Letters, June 2011

Rebels with a psychological cause
More than five months of collective protests against autocratic regimes have been staged across the different countries in the Middle East. It is clear to both the protagonist groups and their international spectators that big shifts have taken place in the hearts and minds of ordinary people to cause these extraordinary events. Psychology seems to be well placed here to identify the causal factors of such events. Once identified, they may help us formulate predictions about their outcomes in the affected regions and elsewhere. Reicher and Haslam, for example, have eloquently offered their analysis of the events leading up to Mubarak's overthrow ('Forum: The real world', March 2011). Beside the driving forces of shared solidarity and social media, the authors explain that the Egyptians did what they did because Tunisians offered them a cognitive alternative to their repressed existence by overthrowing their own autocratic leader.

I generally agree with the authors about the importance of cognitive alternatives in relation to protest. And yet, the alternative realities provided by Tunisia and Egypt have not managed to bring out the kinds of masses on the streets of Libya, Syria and other countries in the Middle East necessary for ousting brutal leaders. This is not intended to undermine the presence of the brave men and women who are protesting currently across the Middle Eastern countries, in whatever numbers they may appear, and thereby taking risks on their lives. Nor is it a direct challenge to Reicher and Haslam, whose work I much enjoy reading. It is rather a more general challenge to the approach we use to develop our theoretical models and predictions in psychology. And to be clear, I have personally made use of this approach, which I am about to critique, in my own work. So, it's a challenge and a reminder for me, too.

The power of prediction is what makes psychology so attractive to the general public, students, researchers and policy makers. Yet, it has important inherent weaknesses. It is tied to using predictors that primarily account for rational and less impulsive human behaviour. Why should the majority of Libyans feel encouraged to bet their lives, a rather irrational act, because of what happened in Tunisia and Egypt? Gaddafi is not the same as Ben Ali or Mubarak, despite their common brutalities. The following contrast highlights their differences only mildly but sufficiently. Throughout the protests Mubarak and his officials tried to belittle the protesters and their demands by frequently referring to them as children and calling on their parents to call them home. On the other hand, Gaddafi and his officials have called the protesting Libyans Westernised traitors and infidels. These are two distinct messages conveying different levels of harshness and severity, which would naturally inform any protester's risk assessment. Beyond the national level, the peoples of Tunisia, Egypt, Libya, and other countries in the region, often lumped together into the so-called 'Middle East' by us, are in fact very different peoples with different histories, politics, different relations to their military organs and the rest of the world. They are at least as different as the Scots and Northern Irish are different from the English.

Thus, our psychological explanations and predictions hold an inherent tendency to homogenise individuals and, particularly, groups, even if inadvertently. At times, we may impose social categories on to people in the interest of formulating our predictions, whereas the categories may not be shared among the individuals and groups to the extent to which we would like them to be. This can often be misused and mimicked by, for example, policy makers around the world. The ill-informed portrayal of a homogenised British Muslim community by David Cameron shows exactly that. His perception of the British Muslims leaves little room for feminists, environmentalists, gays, and other subcultures to be part of this community. But is psychology willing to sacrifice the power that comes with predictions based on homogenised perceptions, in the interest of tapping the more messy and heterogeneous realities we live in?
Masi Noor
Canterbury Christ Church University


Emotive and misleading
As a psychologist, I am as keen as anyone else to see that children are protected from the sole, or unnecessary, use of medication for mental health problems. Indeed, I have referred quite a few people to the relevant NICE guidelines when they have concerns to me about GPs prescribing drugs to their children instead of making urgent referrals to CAMHS.

As the mother of a child with ADHD, however, I am far from keen on the highly emotive language in Dave Traxson's letter ('Drugging schoolchildren as social control?', May 2011). I particularly object to the statement '…the shocking American practice of drugging 12 per cent of their whole school population for attention difficulties…'. The word 'drugging' carries with it strong connotations of tranquillisation For example, the Compact OED definition of this word is 'make [someone] unconscious or stupefied by administering a drug'.

I am constantly surprised by how many non-clinical colleagues do not know that the medication of choice for ADHD (methylphenidate – Ritalin is a trade name) is, in fact, a stimulant not a narcotic. The apparent paradox of giving a hyperactive and/or inattentive child a stimulant to calm them down is readily explained by the volumes of literature showing that the condition typically results from under-stimulation of areas of frontal cortex known to be associated with control of impulses and planning. The medication stimulates these under-active areas giving the child more personal control over their behaviour.

