Letters, June 2007

Who criticises the critics?

It is regrettable that you chose to devote an issue of The Psychologist (May 2007) to the case against diagnosis, without offering those with an opposing view the opportunity to put their case, but your actions are however consistent with the burning of the DSM on the front cover. Enter the new totalitarians! The provision of effective mental health services is dependent on a knowledge base of what works for whom? If routine mental health practice is not evidence-based, why should it be funded? Since the 1960s a whole range of cognitive-behavioural treatments (CBT) have been found to be efficacious and this has been reflected in the NICE guidelines for a variety of disorders such as post-traumatic stress disorder. The CBT treatment procedures are diagnosis-specific: for example, the treatment of post-traumatic stress disorder is in many ways different to that for generalised anxiety disorder. Indeed it is part of Beck's cognitive theory of emotional disorder that each disorder is characterised by a different cognitive content.Whilst CBT has been found to be efficacious in research trials, its effectiveness in routine clinical practice becomes problematic if a generic form of CBT is adopted that eschews diagnosis, whilst elevating case formulation. There is no empirical evidence for the effectiveness of generic CBT. Whilst a case formulation has always been a part of CBT it was never intended to stand alone. Indeed, case formulations tend to have poor levels of inter-rater reliability.The burden of proof lies with advocates of generic CBT to demonstrate (a) that it is better than the CBT protocols employed in research trials and (b) that it offers the practitioner a greater simplicity and structure to their therapeutic endeavours. Until such a time I will use even a charred copy of DSM IV-TR to keep my door to clients open and hopefully replace it with a new revised DSM V version in the next few years. Maybe the authors of the various articles in the May issue would have been better employed contributing to this revision.
Michael J. Scott
39 Hayles Green
Liverpool

 

Mary Boyle's article 'The problem with diagnosis' (May 2007) left me unconvinced and despondent.Her very first premise is questionable. She claims that diagnosis causes divisions between the normal and the abnormal. That surely is what it is supposed to do. What is important however, is the nature and extent of the division and that is rightly left to the specialist to assess.Some 60 years ago the renowned child psychologist C.W. Valentine wrote a book entitled The Normal Child and Some of His Abnormalities. He pointed out that many seemingly normal children were prone to behaviour which is sometimes regarded as abnormal. Does Professor Boyle not realise that in the areas of psychiatry, psychology or general medicine, consultants are well aware of these possibilities when making a diagnosis (dare we use the term)? They are not so naive as not to realise that it is the degree and complexity of a problematic condition which is important and that a label which may help to pinpoint a condition is merely a guide and can be useful or is even essential for administrative purposes. We are well aware that the labels which are used in a diagnosis are neither descriptive or prescriptive. However when employed carefully they are not necessarily restrictive. Professor Boyle claims that many wrongly assume that 'troublesome behaviours, emotions and psychological experiences will form the same kinds of pattern, conform to the same theoretical frameworks, as bodily complaint.' In some cases they do and in others they may not but surely that does not imply that we should abandon the process of diagnosis. What is does imply is that a diagnosis needs to be detailed and analytic. It should take into consideration the varying causes and nature of a condition. Can she not credit consultants with a little more acumen? We are well aware that most psychiatric or psychological conditions are complex, fluid and they may vary in extent and in some cases may overlap. We also know that further research can refine our understanding of such conditions. But this is not a reason to abandon a procedure which has served us well.
Her second paragraph is entitled 'Diagnostic systems lack any scientific basis'. Is she suggesting, for instance, that the many thousands of highly controlled researches into dyslexia both in this country and abroad lack any scientific basis?
In any case, the condition of 'dyslexia' is hardly an appropriate sample for an article, which purports to focus on the subject of psychiatric diagnosis. Dyslexia is regarded as largely a brain difference and not a brain defect. As with Asperger's syndrome and ADHD it is a developmental condition and not a psychiatric illness. All three are complex conditions and in any diagnosis this should be taken into account. Is the child experiencing visual deficits, auditory problems, a lack of phonemic awareness or associated dysgraphia (handwriting difficulties) which itself may be part of a wider dyspraxia (developmental coordination disorder) type condition. Each is a separate diagnosis under the wider 'dyslexia' umbrella term and each requires a separate treatment.
The same applies to ADHD. In some cases this may arise from a neurological difference or a lack of dopamine. However, in other cases similar behaviours may appear where a highly intelligent child with a lot of mental and physical energy is not being challenged and stretched. It could again result from frustration where a child has an undiagnosed learning difficulty. Alternatively a child who is being abused by an uncle or parent in the home situation could show similar symptoms in the classroom. Everything depends on the quality of the diagnosis.
Again Professor Boyle appears confused when she criticises the concept of comorbidity. Comorbidity does happen at times, and why not diagnose it as such? However the skilled diagnostician is well aware that ADHD for example is not always coupled with hyperactivity and attention deficit is sometimes misdiagnosed for poor short-term or working memory.
Mistakes arise from inadequate investigation. It is hardly fair to attribute them
to the process of diagnosis. Professor Boyle herself admits that diagnosis does serve certain important purposes
such as administration. She confesses that there is nothing to put in its place. So why
does she advocate its abandonment?
Peter Congdon
Hampton Grange
21 Hampton Lane
Solihull

