Forum, January 2009

A call to cooperate

In his 'call to arms' Tony Ward questions the role and legitimacy of the British Association for Behavioural and Cognitive Psychotherapies (BABCP) in the accreditation of CBT therapists, including applied psychologists (Letters, November 2008).

The BABCP was founded in 1972, and its purpose is to advance the theory and practice of cognitive and behavioural psychotherapies (including CBT) by the promotion of scientific research and the application of evidence-based practice, including assessment, therapy and consultancy. BABCP is a charitable organisation that has 7000 members, including just under 3000 psychologists, 429 of whom are accredited cognitive behavioural therapists.

Along with BABCP, the BPS supports the government's Improving Access to Psychological Therapies (IAPT) programme. In fact, the establishment of a psychological therapist career pathway to help to deliver safe and effective psychological interventions was one of the Society's recommendations in its New Ways of Working for Applied Psychologists 2007 report published jointly with the Department of Health (see www.newwaysofworking.org.uk psychology.aspx).

As the only organisation in the UK that currently accredits CBT-specific training courses, BABCP was invited and is well placed to support the IAPT programme in the accreditation of high-intensity training. Clearly this is in line with the Association's purpose. This arrangement was supported by the BPS members on the IAPT Education and Training Project Group, and the accreditation process is in fact supervised by an Accreditation Oversight group that includes representatives from the BPS and other stakeholder organisations. BABCP acknowledges and welcomes the fact that other organisations (including the BPS) may become involved in IAPT accreditation, although the likely regulation of psychotherapists by the Health Professions Council in the near future will change the whole landscape.

Beyond its work to support the initial £173 million investment in IAPT, BABCP, through a well-established liaison group, is working with (and indeed has provided some resources to help) the BPS to look at how psychologists with relevant CBT competences can be accredited in the most efficient way in future. In fact, this joint work on psychologists' CBT competences significantly pre-dates the IAPT concept and inception. Further, along with the BPS and other stakeholder groups, BABCP continues to support and lobby for the expansion of the IAPT programme to include other evidence-based psychological therapies, to improve access to effective therapies for a wider range of client groups (e.g. those with longer-term mental health problems, children and adolescents, people with intellectual disabilities), and to extend the initiative to the other home nations.   

Thus, Ward's claim that BABCP 'undermines the credibility and competence of psychologists' is without foundation; and the evidence points to the contrary. BABCP, rather like the therapeutic approaches it promotes, is working in a collaborative and inclusive way with the BPS and other stakeholders. Instead of a call to arms to fight for passé inter- and intra-professional rivalries that will likely alienate service users and policy makers alike, I would encourage BPS colleagues to join with a collaborative and concerted campaign to extend the IAPT programme to better meet the needs of more of those who would benefit from access to safe and effective psychological therapies.

John L. Taylor President British Association for Behavioural and Cognitive Psychotherapies

 

Where forensic meets clinical  
Denis McVey (Letters, December 2008) raises some pertinent questions about the competencies required in a forensic mental health setting, which the Chair of the Professional Practice Board has not adequately answered. However, Mr McVey only addresses one side of the issue.

It is indeed hard to understand why forensic psychologists should be employed in non-forensic services. However within forensic mental health settings exactly the same questions that Mr McVey poses about psychologists without mental health training could and should be asked about psychologists without forensic training who work with offenders. Forensic and clinical psychology are distinct disciplines and practitioners in the field of forensic mental health require competencies from both disciplines to practise effectively. The professional, ethical and clinical risks associated with employing clinical psychologists who lack the appropriate competencies to work with this service-user group are just as grave as they are with forensic psychologists.

Although forensic psychologists continue to be regarded as second-class citizens by some of our less enlightened colleagues in the health service, the expansion of forensic psychology in forensic mental health services in recent years has brought many benefits, and it can be no coincidence that those services which employ both forensic and clinical psychologists and which encourage members of both disciplines to extend their competencies are among the most innovative and highly regarded.

