Letters: the hidden mental pain of men

The hidden mental pain of men

We are writing in response to the article 'The stressed sex?' by Freeman and Freeman (February 2014). We would wish strongly to take issue both with the conclusions reached by these authors and the methods by which they have arrived at them.

Freeman and Freeman make a very bold and sweeping claim, arguing that the female gender is associated with significantly higher rates of mental health problems than the male. They base this claim primarily on surveys of 'self-reported mental health problems', a source of evidence that they acknowledge has many major weaknesses and limitations. However, having mentioned these limitations, they then appear to completely disregard them.

It is ironic that one of the undisputed and well-established differences between the sexes is that males are significantly less likely from an early age to report problems or seek help (e.g. Benenson & Koulnazarian, 2008). This deep-seated need to appear in control and not to show vulnerability can be said to be one major aspect of traditional masculinity, whatever our particular theory for explaining this. This means that it can be safely predicted that in any self-report measure that relates to health or other problems, men will always significantly underreport. This is therefore an unassailable methodological problem when attempting to use self-report measures to measure true sex differences in something as emotive and self-revealing as mental health. Freeman and Freeman pay only lip-service to this issue. They could find only one study, by Pierce and Kirkpatrick (1992), looking at sex differences in fear levels that included a more 'objective' physiological measure (heart rate) of fear. Once heart rate was taken into account it was clear from the evidence that men were significantly underreporting their fear levels. Again, however, Freeman and Freeman do not appear to want to listen to this warning from their own evidence.

In addition, Freeman and Freeman do not address the lack of universal acceptance of the ICD and DSM criteria as ways to determine psychological distress. Work in the area of male mental health suggests that the current criteria exclude some of the ways in which men manifest psychological distress. Martin et al. (2013) re-examined data from one of the large US-based surveys included in the Freeman and Freeman paper, the NCS-R. They used data from studies of depression in men to construct a new measure that incorporated the ways men have been found to experience depressive symptoms. When they re-examined the NCS-R data using the new 'male-derived' scale, they found no differences at all in the prevalence of depression between men and women. They concluded that 'relying only on men's disclosure of traditional symptoms could lead to an under-diagnosis of depression in men'.

There are other several more reliable sources of data that need to be considered alongside surveys of the type summarised by Freeman and Freeman. The following statistics are undisputed and speak for themselves:
I    Men represent a large majority of all suicides across the world (World Health Organization, 2011).
I    Men represent a large majority of those with major addiction problems in the UK (Department of Health, 2012).
I    Men represent a significant majority of single homeless people in England (Crisis, 2011).
I    Men represent 95 per cent of the prison population (Wilkins, 2010).
I    A significant majority of prisoners have very serious mental health problems (Office for National Statistics, 1998).

Considering all this data does not suggest to us that women have higher levels of mental health problems. The Central London Samaritans where one of us (MS) is a branch consultant consistently receives equal numbers of calls from men and women. This appears to reflect the fact that when callers are given anonymity, men feel less shame at reporting distress or weakness. A simple glance at human art including blues songs, plays, books and films also show us the clear evidence of the mental pain of men (as well as women). The arguments used by Freeman and Freeman therefore appear ungrounded and highly selective. They are in danger of placing mental distress back into the outdated realm of the 'hysterical' female and they risk perpetuating the neglect of the hidden mental pain of men to the cost of men and society generally.
Martin Seager
Honorary Consultant Psychologist, Central London Samaritans
Linda Morison
Senior Lecturer in Clinical Psychology, University of Surrey
David Wilkins
Policy Officer, Men's Health Forum
Alison Haggett
Research Fellow, University of Exeter
Luke Sullivan
Clinical Psychologist, Barnet, Enfield & Haringey Mental Health Trust
John Barry
Research Psychologist, UCL Medical School

