherwise manage to No matter what their form, they had all acquire in a locked institution. simply been packed up (or, in the case of Prinzhorn was astounded by patients’ a few larger pieces, photographed) and resourcefulness and by the extraordinary shipped off to Prinzhorn with a tag or a

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few case notes or no notation at all about the circumstances of their creation.

Few of the Prinzhorn artists had done artistic work prior to being institutionalised, and even fewer had formal training. But the urgent need to express their feelings and make sense of their madness experiences had apparently led them to create artworks, sometimes only after years of confinement. The timelessness of asylum life in an age before occupational therapy or ward meetings meant that patients could spend years with no structured activity. They had to find their own ways of occupying themselves. Paradoxically, although few patients at the turn of the 20th century had the benefit of treatment (most institutions were simply custodial), the absence of medication did seem to foster creativity. (Today, August Klett (1866–1928), untitled, dated 1919, Inv. No. 560 patients who have been hospitalised for long periods are often so heavily medicated that their hand-eye coordination is too impaired to produce takeover. Many of the artists who techniques like gassing, later used on complex works of art.) created the works in his collection a wide scale to eradicate the Jewish Prinzhorn left Heidelberg in 1921 were murdered as part of the so-called population, were ‘perfected’ on the and died in 1933, just before the Nazi ‘euthanasia’ programme (in which already captive population of hospitalised

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As a record of the development of the profession, this short history will be highly relevant to psychologists working or training in health care. As a scholarly history it will appeal not only to historians but also to anyone with a general interest in social and political developments in mental health provision. “a landmark study… an impressive collective achievement” – Professor Mathew Thompson “At long last… a fine collection of chapters has appeared on the history of clinical psychology” – Emeritus Professor Mick Carpenter £21.99 (postage paid) from the BPS Shop www.bps.org.uk/CPiB Discounted prices for BPS members (£19.99) and DCP members (£17.99)

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mental patients). However, the artworks themselves were not destroyed because the Nazis wanted to use them for propaganda purposes. (For example, to illustrate the supposed ‘degeneracy’ of Expressionist artists, their work was displayed alongside that of Prinzhorn patients.) Fortunately, thanks to the efforts of many devoted curators and staff at the university’s psychiatric clinic, most of the 5000 works that Prinzhorn collected are now in their own beautiful museum in Heidelberg (http://prinzhorn.ukl-hd.de).

These images stimulate a range of questions about the visual depiction of mental life. Diamond’s photographs and the works of the Prinzhorn artists are clearly fascinating, but can we say that they actually give us ‘ways of knowing’ madness? Is such a thing even possible, or does profound emotional distress simply defy any attempt to represent it fully? However we choose to answer these questions, we have to acknowledge that such difficulties have not stopped people from trying. From the colourful PET scans of the so-called ‘schizophrenic brain’ that now fill psychiatric textbooks, to the cartoon images of neurotransmitters in pharmaceutical advertisements, to the extravagant performance art created by activists in today’s mad movement, images of madness are everywhere. I myself think that the only meaningful approach is to start with the lived experience of individuals, contextualising their ‘madness’ within the rest of their life story and experience. The title character of my recent book, for example, is a Prinzhorn artist, Agnes Richter (Hornstein, 2009).

She told her story in the form of an extraordinary jacket – which she constructed out of a re-sewn hospital uniform and then turned into an autobiographical text (see box). What did Agnes and the thousands of other psychiatric patients who have left narratives want us to understand about their experiences? To me, that is the key question to be asking – what is madness from the inside?

I Gail A. Hornstein is Professor of Psychology at Mount Holyoke College, South Hadley, Massachusetts www.gailhornstein.com She will be a keynote speaker at the joint conference of the History and Philosophy of Psychology Section of the British Psychological Society and the UK Critical Psychiatry Network, to be held at Leeds Trinity University 22– 23 March 2016. Details and abstract submission are available at www.kc-jones.co.uk/history2016

Agnes Richter and her ‘remarkable jacket’ Agnes Emma Richter, born 21 March 1844 near Dresden, Germany, was a skilled seamstress who supported herself doing that work in Germany and America until her late forties. She had saved up a considerable sum by that time, and when police forcibly admitted her to a local mental institution because of complaints from her neighbours, she told them that people were plotting to steal her money and she ‘believed her life to be in danger’. Increasingly angry and ‘non-compliant’ with her incarceration, she was transferred in 1895 to the state asylum at Hubertusberg, where she was kept against her will for the next 23 years, until her death on 1 July 1918.

We know practically nothing about the details of Agnes’s life in the asylum. Of the 76 pages of her case file, 70 deal entirely with disputes about who will pay the costs of her institutionalisation (suggesting that her concerns about people ‘stealing her money’ may have been well founded and not ‘paranoid ravings’). An unknown asylum staff member sent Agnes’s remarkable jacket to Hans Prinzhorn, accompanied by a tag that read ‘memories of her life in every piece of washing and clothing’. Even among the thousands of extraordinary objects in Prinzhorn’s collection, the jacket stands out – a powerful and intensely personal piece of textile art with a challenging message.

