Forum, June 2010

Giving voice to the voiceless' – high-tech speculation, or basic respect?

Our sister is one of the so-called 'living dead' referred to in your news report ('Mind of the living dead', March 2010). Serious brain injuries sustained over a year ago left her first in a coma and now in a minimally conscious state (MCS) from which she is extremely unlikely to recover. 

We read your report with dismay since we do not share your excitement about the 'amazing' findings emerging from brain-imaging research and we feel that psychologists should be more critically engaged with the wider issues such research raises.

Your report seemed to reflect and reiterate, rather than challenge, some of the uncritical reporting so often evident in mass media coverage of this topic (Racine et al., 2006). Although the New Scientist and Independent – in the two articles you cite – were better than most, their headlines are hardly, as you claim, 'justified', but instead typify the overblown claims that often accompany reporting about brain imaging. We challenge the notion that imaging allows scientists to 'read minds' (the Independent's headline) or that it provides 'A voice for the voiceless' (New Scientist).

Uncritical summaries of this field fail to address the limitations of brain-imaging technology or to challenge the basic assumption that increased blood flow to the brain is an accurate surrogate for consciousness (see Poldrack, 2006). 

There is also often no acknowledgement that for severely brain-damaged MCS patients 'consciousness' does not mean an intact cognition, the capacity to weigh up different clinical options, or to 'converse' with caregivers about treatments and to make decisions.

The recent jubilance about fMRI scanning feeds into a culture of misunderstanding encouraged by false media reports about patients diagnosed as vegetative being able to type complex sentences (as in the recent case of the much-publicised Belgian 'coma writer', Rom Houben) or grossly inaccurate films featuring patients waking up from even prolonged comas with fully intact cognition. 

In fact, the prognosis after prolonged coma, vegetative and MCS states is bleak; for example, 'there are no reports of patients in a vegetative state identified as "conscious" by functional neuroimaging making a recovery to functional independence' (Wilkinson et al., 2009, p.509).

We believe that 'giving a voice' to such patients (to use neurologist Steven Laureys' phrase in the New Scientist report) should not simply be pursued by expensive fMRI scanning – with whatever remote 'hope' that offers. Instead (or as well) it requires more basic listening skills – and psychologists already have a key, albeit often neglected, role to play here. 

Our sister's 'voice' was, for many months, expressed mainly through grimaces of pain, moaning or frantic kicking, and her opinions before brain injury were clearly articulated in her poetry, letters and conversations with family and friends. Ensuring that her voice is heard means paying attention to these more transparent indications of what she might now want – we do not need brain imaging to understand this. 

Unfortunately, we have found that public enthusiasm for research that 'listens' (via fMRI) to patients answering questions about their father's name by imagining a tennis game [see p.478] is matched by professionals' total lack of interest in patients' clearly expressed values and beliefs. For the first 11 months our sister's clinical team never asked about what our sister might want in this situation, nor did they take seriously the efforts of family and friends to communicate this.

The Mental Capacity Act 2005 is supposed to put the person who lacks capacity at the centre of any decision-making about them. It builds on a strong disability-rights perspective and on the long experience of organisations of, and for, people with mental incapacities of all types. 

The Act spells out the fact that 'best interest' decisions about medical treatment, for example, are not purely clinical: they are supposed to take into account the person's past and present wishes and feelings. There is a crucial place for psychologists here. 

Psychologists can support families and friends to 'give a voice' to incapacitated patients by ensuring that we distinguish between what we might want for ourselves, or for the patient, and what the patient might want for herself. Psychologists can support families and friends to articulate the patient's views and help decision-makers to take these views into account in decisions about the patient's best interest.

The Mental Capacity Act, and the values that underpin it, are not as 'sexy' as the supposedly dramatic findings revealed by fMRI. However, ensuring that all psychologists understand the Act and help to implement it, is a key place to start if a patient's voice is really to be 'heard'. Only then can we hope to reinstate 'A voice for the voiceless'.