References
Benenson, J.F. & Koulnazarian, M. (2008). Sex differences in help-seeking appear in early childhood. British Journal of Developmental Psychology, 26(2), 163–170.
Crisis (2011). The hidden truth about homelessness: Experiences of single homelessness in England. London: Author.
Department of Health (2012). Statistics from the National Drug Treatment Monitoring System, Vol. 1: The numbers. London: Department of Health/National Treatment Agency for Substance Abuse.
Martin, L.A., Neighbors, H.W. & Griffith, D.M. (2013). The experience of symptoms of depression in men vs women: Analysis of the National Comorbidity Survey Replication. JAMA Psychiatry, 70(10), 1100–1106.
Office for National Statistics (1998). Psychiatric morbidity among prisoners: Summary report. London: The Stationery Office.
Pierce, K. & Kirkpatrick, D. (1992). Do men lie on fear surveys? Behaviour Research and Therapy, 30, 415–418.
World Health Organization (2011). Suicide rates per 100,000 by country, year and sex. Available at www.who.int/mental_health/prevention/suicide_rates/en
Wilkins, D. (2010). Untold problems: A review of the essential issues in the mental health of boys and men. London: Men's Health Forum.

An 'action plan' without the plan 

Nick Clegg has recently presented his new mental health action plan, to improve services for both adults and young people. This action plan was separated into four main sections: increasing access to mental health services; integrating physical and mental health care; starting early to promote mental well-being and prevent mental health problems; and improving the quality of life of people with mental health problems.

Clegg claims to want to eradicate stigma, bring equality both socially and legally to physical and mental health and improve access to improved mental health services. These ideals sound great to anyone who has known, cared for, or been through mental health issues. However, there are several areas that are not quite so well developed, such as the way in which to achieve all of these goals by 2018.

Although stating an increase in funding has been given to training, this is not specific. Does this means further training for qualified GPs and nurses, or increasing clinical psychology doctorate posts? How will hospital beds be provided for all that need them? If patients are to be able to choose their type of care, should NICE research whether new and varied types of therapies are acceptable, other than just CBT and IPT? Overall, this is a big step in the right direction, but further plans and details will need to be made.
Beth Yorath 
Psychology undergraduate
Birmingham City University

IAPT – the cure for incurable boredom?

Did anyone else hear BBC Radio 4's Today programme on Saturday 11 January? Professor Lord Richard Layard was on the show (pioneer of IAPT and project leader of The Depression Report: A New Deal For Depression and Anxiety Disorders, a report by the Centre for Economic Performance's Mental Health Policy Group (2006). Professor Lord Layard was asked to comment on Asimov's prediction made in 1964, that 50 years on mankind would suffer badly from the 'disease of boredom'. So much so, that psychiatry would be the most important medical speciality in 2014.

Close but no banana, Asimov! It seems that instead, 16 sessions of psychotherapy provided by any qualified provider (not psychiatrists, or even psychologists) was predicted to cure at least 50 per cent of the depressed and get them well enough to work thus liberating them from being on incapacity benefit.

Would Asimov or even the Centre for Economic Performance have predicted that in just eight years,16 sessions of therapy would be debased to just six or even a few telephone therapy sessions provided by some AQP (not-for-profit) sites. My O-level text book tells me that the third law of supply and demand states that if demand stays unchanged and supply increases, then this will lead to a lower price for therapy. A lower equilibrium price means fewer sessions for your buck, but how low can you go before you get zero return form therapy? All I know is that referrals to the secondary care service I work in are growing, and you might expect them to be diminishing if IAPT is working. I e-mailed the good Lord himself after the programme, and much to my annoyance (as I like a good debate) he totally agreed.

Tom Elliot

CPsychol, AFBPsSRamsgate

The legacy of Professor Julian Rotter 

Professor Julian Rotter died on 6 January this year. Having spent two years during the early 1980s as a postgraduate researcher reviewing his locus of control (LOC) construct, I have remained aware of the way in which it has been presented and often misrepresented. With that in mind, I write here to acknowledge his LOC legacy and to try and represent it simply and faithfully, and as a corrective to some of the misunderstandings that surround his alluring ideas.

