Letters, November 2008

Asking the big questions
It is 20 years since I started to review clinical psychology in England for the British Psychological Society and Department of Health (MAS, 1989). It was a landmark study in a number of ways: not least the publication as an appendix of the first comprehensive review of clinical effectiveness of psychological therapies compiled, a my request, by Fraser Watts. The review resulted in little fundamental change except an increase in numbers of practitioners over the years. I wonder why it is so frequently quoted, when few of its ideas have been enacted.

When I look at how far clinical psychology has progressed since 1989, I wonder what has gone wrong. What have been the influences that have prevented the general public from benefiting from the application of psychological science? Obviously this is being addressed through the Improving Access to Psychological Therapies programme, a demonstration of how an idea can move from a thought to an action when well managed, and with the appropriate support from those who have power and influence in these matters. But what about the whole spectrum of psychology applied to health?

In my review I tried to demonstrate that psychology applied to health could benefit people with a broad range of concerns, from therapy and management to the delivery of healthcare. However, this depended on psychologists working at level 3 – the level of working that requires an eclectic appreciation of a broad range of psychological theories and principles, combined with experience in depth. Instead, level 3 practitioners exist but their work, in many situations, appears to have been confined to complex mental ill health in individuals, whilst the bulk of therapy is delivered by therapists working at level 2 – the same level that is now being expanded to open up access to psychological therapies. My attempt, along with others, to introduce the Psychology Associate (MAS, 2003) as a response to this growing trend didn't receive the support it was begging for; in fact there was (and probably still is) a huge resistance to the idea. Too late;  the jobs are going elsewhere. Now clinical psychologists look even more expensive than ever before.

I would like to see clinical and other psychologists play a major role in the health and wellbeing of the UK population. The platform for doing this seems shaky. I gain the impression there is an Anglo-Saxon reserve amongst the majority of psychologists in this field, combined with a kind of struggle to get a momentum of support to make a difference. I also find that sometimes I hear the mantra that psychologists ought to be recognised because they exist, not because of any major contribution to the problems faced by us all. And, of course, the NHS is a relatively safe haven... but for how long?

I have two proposals. The first, originally published in The Psychologist (Mowbray, 1991), is intended to bring together psychologists from any specialty or scientific focus to undertake research, and to apply research in the subject areas that have an influence on health and well-being. These areas are those that determine health policy in the UK – poverty and deprivation, lifestyle, environment, scientific development, globalisation, technology, public expectations, disease and demographics. The focus for research and its application, I suggest, could be: prevention, preventing deterioration, restoration, maintenance of high quality of life in those deteriorating and sustainability. The vehicle for drawing psychologists together, to pool their different perspectives and scientific bases, could be an Institute of Psychology Applied to Health and Well-being – an independent body devoted solely to the development of psychology as a science and as a means for application to practice.

My second proposal is to bring the many and varied psychological interests to bear on the psychological problems of people at home and at work. This proposal is the bringing together of psychologists with psychological therapists, and others, in a parallel service delivery model to that of general medicine. The vehicles for this are Centres for Psychological Health and Well-being, located everywhere.

I expect that, as a by-product of these proposals being implemented, we will see the emergence of a psychological language that is neither too simple nor too complicated for the general public to understand, yet sufficiently different to convey accurate meaning. Still further,

I expect a psychological culture to emerge that is based on the attentiveness of people to each other, and a widespread concern for the well-being of people This is a 'big ask'. I have a feeling, however, that there may be someone out there sufficiently interested in growing psychology to consider these ideas, modify them as necessary, and then find the energy to make things happen. I am awaiting your call.

Derek Mowbray
Visiting Professor at Northumbria University and Director of OrganisationHealth

References
Management Advisory Service (1989). Review of clinical psychology services. Cheltenham: Author.
Management Advisory Service (2003). The development of the role of associate clinical psychologist: A feasibility study. Cheltenham: Author.
Mowbray, D. (1991). Towards a College of Health Care Psychology? The Psychologist, 4, 360–361.