 

The regular polemic and 'critical' approaches to psychological topics in The Psychologist (e.g. the special issue on psychiatric diagnosis, May 2007) are refreshing to the extent that they help us to think more broadly about what we think we know, and so develop a more nuanced view of the subject. But, who 'criticises' the 'critics'? And if they do, do 'critical of critical' psychologists get replies without being subject to ad-hominem arguments as to their ideological shortcomings, or an answer that addresses the substance of the criticisms of the critique? Or is 'critical psychology' 'privileged' and impossible to challenge due to the defensive rhetoric it throws up when dissenters have the audacity to question its authority? If so, it doesn't sound so different from much it seems to criticise.
Vincent Egan
Department of Psychology
Glasgow Caledonian University

 

Wouldn't it be lovely?

Our clinical colleagues are fortunate to be able to discuss and debate a very costly, reasonably systematic diagnostic scheme (DSM) which has evolved through four editions and which is produced by a task force of over a 1000. We in the occupational field are not so fortunate. So the first question in the box on p.291 of the May Psychologist, can be answered by: 'No – in fact it would be great if we had the equivalent of DSM in our corner of psychology.'
However, that answer would not appear to have much support among my colleagues. In 2003 I published a piece in The Occupational Psychologist arguing the need for a diagnostic framework for helping the task of deciding how an organisation should change next and inviting discussion with me and debate within the Division. I had one reply, from a consultant who was applying a home-grown scheme. My article encouraged all those consultants and academics who have their personal systems to pool their efforts, as the American Psychiatric Association did in the early 1950s and, with the assistance of WHO, produced the first DSM. The suggestion had fallen on deaf ears.
My next effort to get some action arose last year at a meeting of the Board of Examiners of DOP where I took the opportunity to expose the bee in my bonnet to assembled senior members of my profession. This led to the BPS examinations office circulating a request to all the heads of MSc courses in occupational psychology asking them to let me have their views on the issue and information about how they teach the topic of 'Organisational Diagnosis' on their programmes. I attached my original article and an earlier paper I had published in Management Decision in 1998. I promised to assemble all the information they sent to me and circulate it around the Division to get discussion under way. I had just two replies.
Despite the arguments put forward in the May Psychologist, I still firmly hold the opinion I expressed at the end of my TOP article – 'Unless and until we have a Manual for Organisational Diagnosis, MOD, that is derived from and respected by academics, consultants and managers, that would allow us to prescribe with real confidence how an organisation should change next to make it more effective the status of our discipline will diminish and the standing of our professional work will wither.'
Gerry Randell
University of Bradford
 
References
Randell, G. (1998). Organisational sicknesses and their treatment. Management Decision, 36, 14–18.
Randell, G. (2003, May). The need for a manual for organisational diagnosis. The Occupational Psychologist, Issue 48, 20–23.