As the progenitor of the LOC construct, Professor Rotter (pronounced 'rotor') was in fact the author of an expectancy-value model and social learning theory (1966) of which his 'locus of control beliefs' were but a part. Rotter is perhaps disproportionately remembered for the locus of control component and insufficiently for the theory in which it was embedded. He was at pains to point out that the other important element and predictor of 'behaviour potential', as he called it, was the value an individual places on outcomes associated with the behaviour in question. Also, the nature of LOC beliefs are often not well specified by those who have not read his original work. Put simply, LOC beliefs are about the extent to which an individual believes there is a contingent relationship between action and outcome. If one believes there is such a relationship, Rotter called this an 'internal' LOC. If one does not believe there is contingent relationship between action and outcome, Rotter called this an 'external' LOC, and argued that such individuals would be more likely to attribute the causes of actions to the operation of chance factors ('luck') or to the influence of powerful others.

Rotter lamented that his social learning theory was in effect neglected and his LOC measure often not understood within the context of it, with researchers recurrently omitting to assess values, in addition to LOC expectancies. He made this complaint formally amongst others in
his 1975 paper in the Journal of Consulting & Clinical Psychology – a must-read for anyone interested today.

Whilst his LOC scale (which measures generalised LOC beliefs) was a major contribution to psychology, arguably his expectancy-value model was the major contribution as articulated in his 1966 monograph. To illustrate the point: it isn't possible to predict whether someone is going to brush their teeth just by knowing whether they believe there is a contingent relationship between teeth brushing and the incidence of dental cavities. Rather, you also need to know whether the individual places value on not having holes in their teeth and good dental health. Expectancy x's value = behaviour potential – this is Rotter's simple model. LOC beliefs were but one half of it.

There has been much examination of the structure of LOC beliefs, but in short they have been shown to have three principal components, in line with Rotter's theorising: (1) belief about the relationship between actions and outcomes (i.e. external or internal LOC); (2) belief that outcomes are the result or not of the influence of `powerful others'; and (3) belief that outcomes are the result of chance factors, the operation of `luck'. A questionnaire by Hanna Levenson measures each of these and is featured in one of Herbert Lefcourt's two edited books on LOC, published in 1981 by Academic Press. Levenson's measure is in my view the best available for assessing generalised LOC beliefs – probably better than Rotter's original, though Rotter must of course get the credit for the conceptual origins of the three-part scheme. There was nevertheless a vigorous debate in the literature in the 1980s that domain-specific measures of LOC (such as the Wallstons' health LOC scale) were better predictors of behaviour than the measure of generalised expectancy beliefs which Rotter produced originally, an argument that was never really fully resolved, I think. So researchers still to this day use both or either, perhaps giving less thought than is needed to this as an issue.

Rotter also was clear in his 1975 paper that what he called the 'good boy bad boy' dichotomy in relation to internal vs external LOC was not appropriate, and he illustrated this in relation to what he called 'defensive externality' which could be functional and adaptive: Sometimes it is beneficial to recognise that there are things over which we have no absolute control and to protect ourselves thereby from the notion that we are relatively powerless. For me, though, an additional and often unspoken but very important legacy of Rotter's LOC theorising was that unwittingly he showed how the behavioural notions of reinforcement need unpacking cognitively, that the operation of operant reinforcers is mediated in humans by their expectations about the relationship between action and outcome. So, the legacy of Rotter extends well beyond his LOC measure.

In 1990 he published a further retrospective in the American Psychologist about LOC research. In looking back, he said that his 1966 monograph was like lighting a match, tossing it over his shoulder and then a couple of decades later turning round to see a forest inferno burning behind him. Oh for such research impact! Control orientation has remained high on the agenda of health psychology ever since, with allied constructs such as Bandura's contemporaneous 'self-efficacy' keeping it to the fore, with some attempts by others to measure conceptual variants, such as need for control.

