Letters: men and the mental health minefield

Men and the mental health minefield

I enjoyed the June special feature on male psychology; I have not been drawn to this field in the past, but I found the collection of articles compelling and intriguing and would like to offer my thoughts on some of the issues raised. The opening piece did its job well by grabbing my attention and inspiring interest and enthusiasm: I am a huge advocate for well-being for all, and this article really highlights the need for making changes to improve men's well-being.

The next article, 'A tapestry of oppression', notes the role of the socialisation of gender roles in mental health experience and help-seeking. This strikes a chord with me as I have a strong belief that there is a need to educate and empower people to maintain their well-being from a young age. If we can culturally embed the value of looking after our own well-being, we can in turn contribute to the prevention of mental ill-health. I have not previously thought much about gender differences in this area, but the article in hand has introduced another layer for me to consider in my thinking, which I am grateful for.

Something less appreciated in the aforementioned article is the claim that 'when mental health staff in training are asked to explain why women are usually centre stage in discussions about gender they consistently say it is because men are supposed to be strong and not have mental health problems' and that staff are 'reluctant to engage [men] in therapeutic conversations'. I take these remarks to be unhelpful, offensive and probably untrue. I would imagine that the views expressed by trainees are in fact reflections on society rather than actual beliefs held by those individuals, and from my own experience of working in services, it is simply not true that staff are reluctant to engage with male patients in a meaningful way. It is interesting that not a single reference is provided in this section of the article, which suggests that this set of claims is not supported by evidence. I am inclined to think that the authors have perhaps latched on to a vague or ambiguous finding and distorted or exaggerated it to support their argument, but would be interested to see validation for their claims if I am wrong.

Moving on, I found the concepts introduced in the piece 'Are mental health services inherently feminised?' really intriguing, but was disappointed that the article did not explore some of these in more detail. For instance, it was noted that the majority of frontline staff are female, but I would have liked to have seen more consideration of the mechanisms by which this might impact on men within services, which was sadly absent from the article.

For me, the real value of the article referred to above was the notion that there is a need to tailor mental health services to improve their accessibility and value for men. I have already noted that gender socialisation has been highlighted as important in the development of differential experience and help-seeking in mental health. I have also asserted my own view that well-being education and cultural changes are needed to reduce mental ill-health and improve help-seeking. This leaves us with two very different potential approaches to this complex and delicate field: On the one hand, one can take the view that cultural factors are doing men wrong when it comes to mental health. If this is the case, surely we should be focusing on breaking down the cultural tendencies that lead men to be unsupported with their mental health (which can be done in part by increasing awareness and encouraging everyone to look after their well-being, whether male or female, from a young age). On the other hand, one might argue that gender differences are inevitable and we must adapt services to match this reality.

Personally, I hope that in time we can develop a more resilient culture in which people value and are able to care for their own well-being better, and are able and confident to seek help when appropriate, regardless of sex, gender, age, socio-economic background, and so on. That said, this is a very long-term goal: as illustrated in 'Masculinity and mental health – the long view', current attitudes have been developed over a great many years, and the same will be needed to alter future attitudes. Perhaps what is needed in the medium term are changes in services, but not to the detriment of addressing the underlying factors that result in male–female differences.

I hope I have articulated my thoughts in a way that strikes a chord with some readers. As with any debate in the minefield that is mental health, the solution will be multifaceted and complex; I would imagine there are many intriguing and diverse opinions out there and would be really interested to hear some of them!
Lauren Bishop
Poole, Dorset

Scotland – youthful prospects

The three views on Scottish independence from a psychological perspective (The Psychologist, June 2014) raised another angle on it for me. Comments from fellow English people like 'I'd vote yes if I had the chance, be better without them(!)' and 'I don't understand why they want to leave us when they get more spending per capita than we do' put me in mind of comments made about adolescents leaving home.

The first is often a defensive reaction to the change. People might add 'I'll lock the door when they've gone, etc.' The second suggests a naivety about encouraging a developing self-identity and replacing it with material 'spoiling'.