 

Confusion and the phoneme machine

Valerie Yule is right that the cause of reading difficulty is confusion ('Can literacy be made easier?', April 2007). But the confusion is largely caused by the way that children are first taught about the 44 sounds (phonemes) of spoken English and the 120 main spelling choices (key graphemes) of written English – by well-intentioned hard-working teachers who should know better.For the last 20 years, I have pioneered the English phonics programme THRASS (Teaching Handwriting Reading And Spelling Skills), which is now used widely in schools in the UK, Europe, Africa and Australia. For the last two years, Foundation Phase student-teachers at the University of the Witwatersrand and the University of Pretoria, in South Africa, have attended a compulsory two-day course on THRASS, based around the Phoneme Machine software programme (free and downloadable from www.phonememachine.com). At the time of writing, a large corporate sponsor is set to help finance the implementation of THRASS in South African government and independent schools, with the main focus being on high quality phonics training for student-teachers and teachers. It is my view that, in years to come, the world will visit the universities and teaching colleges of South Africa to see how they managed to remove the main cause of reading difficulties – teachers with poor subject knowledge for the graphs, digraphs, trigraphs and quadgraphs (the one-, two-, three- and four-letter spelling choices) in the English written system.Valerie is right that there should be international research by psychologists, to 'reduce this serious problem'. But I believe the focus should be the relative effectiveness of English phonics programmes that do not depend on learners having to ignore the misleading advice that, when reading, each lower-case letter has a specific sound and, when spelling, each sound has a specific letter – along with having to ignore any associated physical actions, alliterative characters (such as 'Alan Ant') and/or explanations relating to letters being 'silent', 'magic', 'soft', 'tricky' or 'irregular'. It is all-the-more important that in countries like South Africa, with 11 national languages, widespread poverty and a relatively poor state education system, that the children should not be misled when it comes to learning the building blocks of the lingua franca.Alan DaviesTHRASS UKChester

 

Overseas or overseen?

Having just read the Society's 2006 Annual Report, I notice that what used to be called the 'Overseas Branch' is not even mentioned in the details of Branch Membership. Adding the totals of numbers of members of the other branches, and subtracting that total (36,393) from the 'more than 44,000 members' claimed on the inside cover of the report, I reckon that there are more than 7600 of us in the Overseas Branch. This makes us the second largest branch of the Society, and significantly larger than all of the other branches except for London and the Home Counties. I wonder which if any of the Society's Officers or Committees is responsible for considering our needs (and our potential contribution) as a significant Society grouping.Bill FarrellAucklandNew Zealand

BPS President Pam Maras replies: The actual number of Society members overseas is a little over 3000 (once we have removed from your figure the UK members not covered by existing branches). We are conscious that overseas networks are difficult to build and sustain but if readers have suggestions about this I would be pleased to receive them, as we are keen to increase our services to members.

 

Getting out of the traps

I approached my first Annual Conference with both excitement and anxiety. Working with substance users, I hoped for new insights that would inform my practice. My fear was that I really don't 'do' psychology at all; I am only a Graduate Member.
Unfortunately, I felt there was a limited expectation of the research presented. Fans of Fawlty Towers may remember Basil's comment about Sybil that her subject on Mastermind would be 'stating the bleedin' obvious'. Could it be that linking 'mental toughness' to success in business, 'hardiness' to success in sport, shyness to online dating and discovering that teenagers (gifted or otherwise) like rock music is exercising little more than Sybil's talent? The strength and weakness of quantitative research is that there has to be little measured result. Researchers seek out a measuring tool – 'the ability to cook cakes questionnaire'– and then apply it to a situation that might reflect this ability – 'being a patisserie chef' – and then to everyone's relief get a neat correlation but what does that tell us about being a chef?
The cost of more imaginative, adventurous and possibly less measurable research is that the researcher may not be able to find an academic supervisor and may not obtain their MSc, PhD or research post. Sadly the greater cost to psychology of some quantitative research is that we become trapped in circular argument and tunnel vision that leads us nowhere beyond what our human intuition and insight might have already offered us.
It is encouraging that time at the conference was also given to the area of qualitative research. I hope that this may develop.
Joy Richards
11 Hillbank Road
Harrogate