I must say that, in this particular, Dave Traxson's letter would have been more suited to a tabloid than The Psychologist. The decision to medicate or not is hard enough for most of us with these 'full of beans' kids. That decision is made even more difficult for parents in the face of so much misinformation and it is disappointing that The Psychologist is itself failing to oppose such emotive and misleading implications.
Name and address supplied


Addressing the complexity of being human
'Is IAPT the only political option?' (Letters, April) was really refreshing! Being a second-year trainee clinical psychologist and having trained abroad, I feel really concerned by the state of clinical psychology in the UK. I was glad to see that others have started to think about our profession and what we are responding to. IAPT and the NICE guidelines impose methods and ways of working that seem to reflect a particular approach and philosophical stance. However, to me and I hope many more, this does not encompass the realities of the individuals and families we meet in our services. By agreeing to and not questioning the current dominant discourse around clinical psychology, I feel that we are lowering clinical psychology as a profession, and this is scary. More and more, our job seems to be a plaster for political and social difficulties, blaming the individual instead of questioning the way our society functions.

My questions and concerns regarding clinical psychology: Has our profession ever been used as a political plaster to address human distress associated with wider socio-economic problems that governments and politics are unable to address and heal themselves? Are we really trying to improve psychological access to therapy for individuals and groups in distress, or are we improving psychological access to therapy for people off sick from work to put them back to work and respond to politico-socio-economic problems rather than psychological difficulties? And what do people accessing services really want?

In any kind of system, I believe that the imposition of a model of working cannot be beneficial, as it cannot represent the complexity and diversity of human beings, emotions and cultures.

I felt really released to read this article as I felt less isolated in my way of thinking and I really hope that clinical psychologists could unify themselves in a sense of supporting and promoting the profession. I believe that it is not the model we use that matters as such but the way we use. The current climate with CBT and IAPT reminds me of a kind of dictatorship, which I feel is a danger for individuals and families coming to the service.
Who are we really working for and what purpose are we serving?
Leslie Valon
University of Hertfordshire


State of confusion
The 'Looking back' article by Roderick D. Buchanan (April 2011) on Hans Eysenck reminded me of a lecture I attended by Eysenck during the 1950s when he was describing/promoting the Maudsley Personality Inventory.

One of the questions at the end of his lecture asked Eysenck if he did not think that the new instrument, the MPI, would be confused with the existing MMPI (Minnesota Multiphasic Personality Inventory) and, if so, what should be done about it. Eysenck's reply was yes, he agreed that there might be some confusion – and he was considering asking the Governor of Minnesota to change the name of his state. As the MPI's successor was the Eysenck Personality Inventory, Hans had probably given up hope that the Governor would accede to his request.
John McLeod
Saskatoon, Saskatchewan


In defence of PACE
Your summary of the findings of the PACE trial which evaluated the effectiveness of CBT and graded exercise therapy as treatments for ME/CFS (News, April 2011), gave a somewhat misleading impression of the outcomes of this study. You said that self-reports on measures of fatigue and physical function showed that '30 per cent of CBT patients and 28 per cent of exercise patients had returned to "normal" function'. This suggests that nearly one third had recovered with these treatments. Unfortunately this is far from the case.

First, the thresholds for 'normal' were set so low they could include those with considerable disability. The authors defined 'within the normal range' as a Short Form-36 Physical Function (SF-36) score of 60 or more (0–100 scale), yet the problems with physical functioning that characterise CFS were defined by a SF-36 score of up to 65 – which overlaps with normality. The situation with fatigue scores is similar, so that a participant may have met the trial fatigue criteria for CFS yet simultaneously have met the criteria for 'normal'. Consequently the figures you quoted tell us little meaningful about the PACE trial's effectiveness.

Secondly, it is of some concern that the authors inexplicably changed the criteria for positive primary outcomes originally proposed by them in the protocol for the study (White et al., 2007). On the Chalder Fatigue Scale, for example, they stated that a positive outcome would be a 50 per cent reduction in self-reported fatigue, or a score of 3 or less. And on the SF-36 scale of physical function a score of 75 or more, or a 50 per cent increase from baseline would be required. So the figures you reported are misleading.

Thirdly, you omitted to mention the disappointing outcomes on more objective measures of functioning. For example, after a year of treatment, patients receiving graded exercise therapy had on average increased the distance they were able to walk in six minutes from 312 to 379 metres. Even patients suffering from serious chronic cardiopulmonary diseases can manage more than this (in a sample of over 1000 such patients the mean distance walked was 393 metres [Ross et al., 2010]), and at normal walking speed people typically cover around 500 metres. CBT treatment had no significant effect on walking distance.