Jay Haley in Leaving Home describes how the 'young person can be terrified when confronted by self-sufficiency and autonomy'. The response from a 'healthy' family system is surely to support that young person with their 'terror' in this very natural transition. Haley goes on to say that when the young person succeeds outside the home it leads to healthy consequences for the whole organisation.

Applying the model to the Scottish question it becomes clear that all the countries in the UK have a responsibility in supporting the Scottish people in making their decision about what is at best an ambivalent attachment. We English, instead of sitting back and waiting for it all to go wrong, need to attend to the history of oppression by our country on the Scottish people. There is an opportunity now to make amends and support Scotland in becoming the 'fairer and more radical country' that Professor Reicher described last month.

In family terms the successful separation of a young member can lead to rejuvenated relationships within the whole family. Perhaps this could happen too in the political process?

A relationship between the UK countries based on choice and mutual respect could arise rather than the current one, with an undertone of old resentments.

In family terms the successful separation of a young member can lead to rejuvenated relationships within the whole family. Perhaps this could happen too in the political process?

A relationship between the UK countries based on choice and mutual respect could arise rather than the current one, with an undertone of old resentments.
Stewart Shuttleworth
Chester

Thank you for your special feature on male psychology in the June 2014 edition. It is encouraging to see the challenges of engaging men in psychological services given such scrutiny via a number of excellent papers.

I was struck, however, by the continued dominance of an old solution to the dilemma of men and psychology, that being to try and shift the discourses of masculinity from their current position to one more amenable to discourses of psychology as an institution of benefit.

As a commercial enterprise that relies for its survival on engaging men in psychology, Project Ungoodthink has chosen the opposite approach. We have taken hegemonic male discourses as a given and have instead shifted discourses of psychology to become consistent with them, thus minimising resistance to our message. As our starting point, we have created a male-discourse-friendly psychological fitness regime (or counselling in oldspeak) and placed it online. This seems to have had the effect of neutralising issues around perceptions of psychotherapy as a feminised institution. The site uses discourses to create a position where engagement with, rather than rejection of, the regime is consistent with hegemonic masculine norms. Our solution-focused approach couches the achievement of improved psychological fitness (or psychotherapy in oldspeak) as an enterprise wholly consistent with masculinity.

It's early days, but www.ungoodthink.com is receiving very positive feedback from its users, numbers of whom have exceeded our expectations for this stage in the project. I am hopeful that we can continue to attract men to a resource that seemingly makes psychology and masculinity congruent rather than divergent and that our positive outcomes will encourage other service providers to think along similar lines.

Dr John Penny
PFT Family Psychology Ltd

Worth surviving for?

How amusing that Dr Fine (Reviews, June 2014) should claim that The Island is a 'social experiment' and 'an opportunity to identify the unfolding psychological phases of behavioural adaptation and survival, at an individual and group level'. Not long ago, similar bold claims were being made, in these very same pages, about Big Brother, and of course that 'social experiment' has gone on to fill many a learned journal with groundbreaking insights, hasn't it, now?

I admire Dr Fine's enterprising spirit and his capacity to bracket this whole for-profit reality television thing, and look forward to the academic outputs of these endeavours. Yet maybe he could also have read Ceri Parsons on her time with Big Brother on the Couch (The Psychologist, August 2007: see tinyurl.com/psc8ysc) where all the executive producers wanted to hear was 'which housemates wanted fame and who was the most narcissistic', or even Professor David Wilson, who observed new depths of reality television being plumbed – in 2005 (see tinyurl.com/otswp44). To paraphrase Dr Fine: Ultimately, is this worth surviving for?

Dr Alex King
Consultant Clinical Psychologist, Imperial College Healthcare NHS Trust
London

Teaching dyslexic children 

I have been following the correspondence generated by the publication of Elliott and Grigorenko's book The Dyslexia Debate. The authors are concerned that the unitary term 'dyslexia' is too broadly defined, and that what really matters is early intervention when children begin to fail, not diagnosis, given that this diagnosis does not help determine how to intervene.