Professor Celia Kitzinger, University of York
Professor Jenny Kitzinger, Cardiff School of Journalism, Media and Cultural Studies, Cardiff University

References

Poldrack, R.A. (2006). Can cognitive processes be inferred from neuroimaging data? Trends in Cognitive Sciences, 10, 59–63.
Racine, E., Bar-Ilan, O. &Illes, J. (2006). Brain imaging: A decade of coverage in the print media. Science Communication, 28(1), 122–143.
Wilkinson, D.J., Kahane, G., Horne, M. & Savulescu, J. (2009). Functional neuroimaging and withdrawal of life-sustaining treatment from vegetative patients, Journal of Medical Ethics, 35, 508–511.

Black women in the UK – the last of the impostors?

A series of writings in The Psychologist has led me eventually to write this letter that I have been reminding myself to write for about 15 years now. 

Firstly, it was a recent edition about mothers with a colour photograph of a black woman but making no specific mention of black mothers/infants; then it was Yvonne Walsh's letter 'Applied discrimination?' (May 2010) commenting on the omission of mentions of counselling psychology in a recent special edition of The Psychologist on social inclusion; and finally Christian Jarrett's article 'Feeling like a fraud' (May 2010) about females 'masquerading' as males and having a corresponding fear of 'being found out' (as not being viable practitioners and scientists). 

As part of this article, there was a photo of a female named Dr James Barry with her (black male) servant and her dog Psyche.

My concern has for many years now been the invisibility of the psychology of black women in Britain and elsewhere in the world in The Psychologist. 

Do we have a psychology that is distinct and relevant to be commented on in UK psychology journals in general and in The Psychologist in particular? Or are we impostors too (or am I), for trying to make a special case for a feature on psychological research involving black females in the UK, when in fact there are no specific psychological issues for black females in the UK, being no different from white or other ethnic groups of women, indeed no different from any other groups at all?

The editor of The Psychologist assures me that a special issue on psychology and black and minority ethnic groups is in the planning stages. However, I would also echo the sentiments of Yvonne Walsh that at the very least the editors should be asking for some reference to wider groups even if it is to direct readers to more 'specialist' reading that cannot be taken fully on board in the limited writing space that is available to contributors. 

Dr James Barry – said to have practised in the 1800s – would have had to wait until only just over 30 years ago to be considered equal to her male counterparts. Like many others, I am very proud to be a British-trained applied psychologist, but I remain concerned that for some areas of research, UK psychology does appear to be rather slow in advancing to the 21st century.

Jeune Guishard-Pine
Harrow

Wot, no politics?

I was surprised to see that the May edition of The Psychologist was not a little more politically engaged, considering that there was an election on and the inevitable cuts that will affect mental health because of the deficit. I wonder why psychology as a profession is so unwilling to engage in political debate when it can be claimed that 'politics in psychology is inescapable' (Fox & Prilleltensky, 1996). 

By including Jo Silvester's article the magazine seemed to try to step outside of politics and turn a 'scientific' eye on the individual politician instead of confronting the reality that mental health has always been the soft option when it comes to slashing funding in the public service.

If The Psychologist really aims to promote the advancement and diffusion of a knowledge of psychology, does that not include the welfare of the individuals we are supposed to be working with as clinical, counselling, educational, forensic and occupational psychologists, all of whom will be affected by public service cuts? Should the welfare of these individuals, and our duty of care, not come first instead of openly admitting in a respectable magazine that all psychology has to show when it comes to politics is how to McDonaldize a selection process?

Psychology does not exist outside the social and cultural context of which it operates, and can therefore never be apolitical. When asked why critical psychology always tries to make everything into a political issue, Ian Parker (2007) replied: 'The problem is not that we make psychology political, but that it already is political, and this is something mainstream psychology does not like to acknowledge' (p.5). 

Perhaps there is a need to acknowledge this in an open forum such as The Psychologist and engage with what this entails.

Patrick Larsson
London N7

References

Fox, D.R. & Prilleltensky, I. (1996). The inescapable nature of politics in psychology: A response to O'Donohue and Dyslin. New Ideas in Psychology, 14(1), 21–26.
Parker, I. (2007). Critical psychology: What it is and what it is not.Social and Personality Psychology Compass, 1(1), 1–15.