Petty and divisive wrangling about which discipline is the better equipped to work in this setting diminishes the whole profession and distracts from the reality that both disciplines have much to learn from each other and that forensic mental health employers and managers have a duty to ensure that all their psychologists, from whatever discipline, have access to appropriate training and supervision in order to meet the complex needs of this service-user group.
Phil Willmot
Psychology Department
Rampton Hospital

 
Psychology in confusion?
Any newcomer to the discipline would need to look no further than the December issue of The Psychologist to appreciate its confused state. On the one hand, we have correspondents warning us of our continuing philosophical and sociological naivety or ignorance (Dultz and Nel respectively). On the other hand, our current leaders are assuring us that professional psychology has unique answers borne of linear scientific incrementalism and unreflective naive empiricism. From the news pages, one example was the announcement that psychology now has a superior understanding of well-being ('the bank account of the mind' from Cary Cooper et al., which now replaces social capital with 'mental capital'). Another was Professor David Clark reassuring us that models of change preferred by mainstream clinical psychology (for now CBT) should be privileged over the personal qualities of the helping relationship (cf. Pilgrim et al., 2009).

Such non-reflexive reductionism ignores the continuing discourses from philosophy, sociology and religion, which offer some stimulating alternatives about the relationship between experience and behaviour. For example, we could consider Foucault on the unending contestation in the human sciences about ontology, epistemology and methodology (Foucault, 1973). We might also consider the insights of social network analysis (Freeman, 2006) to account for why the current one-dimensional policy of CBT in England has emerged not because of its inherent scientific merits but from the particular metropolitan elite which signed the 'Depression Report'. It consisted of three closely connected peers of the realm and their circle of preferred academic colleagues at the University of London. Disciplinary disloyalty might be required in order to understand psychology and its claims of pre-eminence on the grander stage of life.
David Pilgrim
Faculty of Health and Social Care
University of Central Lancashire

References
Foucault, M. (1973). The order of things: An archaeology of the human sciences. New York: Vintage Books.
Freeman, L. (2006). The development of social network analysis. Vancouver: Empirical Press.
Pilgrim, D., Rogers, A. & Bentall, R. (2009). The centrality of personal relationships in the creation and amelioration of mental health problems: The current interdisciplinary case. Health, 13(2), 237–256.

The need to think philosophically
Ron Dultz is right that psychology suffers from 'A paucity of philosophy' (Letters, December 2008) – indeed I would take an even stronger line than him and argue that such paucity has seriously hampered proper theory development within the discipline.

However, one cannot just 'bolt on' philosophy to a pre-existing discipline; one needs to completely restructure the discipline so that a philosophical style of thought becomes incorporated into the way psychologists do their business. The split between psychology, philosophy and physiology that occurred in the 19th century needs to be repaired.

Consider the fate of neuropsychology. This is a discipline that seeks to discover the relationship between neural and mental events, yet the contribution that philosophy is able to make – even though it is a discipline seeking the same aim – is close to zero. This is because the concepts that philosophers deal with are not such that they can engage with the empirical activities of neuropsychologists.

An examination of the fate of attempts to improve on this situation is instructive. Bennett and Hacker (2008) are two philosophers who have made an important and noble attempt to bring philosophical thinking to bear on neuropsychology in a serious way. For example, they point out how neuropsychologists have confounded levels of description by applying to neural subsystems a terminology that should only be applied to the psychology of whole organisms. The idea that an image of the world is reconstructed in area V1 of the primate cortex is one such idea challenged on this basis.

But their efforts have been met largely with a mix of irritation and puzzlement, and sometimes open hostility. They have defended their position by arguing that all a philosopher can do is help to clarify the concepts used by neuropsychologists. This is true and is probably the best that can be done under the circumstances. But it is the circumstances that lead to members of one discipline having to clarify the concepts used by another that is surely at fault.

The empirical work done by neuropsychologists is nowadays very sophisticated, but it is not matched by an equivalently sophisticated system of thought. Such a system of thought is held by philosophers, but the two need to work together. This could be achieved either by having research teams comprising both philosophers and neuropsychologists, or – what is probably better – by having neuropsychologists schooled in a philosophical style of thinking.
John Campion
Liphook
Hampshire

Reference
Bennett, M.R. & Hacker, P.M.S. (2008). History of cognitive neuroscience. Chichester: Wiley-Blackwell.

Hypopituitarism and our son's suicide

Our son took his life this August at the age of 31. We made a discovery after his death that we feel needs to be shared widely as it has  a bearing on depression.