It seems to me until neuroscience has advanced still further, we shall have to wait for a true understanding of dyslexia; but meanwhile, failing learners need help, and perhaps more attention should be paid to researching what is the best type of help.

My interest in the debate is as head teacher of small dyslexia specialist school for pupils of primary age. I was delighted to see a section in the book about intervention research. It seems the bulk of research is devoted to causality, rather than what is, or should be, actually done to improve the educational chances of dyslexic people, or poor decoders, or the learning disabled – call them what you will. To the dyslexia specialist teachers in my school, they are simply pupils with a common difficulty in the acquisition of literacy and aspects of maths.

Effectively, they have difficulty with any learning that involves phonological encoding or decoding in working memory. That's all language-based learning! So perhaps the proposed deletion of the term 'dyslexia' from the DSM-5 and the replacement with Specific Learning Disorder is apt.

Poor working memory seems to define our pupils and their phonological difficulties can be subsumed within Baddley's model of working memory. It defines them because even when you have taught them to read they still need more explicit teaching than others, and far more reinforcement. Contrary to the research quoted in the book, experience suggests they do benefit from multisensory teaching.

Surely, appealingto all modalities – visual, auditory and kinaesthetic – to improve memory is not contentious, whatever Orton's original motivation for it. We also observe, just as research has shown, that some pupils additionally are slow processors, slow to retrieve words and have attention difficulties.

In 20 years of assessing, teaching and following cohorts of our pupils, it is clear to me that skilled teaching, in a dyslexia-friendly environment, is an absolute prerequisite for success in the face of these problems. The reading programme used is also key – it must have inbuilt phonological awareness training, and it must make the idiosyncratic English code explicit. Dyslexics cannot work it out for themselves. Above all, they must have multiple opportunities throughout the day to practise reading aloud (applying the code) until the goal of automaticity is reached.

Please, researchers, come into specialist schools like ours and study our results and how we achieve them! Follow a cohort from Year 3 to Year 6 and beyond, and you will see that difficulty with reading is only a small part of being dyslexic and that it is improbable that class teachers can successfully teach such children alongside their non-dyslexic peers.

Pamela Lore
Moon Hall School for Dyslexic Children

Counselling psychology in the NHS

I read with great sadness the letter from Carolyne Keenan in the July issue ('Undervaluing competences in the National Health Service'). Having qualified as a counselling psychologist in 1997 and gaining a Statement of Equivalence from the BPS (as my postgraduate training commenced prior to the creation of the Division of Counselling Psychology), I have every sympathy for the plight of newly qualified counselling psychologists. The environment was extremely difficult for counselling psychologists at the time I qualified – many being employed on A&C Grades. This was even more prevalent for qualified counsellors.

The road to gaining recognition for counselling psychologists within the NHS was hard won in the late 1990s, although I have to say that I was lucky enough never to be caught up in the debate of clinical vs. counselling psychologists within the NHS workplace. At a personal level, I received nothing but generosity and help from my clinical colleagues, but I was keenly aware of the debates raging in Clinical Psychology Forum and Counselling Psychology Review.

However, at that time there were many vacancies for psychologists within the NHS and it was a much-valued profession. In time, counselling psychologists were able to obtain parity with their clinical colleagues and advertisements for posts were often for 'Clinical/Counselling Psychologist', although there were sometimes vacancies that required the neuropsychological skills of clinical psychologists, which training unfortunately (at that time) was not available for counselling psychologists. However, I don't ever remember seeing an advertisement for a 'Counselling Psychologist' specifically!

During a 20-year career in the NHS from 1991 (as an assistant psychologist) until 2011 when I retired (my post having been made redundant), and having achieved my ambition of becoming a Consultant Counselling Psychologist, I experienced nothing but respect and support from professional colleagues within the NHS. Sadly, it's a very different story in today's NHS, where fiscal considerations take priority and the counselling psychologist is becoming almost extinct.