Obituary

Elizabeth Campbell (1954–2010)

It is with great sadness I mark the death of my friend, colleague and collaborator Liz Campbell, who died on Good Friday, 2 April 2010, from breast cancer.

Liz was a chartered clinical and forensic psychologist and until recently head of the Division of Psychological Medicine at the University of Glasgow. In 2008 she became President of the British Psychological Society, a role she was proud to undertake and to which she brought her own brand of dash and flair. 

She had held numerous other key roles within the BPS, and had served as a Trustee for many years; at the time of her death, she was Vice President. Most recently she was elected to the role of Secretary General of the European Federation of Psychology Associations. She very much regretted that her illness prevented her from taking up this role.

Her tenure as BPS President was at a particularly difficult time of transition to the statutory regulation of psychologists. Her deft negotiation and attention to detail helped steer the Society to a solution that aimed to protect the public and maintained the integrity of the profession. 

She wrote: 'Psychology and psychologists have a great capacity for contributing to the public good. My vision is to safeguard standards and to maintain the principles and values of the Society.' She achieved just that.

Liz graduated from Edinburgh University with first class honours and subsequently gained an MPhil in clinical psychology. In 1985 she was awarded a DPhil from Green College, Oxford, after completing her thesis on depression in women.

Her first lecturing job was at Surrey where she pioneered three-year practitioner doctorates in counselling and in clinical psychology. She wanted both clinical and counselling psychology put on a professional footing, but, as she told her mother, she had to hope that the validation panel did not notice she was only a junior lecturer. 

She returned to her native city to take up a senior lecturer post in the Section of Psychological Medicine of the University of Glasgow, became Programme Director for the Doctorate in Clinical Psychology and eventually became Head of Section in 2005.

Students and staff in both Surrey and Glasgow benefited immeasurably from her clear and precise teaching, and forceful reality checking on research ideas. She contributed significantly to understanding stress in the police through her research endeavours and her clinical interventions, creating with her Surrey colleagues one of the earliest services for officers and police staff. 

She recently co-edited a Handbook of Forensic Psychology, a work drawing on her considerable scholarship and a project she wanted to be a resource for students, academics and practitioners. Sadly, she did not see the finished book, which was published a couple of weeks after her death.

She was proud to be a Scot but was in no way parochial, always looking out and beyond. She was especially pleased with the collaboration she achieved through her European connections in developing training standards and protocols for psychological interventions following terrorist attacks. In December 2008, she attended the Indian National Academy of Psychology conference, where she signed a memorandum of understanding between our two associations. She was particularly keen to expose psychology to insights from other traditions and philosophies.

Liz was a considerate clinician, an effective administrator, a leader with political acumen and huge emotional intelligence, tempering the making of difficult decisions with compassion. She was also intensely human, felt passionate about injustice, inspired loyal and loving friendships; although she could be impatient when folk just could not keep up. 

The extent of her reach and the affection and regard in which she was held in the UK and internationally is amply illustrated by the number of postings on the Society's discussion forum.

Our thoughts and prayers are with Liz's son and mother, and also with her brothers and their families, who along with her professional colleagues and friends will miss her warmth, sound advice and infectious enthusiasm very much.

Jennifer Brown, University of Surrey

Developing conceptual clarity

At the end of his article in the May issue of The Psychologist, Richard McNally asks, almost as an afterthought, whether Wittgenstein can help illuminate the concept of trauma. So fundamental is the question of conceptual clarity to psychology that, as someone who was fortunate enough to have read Moral Sciences at Cambridge while Wittgenstein was still alive, I must ask you to allow me to expand a little on Professor McNally's tempting hint.

Put simply, what Wittgenstein was trying to make clear was an identifiable difference between two kinds of concept. One kind (Type 1) is an intellectual construction. An example is the concept of electricity, which has no meaning beyond all the observable phenomena we call electrical. The labels of physical objects or categories of objects all belong to this type. The concepts may be abstract but they always refer to something physical, real or imaginary.