 

A call to arms
I read with interest Phil Mollon's observations on the Increasing Access to Psychological Therapies Initiative (IAPT), along with David Clark and Graham Turpin's response (Letters, October 2008). It has been apparent over the summer period that postgraduate courses in low- and high-intensity psychotherapy have been set up at universities up and down the land. The requirement for a training post on these courses is accreditation with the British Association of Behavioural and Cognitive Psychotherapy (BABCP), or at least clear eligibility for it.

The BABCP makes much of its current status in government circles, for example it is stated on the BABCP website: 'The BABCP is the only Government-approved organisation which accredits CBT therapists.' Furthermore, it is clear that the BABCP does not consider applied psychologists to be trained or competent in the correct delivery of CBT. For example, their website states: 'Training to be a Cognitive Behavioural Therapist will usually involve being first trained in a core profession such as Clinical Psychology…and then specialising in CBT by gaining a recognised CBT qualification.'

Thus clinical psychologists will need additional qualifications besides their psychology degrees and three-year doctorates. It seems that the BABCP currently sees itself as the government-approved arbiter of who is competent to carry out, train and supervise CBT practice, and psychologists do not fit the bill.

Turpin and Clark object strongly to the suggestion that being a government adviser and prominent within the BABCP represents a conflict of interest. However, in my view there is a much more important conflict of interest, which Mollon did not mention. This is the conflict between the stated position of the BABCP on the one hand, and the professional interest of psychology and the British Psychological Society on the other.

I have serious issues with psychologists being involved in organisations such as BABCP that undermine the credibility and competence of psychologists in the eyes of government. I would urge colleagues within the BPS to move quickly to review accreditation procedures of professional training programmes, to ensure that core and optional competencies are well documented. We then need to move swiftly on to ensure that government and the public at large are aware that applied psychology is the home discipline of psychological therapy.

It is encouraging that psychology has moved to enable other disciplines to use psychological therapy through the auspices of organisations such as the BABCP. However, I am sure that many colleagues will appreciate with me the irony of the home profession, having developed and established evidence-based approaches, finding itself now judged incapable of delivering what used to be seen as a core skill.

This will be particularly galling for many counselling psychologists that use CBT as a main approach. Their training will have included 450 hours of supervised client work, extensive coverage of theory and production of numerous case reports. Furthermore, they will have developed the sophistication to see that such a narrow approach as CBT will not fit the bill for all clients, and will have a range of other approaches to psychological therapy at their disposal.

Now that the BPS is about to give up its regulatory role, I would urge colleagues to rediscover its campaigning roots. We need to get out there and fight for the profession.

Tony Ward
Head of Psychology and Counselling
Newman University College
Birmingham

 

From citizenship to psychology
I read with interest Julie Bostock's review of psychology teacher training (Careers, October). As a psychology graduate who felt a vocational calling to go into teaching, I was looking to pursuing psychology teacher training. An application to my first choice institution was rejected, but I found that I could still obtain QTS and teach a National Curriculum subject. The subject that would allow me the opportunity to corrupt the youth of tomorrow? Citizenship.

The exact definition of citizenship remains a contentious issue. Yet for me, as a psychologist, citizenship becomes a very real embodiment of psychology as the science of the human mind and behaviour. Specifically, it allows an insight into the actions of individuals and the subsequent impact on the world around them. For example, the National Curriculum requires students to have an awareness of democratic processes: a premise that has no doubt intrigued the many researchers who attempt to understand voting behaviour. Another example would be dictatorships and atrocities. Psychologists have since Stanley Milgram and Philip Zimbardo wanted to understand the nature of obedience and respect for authority figures. It appears that the science of behaviour has a real, and most importantly accessible, presence before the young people in our schools.

There is, however, a rub of almost Shakespearean quality. Whilst psychology gathers momentum and prestige as it strives to be considered an academic science within the curriculum, citizenship is having less success. Considered something of a white elephant, it is overlooked and deprived of the same attention and resources awarded to its curriculum neighbours. Perhaps this is where we as psychologists can take up the challenge in our responsibility towards the people we come into contact with. Be it as teachers, healthcare professionals, or better still as citizens and subjects. As citizens and subjects we have an opportunity through psychology and citizenship to further develop what we already know and conquer that which
we do not.