My own view (which may well be wrong) is that psychologists have been their own worst enemy, particularly since Agenda for Change. This resulted in both clinical and counselling psychologists being banded way above their professional colleagues, but many continued to work purely as therapists. The NHS soon realised that they could employ other therapists much more cost-effectively, especially when IAPT came into being.

I believe that there are lessons to be learned: Academic institutions need to be more honest with students, regarding their job prospects following qualification. Psychologists need to be more proactive in showing the NHS the added value that a psychologist brings, beyond being a 'therapist'. I was also extremely upset that HCPC managed to take over the regulation of Chartered Psychologists when the BPS was already doing an excellent job. I now find myself having to belong to HCPC if I wish to remain recognised as a Registered Psychologist and I also have to belong to the BPS if I wish to maintain chartered status.

I could continue on this topic for ever – but suffice to say, I believe that things will change (they tend to be cyclical), and once again we may see the rise of psychology as a valued profession within the NHS.

June Richards CPsychol, AFBPsS
Godalming, Surrey

Origins of EMDR – a question of integrity?

Robin Logie ('EMDR – more than a therapy for PTSD?', July 2014) invites a debate in The Psychologist and tells us his hope is that his article will provoke one that is lively. With the intention of pleasing I would like to challenge the 'EMDR community' (p.512) on ethical grounds.

As psychologists, our professional practice is underpinned by four ethical principles: Respect, Competence, Responsibility and Integrity. Specifically concerning integrity the BPS Code of Ethics and Conduct (2009) says: 'Psychologists value honesty, accuracy, clarity, and fairness in their interactions with all persons, and seek to promote integrity in all facets of their scientific and professional endeavours.'

As a psychologist, I find each of these values somewhat compromised when I do not read of any contribution of NLP, and specifically Dr John Grinder, in providing the initial impetus and conceptual framing of EMDR and the adaptive information processing model that followed in the EMDR literature. Instead I read the following and variations of this story: 'EMDR is based on a chance observation I made in the spring of 1987. While walking one day, I noticed that some disturbing thoughts I was having suddenly disappeared… At that point I started making the eye movements deliberately while concentrating on a variety of disturbing thoughts and memories, and I found that these thoughts also disappeared and lost their charge' (Shapiro, 2001, p.7).I actually e-mailed Shapiro on 12 March this year to ask her to comment  on the following account of the events preceding the development of EMDR according to Grinder (see tinyurl.com/lnezbj8):
'Francine Shapiro worked (administration and sales) in the Santa Cruz offices of Grinder, Delozier and Associates in the 80s. She approached me one day and told me that a friend of hers from New York has been raped and she wanted to help her through this trauma and ensure that she exited cleanly and without scars. I told Francine to put her in resourceful state (anchored) and have her systematically move her eyes through the various accessing positions typical of the major representational systems (with the exception of the kinesthetic access).

I suggested that she see, hear (but not feel) the events in question – obviously the kinesthetics were to remain resourceful (the anchored state) while she processed the event. She later reported that the work had been successful. You may imagine my surprise when I later learned that she had apparently turned these suggestions into a pattern presented in an extended training, with no reference to source, with a copyright and a rather rigorous set of documents essentially restricting anyone trained in this from offering it to the rest of the world.' In my e-mail I put my request into  the context of PhD research that I was conducting and I also asked her to comment on the article she wrote in Holistic Life magazine (Summer 1985) entitled 'Neuro Linguistic Programming the new success technology', two years before she talks of having that now famous walk in the park.

In the NLP community we have 'known' for a long time the therapeutic effects of working with eye-accessing cues, the use of perceptual positions, sensory representations and their submodalities, rapport, the variable of time, cognitive reframing, anchoring formats, and much more, which make such protocols effective in the context of PTSD and the ever-expanding clinical field that the EMDR community now seek to branch into. The difference is the NLP community has not yet learned to present their findings in a way that is acceptable to the academic community, opting instead for a more commercially oriented and very loose Action Research approach, which I think is unfortunate.

The neurobiological theory of reconsolidation of memory mentioned by Robin Logie in his article is in fact  one of the neurological bases for the NLP protocol which is now being presented in a more academic nature by the NLP Research and Recognition project under the leadership of Dr Frank Bourke (Gray & Liotta 2012).