 

The polymorphic nature of the 5-HTT gene and depression

Keith Oatley's article 'Slings and arrows: Depression and life events' (April 2007) provides an important reminder of the social impact on a healthy mental state. Healthy in this context is defined as responding to serious adversity with anger, frustration and sadness, rather than 'hopeless and disabling despair'. As discussed in the article, the 5-HTT promoter gene may explain individual differences in reactions to loss and adversity, but are such differences necessarily a bad thing? Although depression can be very debilitating, the experience itself may lead to a fundamental re-evaluation of the self, and eventually (for many sufferers) to compensatory action and change. This is akin to the notions of a synthetic approach to therapy, in which psychological symptoms are viewed as a beneficial starting point for the synthesis of change, and indeed to the more general Jungian notions of individuation. However, given the complexity of the 'interactions of the mind and world', depressive states may not necessarily signify personal issues, but rather manifestations of internalised societal/environmental impacts such as perceived injustices or imbalances. Thus, it is perhaps the sensitivity of such people which leads to a recognition for change in the community, some of whom may act in creative ways (e.g. artists, writers) to achieve a social impact.So, in response to the query as to the implication of being able to readily identify a depression gene in children, I believe that this, like any other individual difference, is to be valued as a positive contribution to what makes us social beings. Indeed, perhaps greater respect and appreciation of such individuals is needed, who after all, may be seen as beacons or indicators for societal progress. In other words, if an increasing number of individuals are being diagnosed as depressed (and some evidence suggests this to be the case), then we need to ask ourselves: what are the common adverse life events that our current society is causing, and what are the protective factors which our current society is compromising? Perhaps it is the polymorphic nature of the 5-HTT gene that provides a means for such societal regulation. At the personal-therapy level, possibly greater attention needs to be given to perceived social incompatibilities and the corresponding actions for change, as well as a recognition of the fact that there could be much social accountability for this state. The stance is then one of informed respect for the social world of the individual.
On a wider scale, perhaps we need to listen carefully to what is really missing in the lives of the depressed, and draw themes as to what may be missing in all our lives.
Esat Alpay
Graduate Schools
Imperial College London

 

Keith Oatley's article on depression (April 2007) was sadly illuminating and the first picture, of a seemingly sympathetic person alongside an apparently depressed young woman did illustrate unhappiness – at the cost of space which could have been used for some three hundred words of text; perhaps a good bargain. A second illustration, alongside the invitation to discuss and debate seemed not so helpful – was this young woman pondering a letter to The Psychologist, depressed again, or bored? Two of these – or all three? At the foot of the centre column is some text about two polymorphic genes, with combinations of short and long ones, the disposition of which is crucial to the bearer's life chances. This surely is where a diagram would have been helpful instead. It is not any picture that is worth a thousand words.J.M. Wober17 Lancaster GroveLondon NW3

The Editor, Dr Jon Sutton, replies: We recognise that psychological concepts are often tricky to illustrate and that our readers tend to prefer to give the words more prominence, so we don't actually devote much space to pictures in comparison with other publications. However, as a magazine we have various layout and design considerations that journals do not have, and in this case we had neither the extra text nor a request for the diagram from the author. So we chose pictures to fill the space. But see above!

 