Although our son had a girlfriend for four years, we found from old letters that he had been impotent. This, together with his depression, were what led to their break-up, according to a conversation we had with his girlfriend after his death. This was a terribly sad discovery for us, and it explained so many things, particularly his lack of confidence when he was so attractive, had so many friends and was so capable at his job. It also explained why he had never 'moved on' in the six years after his girlfriend left him – because of course he must have thought his problem would make it impossible to sustain any new relationship. And it made it clear to us why this year had been so hard for him, filled as it was with weddings and babies among his family and friends.

But this was not all we discovered. We also found research that showed his impotence was very likely to have been caused by a bad head injury he'd suffered when he was seven. Damage to the pituitary gland in childhood can show itself years later in adolescence. But nobody ever warned us of this, because the research has mostly only been written in the past few years (e.g. see Einaudi & Bondone, 2007).

Brain-injury-induced hypopituitarism is often not diagnosed, or diagnosed years too late, because professionals do not realise just how common it is. At least five people treated our son for depression, but his past brain injury rang no warning bells. If they had checked his hormone levels, in all probability he could have been treated with testosterone and be alive today. In fact, between 28 and 69 per cent of head injury survivors have pituitary damage – one article describes it as a 'silent epidemic.'

We are now doing all we can to make sure people everywhere know, because we do not believe our son can have been the only victim of this lack of awareness.
Names and address supplied

Reference
Einaudi, S. & Bondone, C. (2007). The effects of head trauma on hypothalamic-pituitary function in children and adolescents. Current Opinion in Pediatrics, 19(4), 465–470.

Obituary
Gwen Thorstad (1922–2007)
Gwen Thorstad can be described as an educational and clinical child psychologist of the old school who initially trained, and later worked, at the Child Guidance Training Centre (CGTC) in the 1960s, 70s and 80s. Many generations of trainee psychologists, psychiatrists and social workers thus passed through her hands
and with great benefit.

She was one of the first cognitive psychologists working in a period before that term became fashionable. She specialised in mental testing and in the assessment of specific learning disabilities. She carried out original research on children's drawings of a 'Plan of a House'. In using this method she was able to demonstrate how children's poor performance at this task pointed to possible neurological and emotional dysfunction. Her work represented an important diagnostic addition to the then prevailing psychoanalytic climate at the CGTC.

It was also as a participating member of a multidisciplinary clinical unit that Gwen excelled and so was highly valued by the team members. Much against the spirit of the times, she strongly believed in the traditional child guidance model and once remarked: 'Just keep talking about it and it will come back into fashion.' The success of the method was displayed by the number of former CGTC trainees who obtained posts throughout Great Britain and who were a major influence on the work of child guidance clinics.

As a teacher Gwen was strict and uncompromising in her assessment approach and methodology, and some students inevitably found this attitude tough going at times. However, later in practice, her students readily acknowledged how much they had benefited from her personal supervision. One of us recalls with gratitude that when he was a newly appointed, anxious child psychiatrist in charge of a clinical unit, Gwen had shrewdly commented: 'You don't have to know everything.'

If a word were selected to sum up Gwen's outstanding contribution to psychology and child guidance it would be 'integrity'. Through an era of great change in the profession and the world at large she held on strongly to certain professional values and standards of care and competence. She was a rather private person, but once her initial reserve had eased, one found a colleague whose warmth, steadfastness and loyalty could be utterly relied upon.

Using her exceptional blend of toughness and tenderness, she also had a remarkable manner of securing and putting a child at ease in the assessment situation. It can be said with conviction that as an all-round practitioner and teacher we will not see her like again.
Bernard Barnett
Director of Psychological Training, Child Guidance Training Centre, 1971–1986
Sebastian Kraemer
Consultant Child and Adolescent Psychiatrist, CGTC, 1980–1985

Baby P – what is our response?

As psychologists and mothers, we share the distress echoed by the British public over the recent death of Baby P.

We have been wondering what we can do as practitioners, educators and parents in order to increase support for parents and professionals, ensuring the protection of children and teenagers.

We appreciate that within this case, there have been numerous discussions over blame and responsibility, and we do not wish to repeat these here. We acknowledge that Baby P was just one of thousands of children who are vulnerable and who live with parents in need of support or greater supervision. 