I feel the EMDR community will be acting in a much more professional way as defined by our own, (BPS) ethical code and with particular attention to integrity, if they addressed these well-known claims by Dr Grinder and Shapiro's association with NLP in a public way.

Bruce Grimley
Chartered Psychologist
Achieving Lives Ltd

References
Gray, R.M. & Liotta, R.F. (2012). PTSD: Extinction, reconsolidation, and the visual-kinesthetic dissociation protocol. Traumatology 18(2) 3–16.
Shapiro, F. (2001). Eye movement desensitization and reprocessing (EMDR): Basic principles, protocols, and procedures (2nd edn) [Kindle version]. New York: 

Engaging with The Psychologist
I've been meaning to get in touch for a long time, to say 'Thank you!' The Psychologist is a fantastic read these days. Not only that, it represents the 'broad church' that is modern psychology, which is wonderful and I am so proud to be a part of it. You are creating a sense of belonging, of community, of respectful debate… this is what I appreciate the most.
Dr Julie Bullen CPsychol
Oxford

The Managing Editor, Dr Jon Sutton, replies: Thank you, Julie, feedback is always very welcome. We have a small team who have worked hard over the years to develop the publication. But the most exciting thing is that none of us are content to rest: we are well aware just how much more we could and should be doing.

In fact, we had an awayday in July to discuss how to take The Psychologist and Research Digest to the next level, to become the authoritative voices in psychology. As you say, that 'broad church' aspect is vital… it never ceases to amaze me just how different two members of the Society can be, so it's quite a challenge to create a community.

I encourage all readers to help by engaging with us: read, respond, contribute. And if you have a colleague who still never gets The Psychologist out of its wrapper, suggest they do so and hopefully they will be pleasantly surprised by what they find. 

Understanding war 

As a writer and peace activist, I read with particular interest the report entitled 'Beyond the mythology of war' (The Psychologist, July 2014). Some points come to mind that might be usefully raised in this context.

Wars are started by middle-aged and elderly men who send young men to fight them. They themselves and their families are usually not at risk. Even when they are risking a nuclear war by refusing to honour relevant treaties, spreading the technology, and so on, they themselves and their families are not at risk since they have used their power to build nuclear shelters for themselves and those around them. Although some of the warmongers fit the category of psychopath many do not. These latter individuals clearly show the capacity for empathy and compassion in relation to their families and those closest to them. At the same time it is difficult not to view them as suffering from some form of psychopathology since many die as the result of their actions and they seem to experience this with equanimity.

Mr Cameron wanted to bomb Syria. This would have been an act of war and many innocent people would have died. It is well known that in modern war at least 15 times as many civilians die as combatants, and the figure is often very much greater. Mr Cameron has illustrated that he cares deeply about his own family when at the same time he can advocate, illegally and in the opinion of many unjustly, the destruction of others. Psychologists could make a major contribution to the understanding of war if the mechanisms underlying this type of mentality were understood and if it could be determined whether it involves a specific type of psychopathology. No doubt denial and splitting are involved, but could there be something else?

A second area in which psychology could make a major contribution is suggested by Steve Taylor's book The Fall. In the Introduction he states 'For the last 6000 years, human beings have been suffering from a kind of collective psychosis. For almost all of recorded history human beings have been – at least to some degree – insane.' It is around this time that war (together with many other inhumane abuses) made its appearance. What is it about modern man that can consider war (a relatively recent invention) a 'sane' way of resolving disputes? What is the root of this 'collective psychosis?