Rotter's life as a psychologist then, without doubt, has been a significant one. And this is of course not even to begin to mention his work as a clinical psychologist, being instrumental in setting up the scientist-practitioner model of training that has proliferated worldwide. Professor Rotter doubtless has enriched psychology and the lives of many as a result. Alas, I never met him. I wish I had.
Professor Mark R. McDermott 
School of Psychology, University
of East London

References
Rotter, J.B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 80 (Whole No. 609), 1–28.
Rotter, J.B. (1975). Some problems and misconceptions related to the construct of internal versus external control of reinforcement. Journal of Consulting & Clinical Psychology, 43, 56–67.
Rotter, J.B. (1990). Internal versus external control of reinforcement: A case history of a variable. American Psychologist, 45, 489–493.

Alternatives to clinical psychology 

I have been following with interest the recent discussions amongst aspiring clinical psychologists about their battles to make it in this field, and feel compelled to contribute something to the debate myself. Less than a year ago I was adamant that all I wanted to do was be a clinical psychologist and would do whatever it took to get there. The main reason for  this was my passion for improving mental health services and I felt clinical psychology would be a career that would help me to do this. I had spent a year applying for research assistant jobs, to no avail, and settled for working in my local mental health hospital as a ward clerk and bank support worker.

I had already developed some very particular interests and values relating to mental health and psychological well-being, but these have both broadened and deepened during my time working in the hospital. I've worked in both admin and clinical roles, which has given me an unusually broad perspective on what goes on. I've seen some amazing work taking place, but have also seen many things that could be improved on, or need to change drastically.

There are things that need to change outside of my own place of work too, not just locally but on a national, cultural level. I'd like to contribute to actually making some of these changes, and have realised that there may be better routes to doing this than clinical psychology. Whilst my work over the last year has helped me to develop my interests and knowledge, it has also enlightened me to other potential career moves, which I am now exploring.

Don't get me wrong, I still love and enormously value psychology. One thing I would like to see is less emphasis on the medical model in mental health services and more provision of psychological therapies informed by the evidence base. But I have realised that committing myself to that career path may not be the best option for me.

This realisation has also been influenced by reading letters in this magazine from people who seem to have been ground down by their struggles to become clinical psychologists. I would much rather make a difference by following my passions in slightly different directions than enslaving myself to the clinical psychology route, which I now fear could potentially end up being unrewarding and beating the enthusiasm out of me.

I don't want readers to think I am being dismissive or derogatory about clinical psychology as a career choice; as I have already mentioned, I still see it as a really valuable and important field. My aim is to convey my reasons for moving away from it, for the time being, in terms of my own career, in the hope that others might be able to take something from this. I would suggest that if you are considering taking the clinical psychology route, it is really worth exploring other possibilities and thinking carefully about your motivations and what you hope you achieve from your career before taking the plunge and making that commitment!
Lauren Bishop
Poole
Dorset

Turning the clock back on social justice

I am so happy that we are discussing the impact of the recession on disadvantaged people. I don't (yet?) know what to do as a psychologist, but I do know we need to get the message out about the growing chasm between the rich and poor in the UK as psychologists and as citizens. We are facing a political and ethical crisis, the order of which many of us have not encountered in our lifetimes.

Cameron said that 'the broadest shoulders would bear the burden' of the impact of the recession. When he was challenged recently in the Commons that our society was poorer, he claimed 'we are all poorer, we are in recession'. Is this true? Are we all poorer?

It is definitely not true in the USA: '…those at the top have never done better… But average wages have barely budged', said Barack Obama in is State of the Union Address, January 2014. And according to University of California, Berkley economist Emmanuel Saez, '[t]he top 10 per cent earners collected more than half the nation's total income in 2012. This is the largest proportion since the US started gathering data in 1917. The top 1 per cent saw their earnings grow by 31.4 per cent between 2009 and 2012', the peak of the recession. And the rest of the population? They showed a growth, on average, of 0.4 per cent (reported by www.bloomberg.com, 29 January 2014).