It would be helpful if individual Society members and the BPS as a whole could take a lead on providing information to both members nd the public on the following areas, from an evidence-based perspective:I    adoption and fostering
I    preventing violence and abuse
I    educating and supporting social workers and allied
professions
I    training for teachers and health workers
I    examples of good practice in community, counselling and clinical care
I    providing support for members of the public affected by the recent distressing media coverage of Baby P.

We would be interested to hear from the Society what steps the organisation may be taking in their response to Baby P's death? We would also like to hear from those psychologists working with families and children in a clinical, counselling educational, research or voluntary capacity about how they feel we can work with communities and individuals at all levels to ensure child and family welfare is improved.
Petra Boynton
Department of Primary Care and Population Health
University College London
Irina Anderson
School of Psychology
University of East London

 

ABA – a question of misinformation?
The accurate dissemination of research findings is crucial for the uptake of scientific practices by a community. Unfortunately, because there are no other avenues, I find myself in the uncomfortable position of publicly highlighting an issue created by the BPS that runs counter to the professional standards we expect of our organisation.

After lobbying by me, I persuaded the then President (Pam Maras) to instigate a review on the Northern Ireland task group report on autism (commissioned by the Minister for Education). The focus was on the responsibility of the BPS to ensure that the public are not misinformed about psychological treatments; much of the Northern Ireland task group report contained serious misinformation about applied behaviour analysis (ABA). My request for the review was supported by leading international professionals in ABA who agreed on the extent of the misinformation I had identified.

To aid the review I was asked to submit material for consideration. The final document, however, incorporated little of the material I had submitted. Even a comment in the Northern Ireland report that intensive ABA might cause psychological damage to children was not addressed. Worryingly, there were no ABA professionals involved in producing the review. This is a remarkable omission given the remit and the Society's code of ethics and conduct on operating outside one's area of competence.

Now the BPS is engaged in stonewalling. They have declined to answer incisive questions from the chairperson of a local autism charity concerned with teaching ABA to parents (his letter can be viewed at tinyurl.com/567mp6). Furthermore, an offer to meet with representatives of the European Association of Behaviour Analysis (EABA) to discuss the review was declined.

Currently the BPS is coordinating a response to the Northern Ireland consultation on the Autism Spectrum Disorder Strategic Action Plan 2008/9–2010/11. Documents to be discussed include a recent report from Lord Maginnis (commissioned by the Minister for Health). As in the Education task group, ABA professionals were excluded from participating and again serious inaccuracies appear in the depiction
of ABA. In stark contrast to support parents have received from the BPS, other international organisations have written directly to Lord Maginnis (see www.peatni.org).

Behaviour analysis has few proponents within the BPS, and generally the teaching of this science lags far behind developments in the field. Antagonism to the science for historical reasons, however, does not justify misrepresentation of its findings. A cognitive psychologist and past President of the American Psychological Society agrees:

Behaviorism is alive and well.. Counting affiliate organizations around the world, there are some 12,000 members…and… around 250 new members a year just in the U.S. … Why the enthusiasm? Because behaviorist analyses work! ... For an autistic child, Lovaas's behaviorist techniques provide the greatest (indeed, so far the only) hope. (Roediger, 2004)

I urge members to write to the President to persuade the BPS to answer the questions posed by a parent and to reconsider its refusal to meet with EABA. Policy decisions in our community need to be protected from misinformation.
Mickey Keenan
School of Psychology
University of Ulster
Coleraine

Reference
Roediger, R. (2004). What happened to behaviorism. APS Observer, Vol. 17. No. 3. Retrieved 2 December 2008 from www.psychologicalscience.org/
observer/getArticle.cfm?id=1540

Reply from Professor Martin Conway, Chair of the Research Board, and Dr Martin Crawshaw, Chair of the Professional Practice Board: The Society's commentary on the Northern Ireland task force report was prepared, at the request of the Research Board and Professional Practice Board, by a number of members of the Society with specific expertise in the field of autism (they had also been key contributors to the Society's Working Party Report on Autistic Spectrum Disorder). The remit of the group was to review the Northern Ireland report and to identify any shortfalls in the document and specifically in relation to the current empirical evidence base for different treatments and interventions for autism (including applied behavioural analysis).

Whilst we acknowledge that proponents of ABA are dissatisfied by the conclusions drawn in the commentary on the report, when preparing commentary on official reports it is incumbent upon the Society to remain impartial and to consider the best available scientific evidence base. The empirical evidence base for applied behaviour analysis was therefore reviewed by the group and reported accordingly.