Punam Farmah
Newman University College
Birmingham

 

Adults with Asperger's
I read, with interest, Lee Wilkinson's article 'A childhood disorder grows up' discussing the needs of adults with Asperger's syndrome (September 2008). For nearly five years, I have been clinical psychologist within the first and, until recently, the only multidisciplinary health and social care team for adults with Asperger's syndrome in the UK, which remains one of the few services working directly with this population. Although I did not agree with all the points raised by Lee in his article, I was pleased to see that he particularly highlighted the needs of adults with Asperger's syndrome since, across the majority of the UK, these individuals are typically excluded from mainstream mental health and learning disabilities services, and often struggle  to receive any kind of support at all.

It is perhaps worth pointing out that the needs of this client group are currently fairly high on the political agenda – the National Autistic Society launched its 'I Exist' campaign this year to highlight the needs of adults with autism in the UK (with adults with Asperger's syndrome the most likely to be excluded from services, since they typically do not have concurrent global learning disabilities). The Welsh Assembly has recently published its own strategy for people with Autism Spectrum Disorders and, on 8 May the Minister for Care Services announced that the government will fund a prevalence study into the numbers of adults with autism in the UK and that a special adviser for autism would be recruited to the Department of Health to develop policy on autism spectrum difficulties.

Perhaps understandably, Lee's article focused entirely on the psychological needs of adults with Asperger's syndrome. However, I would wish to emphasise his point that the vast majority of the psychological difficulties that we see in this population occur as part of a wider problem of social exclusion and material deprivation. My experience is that many people with Asperger's syndrome and their families often struggle with even the most basic issues of access to appropriate benefits and housing or of continued abuse and exclusion by others. It is perhaps not surprising, then, that this often leads to longer-term psychological difficulties, and psychological interventions are only a small part of the solution. I do, however, think it is extremely likely that psychologists in general, and clinical psychologists in particular, will be increasingly asked to work with this population over the coming years and would like to thank Lee for raising these issues in The Psychologist.

Paul Skirrow
Liverpool Asperger Team
Learning Disabilities Directorate
Mersey Care NHS Trust

 

We were delighted to read the article in September's issue, in which Lee Wilkinson highlighted some of the many complex issues faced by adults with Asperger's syndrome (AS), a condition previously subsumed by other autistic spectrum disorders. There continues to be a need to raise awareness that AS is not a disorder solely experienced by children (as evidenced by the 'I Exist' campaign), and therefore more research focusing on adults is urgently required. On that note, we would like to illustrate some of the complex issues we have found in working with this client group and to debate the suitability of skill-based training outlined by Wilkinson.

How do adequate social skills develop? Wilkinson uses the term 'learned instinctively' to describe the process by which the typical individual develops social competence. We would argue that 'instinctive learning' is not actually possible, as these terms are contradictory. We believe that there are social rules that are acquired intuitively (not instinctively), but also that many of these rules are, in fact, taught explicitly. Social skills, such as not interrupting others while they are talking and taking turns in conversation, are not 'unstated or hidden social standards' as argued by Wilkinson; how many times did your parent remind you to wait while they were talking? Parents of children with AS may provide comprehensive social guidance, alongside other aspects of behaviour management, but this would be in vain if the child is not aware of their impact upon others and their environment.

Research has evidenced the successful training of self-monitoring skills to children and adolescents with autistic spectrum disorders (Lee et al., 2007; Morrison et al., 2001; Wilkinson, 2008). However, this appears to be monitoring what the individual is aware of in terms of his own behaviour, as part of the internal self-monitoring process, and not the reactions of others. Do we make use of an 'unconscious navigator' or are we also steered through these obstacles by our experiences during the developmental process of becoming a social being?