Perhaps these results are unsurprising, given that the treatments focused on reducing patients' assumed fear of engaging in activity, and completely failed to acknowledge the complexity of this illness. We are much concerned that exaggerated claims for these treatments will create a false impression of the effectiveness of PACE amongst psychologists, and will continue to divert scarce resources away from effective medical treatments for this devastating condition.
Jennifer M. Kidd
London N10
Simon McGrath
Monmouth

References
Ross, R.M., Murthy, J.N., Wollak, I.D., & Jackson, A.J. (2010). The six-minute walk test accurately estimates mean peak oxygen uptake. BMC Pulmonary Medicine, 10, 31.
White P.D., Sharpe M.C., Chalder T. et al. (2007). Protocol for the PACE trial. BMC Neurology, 7, 6.


The headline 'Fatigue evidence gathers PACE' may well have been misleading, given that 'pacing' was under the cosh from the latest research into effective approaches for those with ME/chronic fatigue syndrome (CFS)! I read with great interest the results of the PACE randomised study on CBT and GET (graded exercise therapy). However, my experience of working with 'pacing' doesn't necessarily follow the findings. I am a Chartered Sport and Exercise Psychologist, working especially in clinical sport psychology, and also with clients experiencing clinical obesity, and fatigue amongst other presentations. I have also had a three-year history of CFS myself, and was involved in clinical trials in 2002/3, involving CBT, GET and pacing.
My experience as a participant in that study, was that the principle of 'pacing', was simplistic, yet for me significant in understanding my own 'boom and bust' approach to recovery, a typical presentation. The concept that keeping one's 'energy tank' with reserves by the end of a day, to enable activity the next day, may appear obvious, unquestionable, simplistic and 'common sense'. Yet for me within my 'internal world', it was a life-changing factor in 'pacing' my recovery. It enabled me to engage in GET, which produced a positive outcome, not just due to GET's approach, but because I was able to steer myself away from 'boom and bust', by accepting that minor changes in muscle strength and aerobic capacity, integral to the 'pacing' approach, would eventually lead me to a functional fitness. Whilst CBT investigated my overtraining approach, it was without doubt that 'pacing' changed my perception of my own exercise behaviour and re-assured me, that graduated and graded exercise worked.

Regardless of the structure of the PACE study, I consider the concept of 'pacing' to be easily integrated into cognitive and Socratic questioning, rational analysis and challenge, and in that process, the impact of 'pacing' may then be minimised. I see the concept of 'pacing' as the precursor to cognitive change, and that certainly was the case in my situation and, subsequently, those of my clients. It facilitates positive outcomes in using GET, supported by the wider benefits that CBT brings. Used in this way, the dynamic of 'pacing' may be a variable, difficult for researchers to 'tie down'.
Phil Johnson
Bridgetown, Somerset


Religious questions for psychology
The interesting articles in the April 2011 special issue on religion and spirituality seem to me to imply a unitary conception of religion. I follow other writers such as Sperber (e.g. 2004) in regarding it as a polythetic concept (Radford, 2006. 2009). There is a set of characteristics (I suggest at least 20), of which each particular religion manifests a selection. Some are almost invariable, others rarer. Some overlap with spirituality, which also has its own characteristics. I suggest the religious elements can be summarised most simply as Practices and Doctrine (teaching), the latter subdivided into Beliefs and Instructions. These are not sharp distinctions: Muslims are instructed to pray five times a day, and believe they do so to Allah. Practices include some that are not peculiar to religion. Parish Council meetings are much like other committees, but can be an important part of being a practising Anglican. Prayer, on the other hand, has no obvious non-religious exemplar. Some practices appear to be beneficial in general, others less so, as Loewenthal and Lewis discuss. The psychological issues are then Which? and Why? And this must surely include whether or not the effects are due to supernatural causes. Is prayer, for example, merely supportive, or does it attract divine assistance? Instructions often include some on which there is psychological evidence. The Book of Proverbs (frequently quoted on religious websites) insists that corporal punishment is essential in child-rearing. Psychology tells us fairly clearly that it is not, but is generally ineffective and can be harmful.