Responses have been made to the letters from the Chairman of PEAT and from EABA outlining the scientific basis upon which the document was prepared and acknowledging that there are strong differences of opinion in this area.

The autism 'trip' – a lifetime of altered perception?
Following my son's diagnosis of autism some years ago, I have developed a theory that I would like to share with readers and ask whether anyone has any related evidence or would like to seek some. 

I published a paper on my theory with the National Autistic Society, and delivered it at the NHS research conference Experimental Biology and the Autistic Syndromes at Sunderland University.

Many behavioural characteristics typical of autism closely parallel the effects of psychoactive compounds such as LSD and mescaline. I believe that if one were to be in a permanent state of altered perception, such as would be the case if the brain was spontaneously producing an endogenous psychoactive compound, you would effectively get the autistic state, which was why I called the paper 'The Trip of a Lifetime'.

One of the most common findings in the biochemical makeup of autistic children is the presence of high levels of bufotenin. Bufotenin is a minor metabolite of tryptophan, the amino acid precursor of the neurotransmitter serotonin. Another reason to suspect bufotenin is that the tryptophan molecule's structure is 'indole'; it is the only amino acid in the body to be so and shares this characteristic with psychoactive compounds such as LSD and mescaline. It is, if you like, the common 'link' between the two states.

Bufotenin levels are normally held in balance by monoamine oxidase (MAO). If, however, MAO was inhibited, bufotenin levels could rise to a point where concentrations become such that behaviour is affected and the subject effectively begins to 'trip'.

This idea seems to be supported by recent research, published in New Scientist, carried out by Dr Ira Cohen, a psychologist at New York's State Institute for Basic Research in New York. Dr Cohen's research team has identified a relationship between the more severely affected autistic boys in their control group and a variation in the length of a control region at the start of the MAO gene. The variation determines how much of  the enzyme is produced. Dr Cohen's work also seems to support the prevalence of autism in males, inasmuch as boys have only one copy of the gene, because it is only found on the X chromosome, while females of course have two. 

In summary I believe that we should be doing studies to confirm the presence of bufotenin in both the autistic child and in their parents – this would be relatively simple because it's detectable in urine – and then perhaps developing a drug to block bufotenin receptor sites in the brain.
David Selwyn
Tooting
London
SW17

 
Gendered occupations?
John Sloboda, in his 'One on one' interview, asks 'Why has psychology at degree level become more and more gender-unbalanced (currently 85 per cent female in my institution)?'

I have not examined this in detail for about 10 years, but I have noticed nothing that radically changes the conclusions I reached then (e.g. Radford, 1998). Subjects, and occupations, are seen as more or less 'suitable' for males and females. They are placed on a continuum of psychological masculinity–femininity. This seems to be based not so much on content as on what the subject is perceived as 'for' or 'about'. This in turn roughly corresponds to 'things' or 'people'. Technology, for example, is generally strongly masculine, with two exceptions, food and textiles. Psychology is well towards the feminine end. Ratings of subjects on this scale by students correspond closely to actual enrolments.

Individuals are similarly placed on this continuum, and the two tend to match. Men tend to be more 'masculine' and women more 'feminine', with of course many exceptions. Within a particular subject, the inclinations of men and women tend to be similar. These differences show up rather dramatically when the National Curriculum years end, and students immediately divide along these lines for A-levels. The pattern is also widely found, for example in China, Europe and the United States.

The main reason for this increasingly affecting psychology at degree level is the growth of numbers of women in higher education. Women entrants exceeded men for the first time in 1993, and the gap is still widening. There is probably a consequential factor, that increasing numbers of women have changed the psychology that is offered in a 'feminine' direction. And there is probably also a tendency for a large majority in one sex to put off members of the other. Male nurses have told me that they get odd reactions when they reveal their occupation. More women students have also meant more women teachers of the subject, with their own interests.

A colleague some years ago had a weekly seminar. One week only four men were present. He gave them a choice of what they would like to talk about. They looked sheepishly at each other and then one, who had clearly been designated as the spokesman, said 'Anything but f—g babies!'
John Radford
University of East London

Reference
Radford, J. (Ed.) (1998). Gender and choice in education and occupation. London: Routledge.