We would like to propose that neurotypical individuals develop the use of a feedback loop, a sophisticated mechanism that helps to regulate behaviour in an adaptive way to suit our (social) environment. Non-Asperger's children often engage in childhood banter and learn social rules through this and other mediums, such as embarrassing encounters, which could be key factors in the social development process. Children with AS may not share these experiences, and consequently will not be exposed to the external feedback method, which could help produce our internal self-monitoring system. Thus, a modular approach to social skills training is inadequate, as it does not take into account the process of adapting our responses based on the actions of others.
Susan Cake
Rosie Noyce
Clinical Psychology Department
Autism Care UK

References
Lee, S.H., Simpson, R.L. & Shogren, K.A. (2007). Effects and implications of self-management for students with autism: A meta-analysis. Focus on Autism and Other Developmental Disabilities, 22(1), 2–13.
Morrison, L., Kamps, D., Garcia, J. & Parker, D. (2001). Peer mediation and monitoring strategies to improve initiations and social skills for students with autism. Journal of Positive Behaviour Interventions, 3(4), 237–250.
Wilkinson, L.A. (2008). Self-management for children with high-functioning autism spectrum disorders. Intervention in School and Clinic, 43(3), 150–157.

 

Self-diagnosed Asperger's reports are varied but 'social learning difficulties' are problems in common, hindering their happiness and competence. Wilkinson describes therapy strategies to teach recognising how others feel, in order to respond less gauchely and apparently blind to social cues. But if the cause is actually hypersensitivity (Szalavitz, 2008), people with Asperger's may be over-aware of others' emotions, but do not know how to respond. Compare a poor driver who can see the risks but lacks the driving skills to avoid them. Parents and others can give intensive training about how to behave – but in the next social situation, it flies out of their heads or they behave stiffly in trying to follow instructions. They sense how people react to them, anxiety rises and behaviour worsens. Many comedians – possibly Asperger's – raise laughs about such gaffes.

Why, for example, avoid eye-contact? Perhaps too much sensitivity, and fear of what may be seen by meeting eyes that reveal more than any assumed kindliness of voice or gesture.

Helpful therapy might be to enable watching, privately, videos of clients' own public behaviour, so they can see where they go wrong, and see why it repels others. Such undirected viewing in a non-threatening situation can also enable more alertness watching how others get it right. The video experiments that I had opportunity to do with children found parents remarking on how their child had suddenly become more likable.

Society itself needs 'therapy' – to value sociodiversity like biodiversity. So much waste of people when seeking to 'normalise' everyone. Rather, recognise that oddity may have potential for independent thinking and discovery, as in lists being compiled of people with 'probable' Asperger's, from Newton to Mark Twain and Henry Ford. 'People they laughed at' could be a text for all schools and libraries. We need to accept an etiquette of how to tell people pleasantly when they bore or irritate, with kindly humour as the lubricant. And mothers of 'odd' children can be helped to appreciate their strange child as precious china, with a possibly beautiful future. Parents can learn how to love their child without requiring to be loved first, as some expect.

All children can learn to enjoy the variety amongst them, as they love the variety of the rest of nature. They can be co-teachers, because it is from other children who accept them that there is most chance for young people with Asperger's to absorb the social skills training they need – isolated, their problems worsen.
Valerie Yule
Mount Waverley
Victoria, Australia

References
Szalavitz, M. (2008, 20 September). Welcome to my world: Could autism be explained by a brain in overdrive? New Scientist, pp.34–37.

 

Unacceptable trade
I greatly enjoyed Jim Horne's 'Looking back' piece in the October issue ('Insomnia – Victorian style'), but he attempts to rewrite history in one unacceptable way.The Opium Wars were not fought to maintain supplies from China, but to force her to accept imports of British opium grown in India. It was one of the more shameful episodes in our history, and we should not avoid the fact that the British Empire was one of the principal drug exporters of the 19th century.
Bruce Napier
Stretton, Burton-on-Trent

 

Thumbs up for Little Albert…
I enjoyed the 'Foundations of sand?' article in the September issue. It's a fabulous exposé of some of our most cherished studies. As someone who is very interested in the historical development of psychological ideas, I loved this contribution.