Lateral transfer within the family of psychology

I am writing on behalf of the Yorkshire Forensic Special Interest Group. In recent meetings we have spent some time discussing the issue of lateral transfer between different disciplines within the psychology family. We are primarily a group of clinical psychologists who work within forensic settings with service users who are classified as being mentally disordered offenders. This type of work requires the skills provided by clinical psychology training as well as further skills that are particularly relevant to working within the forensic setting. In recognition of these further skills, in the past it was possible for clinical psychologists within this setting to qualify for chartered forensic psychologist status as well as chartered clinical psychologist status through a grandparenting scheme, which has in recent months been stopped. We are aware, and welcome the fact, that forensic psychologists are able to achieve chartered clinical psychologist status through a lateral transfer scheme but are unaware of any way in which clinical psychologists can in a similar way achieve chartered forensic status, other than through completion of the full forensic psychology master's training. Whilst there would be aspects of this training that clearly would be useful in enhancing clinical psychologists skills, equally there would be large amounts covered in this training that would be repetition of the skills gained within the clinical psychology training and wider experience.
Whilst considering this it was noted that there were perhaps a large number of specialist areas within which clinical psychologists work where this issue might be of relevance, such as neuropsychology, counselling psychology and health psychology. Non-clinical psychologists working in these areas are able to have their clinical skills and competencies recognised in order to achieve chartered clinical psychologist status, without, as far as we are aware, there being a similar process, by which clinical psychologists can achieve chartered status in the opposite direction.
As a group we are certainly not wanting to be critical of our forensic colleagues and the valuable skills and expertise they bring to our area of work and equally their right to have their competencies recognised in order to achieve clinical psychology status. Indeed, we welcome and value the contribution they are able to make to work in this setting. However, we are concerned that as more forensic psychologists achieve dual-chartership status and clinical psychologists remain only able to hold single chartership status, the clinical psychologists may become 'poor relations' and hence become less valued and their skills less recognised.
It was felt that it is important to bring this issue and the discussions we are having around it, to the attention of BPS members given the role of the BPS in coordinating the different specialties and ensuring the maintenance of a coherent professional body. As well as to ascertain both whether others within forensic and other specialties are having similar discussions and whether as a wider family of psychologists the issue can be addressed.
Simon Hamilton
Leeds Mental Health NHS Trust

 

Harder than you'd think

Jonathan Hume's letter (May 2007) could not have come at a better time. As a teacher of pre-degree psychology I am continually met with derision from those who believe psychology to be a soft option. Its very popularity perhaps fuels this misperception, applying the logic that what is popular cannot be difficult. That said, after the recent release of the draft specifications for A-level psychology from 2008 some critics of psychology may be forgiven for thinking that psychology belongs alongside basket weaving. How is psychology (especially at A-level) supposed to be taken seriously when those involved in its implementation grossly underestimate the ability of our students? There is also, as Jonathan Hume points out, an ignorance that exists from potential psychology students. In a recent debate involving the question 'Is psychology a science?' one of my students argued that it could not possibly be a science because if it was he would never have chosen to study it. Many years have been spent attempting to have psychology recognised as a serious scientific discipline both in schools and at university and yet the media image of the subject continues to prevail. Now the awarding bodies attitude appears to have followed the same path by 'dumbing down' an area of study that was already thought to be easy. If universities were to introduce an exam on critical thinking, as Jonathan Hume suggests, I fear the university psychology departments would find their lecture theatres all but bare.Marc SmithGuiseley SchoolLeeds

 

Addressing the problem

At the end of Cartwright and Cooper's thought-provoking article ('Hazards to health: The problem of workplace bullying', May 2007) the question is posed as to what role psychologists can play in dealing with bullies. It is an important question to ask. Psychologists have the skills and expertise to help both victims and bullies. At the same time, we need to be aware that psychologists are not immune to being bullied or becoming bullies themselves.
Training is a particularly vulnerable period where a power imbalance exists between trainees, qualified psychologists, and other professionals. Changes within the NHS, uncertainty about job future, imminent changes in statutory regulation, demands made on qualified staff and trainees alike, are but a few factors, which may contribute to some becoming excessively critical about the work efforts of trainees and colleagues.
In my experience, clinical psychology is a competitive environment characterised by work overload and environmental pressures. Bullying occurs within our profession at all levels. However, whilst some qualified psychologists seem to believe that 'putting your head down' is an inherent part of training, others disagree with this view.
As a future clinical psychologist, the latter have given me hope, and been a role model for me. When thinking about how to support other professions, we need to be prepared to acknowledge and address bullying amongst our own profession. The British Psychological Society and training organisations can play an important role in this process.
In times of uncertainty, we do need to look after our own profession first.
Susanne Iqbal
Salomons
Canterbury Christ Church University