Jim McCluskey
Twickenham

I enjoyed reading `Beyond the mythology of war' in the July 2014 issue of The Psychologist. An additional myth about WWII to those considered in Jon Sutton's report is that children were mostly observers of the conflict; some children, however, were active participants. I know this firsthand since my father, Leslie McDermott-Brown, at the age of 15, in May of 1940 joined the Merchant Navy as a cadet, following in the footsteps of his uncle Archie who had signed up similarly in 1918 at the end of WWI. Leslie's ship however, the SS Kemmendine, sailing out of Glasgow, was sunk during his first voyage in July of 1940 in the Indian Ocean by the German surface raider, the Atlantis. He was picked up, after swimming for two hours, only for his rescue boat, a prize ship called the Tirranna, to be torpedoed shortly afterwards, with the loss of 100 people on board. Thereafter, Leslie was rescued from the sea by an enemy boat, and so from then as POW No. 1058, was incarcerated until the end of the war in German prisoner of war camps, notably in Sandbostel, near Bremen, home to 25,000 prisoners.

My father's story, as one of the youngest POWs at the start of WWII, in fact is one of a considerable number that are told in revealing detail in Sean Longden's book Blitz Kids: The Children's War Against Hitler (2012, Constable). What is not told there, however, is the story of the long-term psychological effects of protracted internment. These effects are evidenced in a variety of studies (Eberlay & Engdahl, 1991; Klonoff, 1976; Sutker & Allain, 1991; Sutker et al., 1993; Venn & Guest, 1991), wherein are reported raised rates of subclinical post-traumatic stress disorder and of somatic health complaints amongst such captives three and four decades after the end of the conflict.

In the aftermath of WWI and WWII, the Vietnam War, the Falklands War, the wars in Iraq and Afghanistan, and others past and ongoing, the long-term biopsychosocial consequences of such conflicts for those directly involved cannot be overstated, notwithstanding the trans-generational effects also. An awareness of such a body of empirical evidence might help politicians in charge of national militias to pause for additional thought before committing their people to combat, and to persist a little longer with trying to resolve diplomatically the numerous ethno-political and international conflicts that still beset humanity with alarming regularity.
Professor Mark R. McDermott
University of East Londonn

References
Eberlay, R.E. & Engdahl, B.E. (1991). Prevalence of somatic and psychiatric disorders among former prisoners of war. Hospital & Community Psychiatry, 42(8), 807–813.
Klonoff, H. (1976). The neuropsychological, psychiatric and physical effects of prolonged and severe stress: 30 years later. Journal of Nervous & Mental Disease, 163(4), 246–252.
Sutker, P.B. & Allain, A.N. (1991). MMPI profiles of veterans of WWII and Korea: Comparisons of former POWs and combat survivors. Psychological Reports, 61(1), 279–284.
Sutker, P.B., Allain, A.N. & Winstead, D.K. (1993). Psychopathology and psychiatric diagnoses of World War II Pacific theatre prisoner of war survivors and combat veterans. American Journal of Psychiatry, 150(2), 240–245.
Venn, A.J. & Guest, C.S. (1991). Chronic morbidity of former prisoners of war and other Australian veterans. Medical Journal of Australia, 155(10), 

What do implicit attitudes actually assess?

I was interested to read Tom Stafford's digest article 'Getting to grips with implicit bias' in the June edition of The Psychologist. This article reviewed research that examined the efficacy of 17 interventions to reduce implicit race-bias (Lai et al., 2014).

Results indicated that interventions that aimed to change individuals' underlying attitudes, such as imagined social contact, emotion induction, and reconsidering egalitarian values were ineffective. Successful interventions included priming counter-stereotypical exemplars, and providing response strategies to eliminate implicit bias. This last intervention provides evidence that teaching individuals to practise – or to fake – the implicit association test leads to a decrease in implicit prejudice. This may therefore suggest that – similar to explicit responses – participants' implicit attitudes may be subject to manipulation via self-presentational motives.

This leads me to question: What are implicit measures actually measuring? Is it good enough to surmise that reaction times reflect our associative beliefs? Do these associative beliefs reflect our own underlying attitudes, or the more generalised nature of stereotypical preferences? Do they reflect our linguistic environment? I feel that such questions are important for researchers whose aim is to develop interventions that successfully reduce prejudice and stigma. After all, the first step in intervention development should stem from an understanding of the mechanism through which implicit attitudes change, and how this may translate to behavioural change.

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