Readers might also be interested in a section at the end of the original article concerning the Little Albert study (see tinyurl.com/yvmwpt). In 'Incidental Observations', the authors describe how Little Albert often didn't cry straightaway when the loud clang was made behind him – he sucked his thumb. It was only when they stopped him from sucking his thumb that they got the response they wanted!
Tim Carey
Centre for Applied Psychology
University of Canberra

We read with interest Christian Jarrett's 'Foundations of sand?' feature (September 2008). Unfortunately, Dr Jarrett has created a set of new myths in the boxed text titled 'The Hawthorne effect'.
In the first instance, referring to an analysis of the Hawthorne studies, Jarrett states: 'One study involved female factory workers witnessing the lights be refitted with ostensibly superior bulbs, which were in fact identical, and those women then showing improved performance.'
I think this stems from Roethlisberger and Dickson's l939 book Management and the Worker: An Account of a Research Program Conducted by the Western Electric Company, Hawthorne Works, Chicago, but those authors copied it word for word from a 1930 document, 'Development of the illumination study and their relationship to other research projects', by Max Howarth of the Hawthorne Works. Seventeen years after the publication of Management and the Worker Dickson, seeking the true story behind this claim, contacted the original 1926 experimenter, identified by Howarth as Homer Hibarger. Hibarger replied on
6 July l956, stating:
When Mr Snow was to leave on his summer vacation I was assigned to keep the production records of the coil winders who were being used in the illumination study. Some time later, I've forgotten how much later, I decided to try an experiment of my own. Accordingly I had the electrician come into the coil winding test room with a number of light bulbs. (This Mr Snow would do when he changed the intensities.) However, when the operators left this Saturday, of course they saw the electrician and his light bulbs. I told him I had changed my mind and would leave the light bulbs as they were.
The following week I heard all sorts of comments about the 'changed' lights, but one comment I got by asking one operator, 'How about the lights?' she replied,' Oh, they're too glary. I've had a headache ever since Monday.' So much for the changed and unchanged light bulbs.

A copy of Hibarger's letter to Dickson is reproduced in the first undersigned's Facts and Fallacies of Hawthorne: A Historical Study of the Origins, Procedures and Results of the Hawthorne Illumination Tests and Their Influence on the Hawthorne Studies (Garland Publishing, l986). In his letter Hibarger says nothing about improved operator performance. Copies of the original output charts of the l926 summer study are preserved at Cornell University. On these charts there is one possible combination of dates that could confirm Hibarger's story. On Saturday 17 July l926, coil output was 12.4 coils an hour. On Monday 19 July l926, coil output was 12.2 coils an hour. The decline in output could be the effect of the headache reported by the operator (and possibly others) from what she thought were brighter lamps.
Dr Jarrett also said there were ventilation studies during the Hawthorne tests. This is untrue. Temperature and humidity records were maintained, but no extensive ventilation studies were conducted, except a brief study of air movement in relation to illumination in l925.
Finally, Jarrett repeats
a fallacy drawn from the Chiesa and Hobbs article cited, by reporting that the term 'Hawthorne effect' was coined in a l953 chapter by John P. French. French, in fact, used this term at least three years earlier in his paper 'Field experiments: Changing group productivity' in James G. Miller's edited collection Experiments in social process: A symposium on social psychology.
Again, we found Dr Jarrett's article to be of interest and simply wish to join him in dispelling the myths of psychology.
Charles D. Wrege
Cornell University
Ithaca, New York
Arthur G. Bedeian
Louisiana State University
Baton Rouge,  Louisiana

Evolving arguments
In the letter 'Evolution – fact and theory' (September 2008) readers were challenged to present unequivocal evidence that the human race does in fact have primate lineage.

The lineage of all living creatures including humans is based on many 'facts' (i.e. shared characteristics). This system of classification was originally devised by the Swedish botanist Carl Linnaeus in 1735. One 'fact' we know today is that humans share nearly 99 per cent of their DNA – the long molecule of heredity – with chimpanzees and gorillas.