Beliefs specifically raise the question of truth. I do not see how this can be 'bracketed out' as Fraser Watts puts it. I am not a clinical psychologist, but if X complained of hearing voices when at home, I should want to know if his neighbours were noisy and his walls thin. If Y says that God commands him to blow up unbelievers, or mutilate his son's penis, the question of whether such a deity exists is important. It will not do to say that Y has misunderstood him, since there is no way of deciding this. Nor will it do to say that Y's belief, true or false, is all that matters, for an instruction from a real god might have an authority that cannot be questioned. A placebo is not medication, though it may produce some of the same effects. Further, religions make quite specific truth claims, on many of which there is psychological (and anthropological, biological, historical, etc.) evidence. Nearly all religions maintain the possibility of life after death. As far as I know there is no evidence for this, and a great deal against it. More specifically, Muslims hold, for example, that the Qur'an is the unaltered direct and final word of God. Christians hold that Jesus Christ was the son of the God of the Jews, and Scientologists that we are all alien Thetans trapped in human bodies. What we know makes these propositions appear highly unlikely. See Richards (2011) for a further discussion.

One final point. Fraser Watts makes the common claim that 'atheism is, in many ways, like a religion'. Atheism means simply 'disbelief in the existence of a God' (Oxford English Dictionary), no less, no more. It is not an entity that can possess any of the characteristics of religions. There are non-theistic religions, but that is another matter.
John Radford
University of East London

References
Radford, J. (2006). Religion and psychology: What are they? History and Philosophy of Psychology, 8, 1–11.
Radford, J. (2009). Religion, spirituality and virtue. Transpersonal Psychology Review, 13, 50–57.
Richards, G. (2011). Psychology, religion and the nature of the soul. New York and London: Springer.
Sperber, D. (2004). Agency, religion and magic. Behavioral and Brain Sciences, 27, 750–751.


When I saw the April edition of The Psychologist, I read it with enthusiasm and was greatly inspired. I am among the psychologists who believe that psychology, religion, and spirituality are inseparable.
Professional therapy should go hand in hand with religion and spirituality when the need arises. I always find it difficult to separate religion and spirituality from psychology in my books (published and unpublished). Psychology, religion, and spirituality are good combination of helping people get a better understanding of themselves and their varying situations. For instance, I had a client in my office for post-test HIV counselling. When I disclosed the result as positive, he fell in my office and started uttering some things in Arabic. With the consent of the client, I referred him to a colleague who is a Muslim. After the session the client came out looking better. My colleague appreciated the referral and told me that she used some quotations from the Qur'an in the course of the counselling that calmed the nerves of the client.
I look forward to seeing psychology move fast to the level of referring clients to therapists of the same faith as them. This I believe will make therapy more effective and sessions, shorter.
Adauzo Ijeoma Ubah
Lagos, Nigeria

Getting boys into psychology
Marc Smith ('Failing boys, failing psychology', May 2011) cites evidence that psychology is a female-dominated subject, which in my experience on the whole has been true, usually between 30 and 40 per cent of students are male. Whilst I agree this is because of the curriculum available there are also other factors to consider. Firstly males and females do have different subject preferences. Women are naturally, and are socialised to be, interested in others, whereas men are encouraged to study 'traditional sciences'.

Secondly, students are strongly influenced by their parents and tutors. I have overheard tutors discouraging students from studying psychology because it is a 'flowery subject', and some parents have warned their children that psychology is 'easy' and 'not worthwhile'. Our cause has not been helped by the recent Russell Group list of Facilitating Subjects whereby psychology did not feature. Such a list will certainly discourage future students from choosing the subject.

After reading Marc Smith's article I asked my male students why they chose psychology, their answers included: that it sounded interesting; parental influences; and that it was a last resort fourth AS subject. I then considered Smith's point about the topics we teach and asked my students whether they thought psychology was a science? Despite my best efforts of trying to convince them over the past year, the majority still believed that it is a not a science. Some of these beliefs came from 'traditional science' teachers. Perhaps what was even more startling was that they did not realise mathematics was a science!

It seems to me that psychology A-level teachers need to promote psychology in the whole school in order to dispel myths and ensure that other staff understand what the subject is. I try to achieve this by running an academic psychology club for years 10–13 where I teach topics that are not on A-level specifications.