So, what's happening in the UK? '…when the Sunday Times published their annual Rich List in 2010, it revealed that the collective wealth of the 1,000 richest people in Britain had increased by 30 per cent. This was the biggest rise in the history of the rich list' (Owen Jones 2011, p.164). This is at the peak of the recession, at the time when working people's wages were flatlining and reducing in value against inflation. At the same time, the CEO of Tesco was earning 900 times more than his checkout workers and shelf stackers (The Guardian, 26 February 2010). At the turn of the millennium top bosses took home, on average, 47 times the average workers pay. This is the general picture for boardroom pay across the UK (Jones, 2011). The widening gap between the rich and poor began before the recession but has continued unabated throughout the recession.

It is simply not true that we are all poorer. As Jeremy Warner stated in the Telegraph, 'It is as if a small elite has captured, and kept for itself, all the spectacular benefits that capitalism is capable of producing' (29 January 2010).

The recession has been cynically and ruthlessly exploited to satisfy unfettered greed and has disastrously turned back the clock on social justice and social mobility, laying untold lives to waste.
We must act.

Dr Julie Bullen CPsychol
Oxford

Reference
Jones, O. (2011). Chavs: The demonization of the working class. London: Verso.

Homosexuality – not in need of explanation

Whilst reading February's edition of The Psychologist I was somewhat surprised to learn that 'even homosexuality can be explained'. This was the declaration contained in a half-page advertisement on page 112. Reading on, the advertisement seemed to imply that homosexuality is a 'mental disorder' and that it is listed in DSM-IV. For a moment I felt that I had travelled back in time.

I imagine the advert had been drafted hastily to meet a deadline and it was not realised how it would be interpreted. In 2014 homosexuality is not a mental disorder; it is not listed in DSM-IV, and has no need for an explanation.

The British Psychological Society has a good reputation with regard to equality and diversity. To maintain this I strongly feel that any articles or advertisements submitted to The Psychologist need to be carefully vetted so as anything that comes across as discriminatory is not included. I also feel it would be a good idea for the editor of The Psychologist to explain to submitters why any materials are rejected so as they have the opportunity to review them.

Homophobia is still very prevalent, and for many the discrimination they face from others and that which they have internalised contributes to prolonged mental health problems. Reading these words in
a reputable publication from an organisation that has a degree of responsibility for the welfare of society is extremely discouraging for LGBT people.

Only back in 2009 there was a lot of press about a study in which mental health professionals said they would attempt to cure people of homosexuality. In The Independent newspaper, an article by Jeremy Laurance declared: 'One in six psychiatrists have tried to turn gays straight' (26 March 2009). Homophobia continues to be a problem in society. Homosexuality does not need explaining, but homophobia does need challenging.
Alexander Rawlins
Birmingham

Intelligence and rationality

Stanovich and West in their article, 'What intelligence tests miss' (February 2014), promise a rich range of tests of rationality, but provide only two crumbs. Imagine studying a menu only to be told that the chef has yet to start locating the recipe, let alone sourcing the raw materials. For the moment, would Sir and Madam like to sample the olives?

We are promised RQ (rationality quotient) tests, but the article only contains two crumbs, which turn out to be simplistic puzzles, such as finding the price of a ball to accompany a bat or the probability of catching a rare virus. Later on we are told to expect 'tasks' not 'tests'. Currently these tasks, 'give us, at a minimum, a hint at what comprehensive assessment of the particular component would look like'. Imagine a restaurant that offered a hint of what we might be eating in 10 years' time.

What they call 'the particular component' is one of 18 components of rationality divided into three columns: Fluid Rationality, Crystallised Facilitators and Crystallised Inhibitors, which are already well known as successful and unsuccessful achievements. For example, the authors' components include: resistance to miserly information processing; risky decision making maximising expected value; financial, literacy and economic thinking, and dysfunctional personal beliefs. Achievements, for example, the Nobel Prize, are assessments made by individuals, groups and organisations that cannot possibly be measured by artificial standardised tests. Each achievement is created by a combination of situational and individual factors and is, therefore, unique. How could there possibly be tests that assessed the 'particular component' of doubling sales, negotiating political agreements or creating a novel psychological theory?