Nothing is known about when or precisely how Agnes created the jacket, except that she seems to have taken apart her shapeless hospital uniform and reconstructed it into a beautiful and elegant garment. The delicate buttonholes, the cuffs flaring from tightly fitted sleeves, and the peplum (a decorative ruffle attached to the bodice) all offer evidence of her considerable talent as a seamstress. The bluish-grey linen is accentuated by sections of brown felt attached to the collar and parts of the back of the torso. But what makes the jacket so extraordinary and so distinctive are the dozens of lines of text that cover practically every inch, sewn in five colours of yarn and thread that give the impression more of a painting than an everyday garment.

The words are stitched with barely any space between them, spiralling around each sleeve, flowing from the outside to the inside, and then at various points simply trailing off.

Agnes used an ornate form of cursive writing (now unintelligible to contemporary German speakers) called Deutsche Schrift, and this, combined with the compressed form of the phrases, give the text an almost hieroglyphic appearance.

Certain sections have, however, been painstakingly deciphered, making clear Agnes’s intention to recount details of her experience at Hubertusberg. The words ‘I’ and ‘me’ appear often, along with various phrases having to do with her sister, her desires, and her anguish, with ‘I plunge headlong into disaster’ being the most provocative.

We cannot now know whether Agnes Richter saw her work as a political act, ‘a weapon of resistance to the constraints of femininity’ as Rozsika Parker labelled the art of embroidery in her classic feminist analysis, The Subversive Stitch (Parker, 1996). But the jacket and its text offer a powerful challenge, reminding us that madness is more code than chemistry, and if we want to understand it, we need native speakers, not just brain scans.

Until the end of January, readers can buy Agnes's Jacket by Gail Hornstein at the special price of £12.00 including P&P. Enter code BPSAGNES at the PCCS Books website checkout.

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ONE ON ONE

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… with Marcus Munafò

‘Science is a very social process’ One reason why you became a psychologist It was chance! I wanted to read philosophy at university, but at Oxford you have to do philosophy with something.

I chose philosophy and psychology, mainly because psychology sounded quite interesting. I’d applied to do single honours philosophy at the other universities I was applying to. After my undergraduate degree I simply kept studying because I was still finding psychology interesting. In a sense I’m still doing that, and one of the reasons I have such a mixed bag of interests is because of this. I have a tendency to follow whatever seems interesting at the time.

One rewarding aspect of your work I love the intellectual and personal freedom. I can have an idea about an interesting research question and get straight down to answering it the next day. There’s no one to

coming soon

Marcus Munafò is Professor of Biological Psychology at the University of Bristol marcus.munafo @bristol.ac.uk

tell me what I should study. Of course, some research questions need substantial resources to answer, but not all of them do.

We’re doing a lot of work using publicly available data from genomewide association studies, and all that really requires is time and effort.

One frustrating aspect of your work There are the usual frustrations – bureaucracy, too many e-mails, that sort of thing. Every job has those though. For the most part I really enjoy my work; the thrill of feeling you might be onto something – a new finding or idea – is unique. One thing I have become concerned about are the incentive structures that scientists work within – the pressure to publish, get grants, generate exciting findings isn’t conducive to good science. It’s hard not to respond to these

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pressures. Fortunately, funding bodies, journals, societies and scientists themselves are thinking about how to address this, but it’s a complex problem.

One of the main challenges facing psychology today I’m not the only one concerned about the impact of incentive structures in science, and there’s a lot of debate around the ‘reproducibility crisis’ in psychology and other

career, and made all the difference. Part of what attracted me to Bristol was the people, and I still work with many of those people (even the ones that are no longer at Bristol). Science is a very social process – you need to share ideas and collaborate on a daily basis.

One other job you could have done Another thing that I love about academic life is that the flexibility gives you the opportunity to pursue other interests. I’ve been a rowing coach and served in the Army Reserves – both in my spare time. So if I hadn’t been a psychologist I probably would have followed one of those paths instead. But I’ve been lucky enough to be able to do all three, rather than just one…

One film Pulp Fiction – it’s the only film where I wanted to go back in and watch it again straight away after seeing it.

One way to unwind Being near water – near it, on it or in it, I find rivers, lakes and the sea (even swimming pools) incredibly relaxing.

sciences. I certainly don’t think the problems are unique to psychology – all disciplines have their own problems, and there are some issues (such as the pressure to publish or get grants) that apply across the board.

One important influence I couldn’t name just one! I was really fortunate to work for some fantastic people early in my career – intellectually generous and willing to let me follow my own ideas. That was perfect for me in my early

One favourite research finding Smokers will change how they smoke when they switch from high-tar to low-tar cigarettes, so as to extract the same amount of nicotine. I think that’s a lovely demonstration of how behaviour can be under close biological control. It also means low-tar cigarettes are just as bad for you as the hightar ones!

One place Bamburgh in Northumberland – a beautiful (and generally empty) beach, hills and dunes to get lost in, and a stunning castle as backdrop. And the sea, of course…

vol 28 no 12

december 2015