The final issue that Marc Smith notes is that most psychology teachers are not psychologists. In my school I am the only specialist (one of three) however, in my previous college all eight members of staff had psychology backgrounds. There is an obvious reason for this. There are only a handful of teacher training institutes that offer psychology as a PGCE subject, but even then the trainee teacher will have to teach another subject as their specialism. I completed a PGDE (a further education teaching qualification), which is acceptable if you work in a college but not if you want to work in a school. So this year I have had to complete a GTTP in psychology and PSHE to enable me to work as a 'qualified teacher'. This is something that needs to be addressed by the government and teacher training providers; as psychology departments may not, as Smith writes, be able to teach more biological topics if they have no subject knowledge other than the textbook. With both GCSE and A-level psychology available we need a specialist PGCE in psychology to ensure a higher quality of education for future psychology students.
Jessica Bloomfield
Bradford on Avon, Wiltshire


Neuroscience and education
The hot topic of neuroscience in education was raised in Paul Howard-Jones' article 'From brain scan to lesson plan' in the February 2011 issue, and followed up by letters from Marc Smith (March) and then Rachel Ingram (April), who raised a good example: BrainGym. Ingram reported having heard positively about this 'neuroscience-based' educational programme from experienced educational psychologists and community paediatricians, and was sobered to find when she looked into this that there is no evidence that the BrainGym programme conveys any educational benefits. Furthermore, the claimed neuroscientific basis for this programme is rejected by neuroscientists.

The situation is even worse in Australia. Despite the fact that it is based on no evidence and has no scientific rationale, BrainGym is widely used in Australian schools, and various state departments of education have provided funding for teachers to attend BrainGym training classes as professional development.

Both Smith and Ingram asked what might be done to reduce the impact of this and other neuromyths on classroom practice. Teacher training programmes would seem the best place to start. We should therefore be sobered yet more by data reported in the original Howard-Jones article: of 158 teacher-training graduates about to enter secondary schools, 82 per cent believed that studies of brain function justify the conclusion that teaching children in their preferred learning style could improve learning outcomes (there are no neuroscientific or other studies justifying this conclusion) and 20 per cent even believed that their brains would shrink if they drank less than six to eight glasses of water a day. The ability to think critically is what's needed if such neuromythical beliefs are to be rejected. Teacher training programmes in the UK and Australia don't seem to be providing this.
Max Coltheart
Centre of Excellence in Cognition and Its Disorders
Macquarie University


Obituary – Deone Bartlet (1925-2010)
Deone was born in Buckinghamshire but her family soon moved to New Zealand where she spent much of her childhood, returning just before war broke out. In 1942 she was recruited to Bletchley Park; it was the unusual lives of the people she met there that fed her early interest in psychology. Subsequently she took her degree in psychology at University College London.

In 1951 she took up a place on the recently established year-long course in clinical psychology at the Institute of Psychiatry, Maudsley Hospital. Some work she did with a small boy in the Children's Department is an example of experimental investigation leading to treatment, the methodology developed by Monte Shapiro (Bartlet & Shapiro, 1956). In her diploma exam Deone gained a distinction and she was invited to join the staff of the Clinical Section. As well as making lifelong friendships it was at the Maudsley she met her husband Eric Bartlet.

While raising their four children Deone did some teaching at Hylton, a Froebel School in Exeter. When she separated from Eric in 1967, it was a challenging time as she combined the responsibilities of an adventurous mother with a demanding career. As her family grew up, her life took a new direction and she fostered children from difficult backgrounds while permanent homes were being found for them. Deone was encouraged to return to clinical psychology and initially worked with children in Exeter. In 1975 she was seconded to spend a year working with Vic Meyer at the Middlesex Hospital. On her return the department was growing under the leadership of Jim Drewery and she was asked to head up the South Devon Department in Torquay.

When she retired from her full-time NHS post she did some sessions at Moretonhampstead Health Centre where her down-to-earth approach was valued by her colleagues and she helped them appreciate the psychological aspects of medical problems and how to manage them. She drew eclectically on various traditions and developed her own style of therapy. She continued this sessional work following retirement and also had a small private practice.

Deone was always very close to her family, and in due course she moved to Cambridge to be geographically nearer to most of them. She applied her horticultural knowledge to developing a lovely garden; she was active in U3A; with friends she continued to visit France and Italy; and in her eighties made trips to the home of one of her daughters in Australia. Her many friends will recall her paintings, many of French scenes, her pottery figures and her poetry writing and love of music. Colleagues and friends alike will miss her kindness and her intelligence as well as her animated spirit and the happy times they spent with her.
Pat Kingerlee
Wymondham
Norfolk

Reference
Bartlet, D. & Shapiro, M.B. (1956). Investigation and treatment of a reading disability in a dull child with severe psychiatric disturbances. British Journal of Educational Psychology, 26(3), 180–190.