Concepts of this first kind are all potentially definable with precision, and therefore quantifiable. A finite list of the criteria for assigning a given phenomenon to a particular concept can be established; borderline questions can be resolved. Circularity is avoidable as definitions can be made other than in terms of the concept itself.

The second kind of concept (Type 2) is experiential in nature, not intellectual. The concepts record a history of felt experiences, not external observations.

No real conceptualising is involved. The abstractions are labels for universally perceptible qualities, like betrayal or compassion. There are societies where there's no concept of electricity, but wherever there are humans, there'll be betrayal and, hopefully, compassion too.

People may think they know what betrayal or compassion means and use the labels as if they were Type 1 concepts, definable in terms of something observable. But this kind of understanding is not the understanding of someone who has not only experienced the feeling of, for example, being betrayed, but also of betraying others. 

These experiences may be accompanied by more or less intense emotions, but the feeling of grasping what something like betrayal means is a separate experience – the experience of realisation, a eureka or conversion experience. The context for the original experience is unpredictable enough, but it's quite impossible to say what might be a trigger for the sense of grasping what it means.

Although the meaning is instantaneously graspable, Type 2 concepts are impossible to define or to describe in anything like a complete way. There are always additional aspects to be revealed. Expressions of these concepts are of mental phenomena with no finite boundaries and are limitless and countless.

Whereas observations of, and ideas about, physical events can be organised by means of mental activities like conceptualisation, there is no analogous way of organising knowledge of mental events by using physical activities. The only way of doing this is by using clever metaphors. 

This is the reason experts in the use of metaphor – poets, novelists and dramatists – can often help us not only feel the related experiences vicariously but often grasp their meaning as well. An evening spent watching a performance of Othello has often proved the trigger for a 'eureka' experience with regard to jealousy.

This distinction between the two types of concept is not important for most scientists as the objects of their study are always physical and so they only need Type 1 concepts. For psychologists, however, it's another story. Their prime objects of study are the non-physical, mental, aspects of human beings, but they are not normally skilled in the use of metaphor. 

As a consequence, other less satisfactory methods are used for managing the narrative of Type 2 concepts. One way is to devise a Type 1 concept, covering a limited set of features abstracted from the Type 2 concept you wish to study, and with the same name. This trick appears to render a Type 2 concept quantifiable and gives an illusion of objectivity. 

Another is to conceive of the mind as a binary state phenomenon – disturbed or undisturbed – and use presumed triggers or presumed expressions to identify these states. Richard McNally demonstrates very effectively with the concept of trauma the kind of intellectual confusion that the application of these methods produces.

Euan Hill
Tunbridge Wells

Concepts of stress

The inclusion of a category of prolonged duress stress disorder (PDSD) in DSM-5 (to be published in 2013) would relieve much of the pressure to include a widening range of stressors under the heading post-traumatic stress disorder (PTSD), and avoid thereby devaluing the construct, as Richard McNally has persuasively argued would happen ('Can we salvage the concept of psychological trauma?' May 2010).

The clinical reality is that clients do present with the symptom profile of PTSD but in response to lower-level chronic stressors, such as bullying at work, or care of a loved one with a progressive neurological disorder (Scott and Stradling (1994). 

Further, the PDSD description (intrusive imagery, nightmares, etc.) resonates more with these clients than alternative descriptors legitimised by DSM-IV (e.g. anxiety disorder not otherwise specified or depression). Treatment (Scott, 2008) draws upon some of the strategies used in PTSD protocols, such as writing about the chronic stressor.

It is important that DSM-5 takes 'milder' disorders like PDSD as seriously as the more severe, such as PTSD. I would suspect that there is a different neurobiology between PTSD and PDSD, but this remains to be elucidated. As Richard McNally suggests, trauma is probably not a unitary phenomenon. The work of Kelley et al. (2009) suggests that different trauma types lead to unique variants of the PTSD syndrome.