Lemurs, monkeys, humans and other apes are primates because they share biological and anatomical features that distinguish them from all other mammals. Humans are apes and not monkeys partly because their shoulder blades are not tightly bound to the ribcage. This earlier adaptation for brachiation would later help hominids to throw projectiles and humans to bowl cricket balls.

Thomas Huxley pointed out in Darwin's The Descent of Man (1871) that '[e]very principal gyrus and sulcus of a chimpanzee's brains is clearly represented in that of man'. Humans do have particularly large primate brains, but we now have hundreds of cranial fossils that document when this evaluation expansion occurred.

The theory of evolution is supported by a rich array of 'facts' or evidence from a wide range of scientific disciplines. According to Theodosius Dobzhansky, 'nothing in biology makes sense except in the light of evolution'. If evolution is just a theory then so is the theory that the earth is flat. All the evidence in the world may not convince that humans evolved and that the world is not flat. One can only hope that such creationists and flat-earthers do not call themselves 'scientist' or indeed 'psychologist'.
Peter Eastham
Lewes
East Sussex

I note the continuing correspondence over the claim that evolutionary theory is being presented as fact rather than theory. Hardman, Dickins and Sergeant present a spirited defence of contemporary evolutionary theory; in contrast MacKay supports James's assertion that theory is being presented as fact. However, all correspondents have failed to make the distinction between evolution itself and the posited mechanisms responsible for evolution.

Evolution is a fact (as much as anything is a fact). It can even be demonstrated in the laboratory. The conflating of how we explain evolution and the fact of evolution is very unhelpful. It leads to the idea that any debate about the mechanisms that are responsible for evolution is placing in doubt the fact of evolution. Proponents (e.g. Dawkins, Tooby and Cosmides) of the 'modern synthesis' are so convinced of its all-encompassing power that they are quite happy to make a package of the phenomenon and the theory.

An attack on contemporary evolutionary theory is interpreted as an attack on evolution itself. I am convinced of the fact of evolution. However, I remain extremely dubious of the many claims of contemporary evolutionary biology and psychology and the all-embracing power of the 'modern synthesis'.
Paul Morris
Department of Psychology
University of Portsmouth

Everything is not in the new Mental Health Act
On 3 November, most of the changes made by the Mental Health Act 2007 will come into effect. Practitioners who wish to take on the new roles those changes create will need to know about the Act, of course, but they won't be able to let go of the old law just yet.

The new Act simply amends the Mental Health Act 1983, and once it has done its job it will melt away. But because many of the provisions in the 1983 Act will remain in force, the way they have been interpreted will continue to be relevant.

This is certainly the case with patients who have a personality disorder. It is now clear (even if it wasn't so before) that many such patients come within the Mental Health Act. The government said so explicitly in Parliament and the changes it has introduced make much the same point: 'treatment' has been redefined, first, by explicitly including psychological intervention, and secondly, by removing the requirement that it be under medical supervision; and we are told that the old 'treatability test' has disappeared. In its place there is simply the requirement that before a patient can be detained, 'appropriate' treatment must be 'available' for him or her.

In fact, the treatability test remains, albeit in somewhat weakened form: the amended Act says that treatment will only be worthy of the name – and will only justify detention – if its purpose is to alleviate, or prevent a worsening of, the patient's mental disorder or one or more of its symptoms or manifestations. The unamended Act, of course, said this must be the likely effect of the treatment.

Because the treatability test has not gone away, the cases it spawned will still need to be borne in mind. They include Reid, in which the House of Lords ruled that the purpose of treatment might legitimately extend 'from cure to containment', and that patients might be treatable – and therefore detainable – simply because their anger management improved in the structured setting of a hospital.

This decision is one of many that might have influenced the changes to the Mental Health Act but will still have to be considered on their own account.
David Hewitt
Mental Health Law Specialist
Weightmans LLP

On plethysmography and being 'kinky'
The penile plethysmography guidelines mentioned in The Psychologist (September 2008) raise