It is their article, not an intelligence test, that misses the fundamental distinction between potential to acquire and actually acquiring knowledge and skills. In 1903 Binet published an intelligence test that saved slow-learning children from being punished because they were supposed to be too lazy to get to grips with their lessons as quickly and competently as their fellow pupils. Since then a wide variety of intelligence tests have helped clinicians, employers and teachers identify people's potential to acquire knowledge at different levels of complexity and to develop skills to different levels of proficiency.
Stanovich and West's article and work is actually about the identification and development of reasoning skills that, combined with other factors, might help us all produce more rational explanations, judgements and decisions. So, roll on 2024 when all will be revealed.
Joshua Fox 
Uckfield, East Sussex

Parental alienation – new diagnostic category or reification?

I read with interest the article by Sue Whitcombe in the January issue ('New voices'). It should be borne in mind that although a very worrying scenario, this set of behaviours is only this extreme in a small number of cases, although in  a lesser form is apparent in most cases
of parental separation.

I have been carrying out psychological assessments for courts in relation to contested contact and residency for over 25 years and I am very familiar with the patterns of behaviour outlined the description of parental alienation. This behaviour is often thought to be being carried out by the parent with the main influence on the child/children, but is not often evidenced. The impact upon the child is thought to lead to the child rejecting the other parent and other side of their family, although again this is not always evidenced. I am also very familiar with the scenario of the non-resident parents alleging the parent with residence having such influence. I have considered the behaviour of the parent/s to be emotionally abusive to the child by way of cognitive distortion, amongst other possible types of emotional abuse. Although in some cases there are legitimate reasons why the parent with influence would want the child to reject the other parent, in others there is not.

I have read some of the American work on this topic and found it very useful in helping me think through work I have carried out. I had understood the term 'parental alienation' to refer to the impact of the behaviour of the influencing parent on the child and not a 'mental illness' suffered by the child. Making a new psychiatric diagnostic category to explain why a child rejects a parent, without any evidenced reason or just cause, will not prevent it happening, nor will it give us a method with which to deal with it.

Sturge and Glaser refer to the same set of behaviours as 'implacable hostility', which places the behaviour firmly with the adults and perhaps gives more of an idea of where to deal with it.

What do we do about it? Make a new diagnostic category?
Courts will still be left with the difficult decision of what to do, should they: leave things as they are in the hope that the child will see reason in later years; force a child to have contact seemingly against their will; or in the most extreme of cases, remove the child from the parent with residency and place it with the other parent, other kin or even foster care in the hopes that this will make the parents see sense? As experts it is our responsibility to give an opinion about which of these options is likely to lead to the least emotional harm for the child in the short, medium and long term. Rather than a new diagnostic category we need:
I    Impartial research in this area of emotional abuse to help with the decision making process.
I    Decisions made upon thorough assessments on all parties.
I    Agencies to routinely involve both parents in work with the child so that they do not formulate by drawing from biased views.
Teresa Wall
Clinical Psychologist, Children, Young People and Families
Barnsley

Something significant to offer 

Sandie Hobley rightly argues the case for care-based research in relation to dementia (Letters, February 2014). However, I believe she is wrong in dismissing the work of the Faculty of Psychology of Older People (FPOP) as 'some sort of subsection [of the Division of Clinical Psychology] on the topic but little exposure beyond its own confines'.

The Faculty began in 1980 as PSIGE (Psychologists Special Interest Group for the Elderly) and was an important vehicle to bring together researchers and professional practitioners with an interest in gerontology and the psychology of later life. It facilitated lobbying within the profession and among policymakers for increased recognition and resources for research in health and social care in later life, including for people with dementia. As I understand it PSIGE only changed its name to FPOP and became a formal faculty of the DCP since my retirement some three years ago.