Michael J. Scott
Liverpool

References

Kelley et al. (2009). A comparison of PTSD symptom patterns in three types of civilian trauma. Journal of Traumatic Stress, 22, 227–235.
Scott, M.J. (2008). Moving on after trauma: A guide for survivors, family and friends. London: Routledge.
Scott, M.J. & Stradling, S.G. (1994). Post-traumatic stress disorder without the trauma. British Journal of Clinical Psychology, 33, 71–74.

Diversity and clinical psychology recruitment

I am a 37-year-old male, with a disability, trying to meet the requirements for assistant psychology posts. I strive to meet the evidential requirements for an ultimate place on a clinical psychology course. It does not matter that I have an immensely diverse background or a string of distinction-level qualifications. I operate within a dual discourse that complains about the homogeneity of the current clinical psychology pool while setting the specifications that maintain this very homogeneity.

I work in a forensic setting for Sheffield Child and Young People Services, travelling 90 miles to obtain my 'relevant experience'; I also have two young children. Despite the absence of the term 'assistant psychologist' from the clinical clearing system specific criteria, it is clear that up and down the country this is what is expected now, in a very competitive system. 

This is not simply an expression of anecdote and angst but gleaned from personal communication from a number of clinicians who have been involved with different recruitment processes for clinical psychology for several universities. It is not necessary to explicitly state 'assistant psychologist' as a pre-requisite as it is implicit by virtue of scalar-scoring candidates on the quality of their relevant experience through the presence or absence of a clinical supervisor. 

For a role to be advertised as 'psychology assistant' it must have a clinical supervisor under BPS guidelines. These posts are also only available to those with an intention to pursue clinical training.

The prevailing wisdom is that one should be 'willing to pursue such posts to hell and back', and 'be willing to travel to do so'. This is problematic with two young children who also need a father. Already they lose me for days and nights at a time as I try to gain my 'relevant experience'. 

If I want to pursue an honorary psychology assistant role I must sacrifice ever more time from my parenting role. So to achieve a fighting chance, to gather the experience necessary to follow a career, which is dedicated in a large proportion of its application to resolving problems rooted in childhood and upbringing, I must sacrifice the parenting time of my own children.

From discussions with seasoned clinicians, I am aware that the problem does not stop there. A further impact of the application process is that many women put off motherhood until they have achieved and completed their clinical training positions. As a consequence, the NHS loses a good percentage of successful candidates, which it has just invested three years' worth of training, as they can finally relax to pursue an opportunity of motherhood.

The cry is for greater diversity within clinical psychology; greater maturity of candidates; more life experiences to enrich the generally homogeneous classes of clinical psychology students. I have heard this cry before from my previous career in South Yorkshire Police. The problem then was structural and process-related, indirectly discriminating against the very qualities it sought to recruit. Can clinical psychology not learn from this example to remove its own discriminating barriers to diversity?

Andrew Williamson
Malton
North Yorkshire

Getting together on homelessness

I was most interested to see Christian Jarrett's article 'Helping the homeless' in the April issue.

As a psychologist who, after being in care with the local authority, was homeless for far too long, I am aware of how quixotic fortune can be. One can be homeless without any educational qualification, and in less than half a decade become a chartered psychologist.

Even if we did not personally experience homelessness and its consequent negative social conditions, there are still reasons why we as professional psychologists, in a practical, academic and humane profession, should engage deeply with such social issues. 

The more revered academic aspects of psychology in 2010 are morphing into practices that see psychology being put into action and research that has an application. As Dr Jarrett notes in his article, the American Psychological Association recently presented a presidential task force report on 'psychology's contribution to end homelessness'. 

I hope that psychologists here in the UK can be garnered into something similar, and I shall write to our President to see if they kindly will lend the weight of their office to support this.

Peter McParlin
Leeds

Response from society President Sue Gardner: Thank you for your suggestion. This is clearly an important area, and one that I think would benefit from the society's input across the Research Board and Professional Practice Board. Anyone keen to contribute should e-mail [email protected].

Obedience in naturalistic settings

Jean-Léon Beavois's replication of Milgram's obedience experiment in a French TV game show ('Game of death', News, May 2010) was intriguing, but it was not 'the first [replication] in a social field where science was not the source of legitimacy for the agent of authority'. There have been a few, starting with Hofling et al.'s (1966) 'experimental study in nurse-physician relationships'.

In Gamson et al.'s (1982) diabolically cunning and unjustly neglected field experiment, the source of legitimacy was a consultancy firm. 

When volunteers telephoned offering to participate, they were asked whether they would be willing to take part in (a) research on brand recognition of commercial products, (b) research on product safety, (c) research in which you will be misled about the purpose until afterwards, and (d) research involving group standards. Most agreed to all four, but all were immediately told (untruthfully) that they were assigned to (d) and were asked to go to a local Holiday Inn. 

The deception had already begun, and because they had agreed to (c), they had arguably given informed consent to be deceived!

In the testing sessions, groups of nine participants were asked by an employee of 'Manufacturers Human Relations Consultants to act in a highly unethical and damaging way towards an innocent victim, the apparent motive being to bolster the legal case of a large oil company against a garage owner whom they had sacked on patently unreasonable grounds. 

Without going into details, the results showed a level of full compliance of 25 per cent, compared with Milgram's 65 per cent, but various features of the experiment that could account for this difference.

Andrew M. Colman
University of Leicester

A sense of purpose

Jesse Bering ('The nonexistent purpose of people', April 2010) argued cogently that a sense of purpose, destiny and meaning is an artefact of irrational pre-scientific human cognition, but ended his article with examples only of the unhelpful consequences of this (suicidal violence by religious extremists and chronic self-doubts for young people).

To redress the balance, it should be said that there is considerable evidence from the research and therapy literature of the beneficial effect of having some sense of purpose and meaning to one's life and activities. This might take a spiritual, social, communal or other form. 

Whether or not this is illusory hardly matters. Furthermore, it is recognised that active membership of a church community in this country has a significant positive effect on health, psychological well-being and mortality.

Linda Shuttleworth
Chester

References

Gamson, W., Fireman, B, & Rytina, S.(1982). Encounters with unjust authority. Homewood, IL: Dorsey Press.
Hofling, C.K., Brotzman, E., Dalrymple, S. et al. (1966). An experimental study in nurse-physician relationships. Journal of Nervous and Mental Disease, 143, 171–180.

Guest Column

Web chat

For anyone interested in the civil war occupying the counselling and psychotherapy professions over their proposed statutory regulation by the Health Professions Council (HPC), the Mental Health Nurse blog provides some up-to-date, if somewhat biased and irreverent, commentary. 

The blog's pseudonymous authors, self-described as 'mostly mental health nurses', claimed early in May to have obtained a leaked document 'purporting to be the United Kingdom Council for Psychotherapy's (UKCP) critique of the proposal for psychotherapy to become regulated by the HPC'. 

This 22-page document, available at http://ht.ly/1Hdz4, argues that the problems with the HPC's proposed regulation 'are so drastic that they do not admit of "fixes".' The document has no named author although it states it was coordinated by UKCP chair Professor Andrew Samuels. 

Writing for the blog, 'Zarathustra' describes the document as 'sort of badly-argued tosh that would make a humanities graduate weep'.

In earlier posts, writers on the blog have pointed to the case of arts therapist Derek Gale to show why the state regulation of psychotherapy is so important. After being found guilty by the HPC of inappropriate conduct, Gale was struck off the HPC register of Arts Therapists and later the UKCP register. 

Yet, for some time at least, he continued to advertise as a psychotherapist and counsellor, as he was entitled to do in the absence of state regulation of these professions.

Another document to appear on the web is a template letter (http://ht.ly/1HdJI), for HPC opponents to send to their MPs, provided by the Alliance of Counselling and Psychotherapy Against State Regulation – an organisation, co-founded by Professor Samuels, which claims to have gathered over 3000 signatories who oppose HPC regulation. 

The letter accuses the HPC of proceeding as if their regulation of counselling and psychotherapy were a 'foregone conclusion'. It also includes four and a half pages of text detailing the problems with the HPC.