Letters: the 'stressed sex' debate continues

Sex as a clinical variable

Seager et al. ('The hidden mental pain of men', Letters, March 2014) are correct to highlight the imbalance in arguments about gender and mental health. Logically some diagnosed mental disorders are only possible because of biological sex (e.g. the diagnoses of puerperal psychosis and postnatal depression) but most of the differences claimed are a function of methodology, proven gender differences in help seeking and professional decision making about risk.

The arguments about methodological artefacts were evident in the 1980s when the rallying feminist text The Female Malady was largely being read uncritically (Showalter, 1987; cf. Busfield, 1988). Showalter argued that in the Victorian era women were differentially oppressed by patriarchal psychiatry, setting a gendered trend. But the prevalence of female asylum inmates was higher because women lived longer than men; once that was taken into account then gender differences disappeared. Today both depression and dementia in older people are gendered for the same reason, if prevalence not incidence is measured. This prevalence/incidence argument remains pertinent today. Women seek help more than men in primary care so are diagnosed more with 'common mental disorders', which means that women are medicated more than men in open community samples. For example, today 1 in 10 American women take antidepressants (twice the consumption of men). In the UK, women and men are admitted to acute care at about the same rate but men are twice as likely to
be present in them. This is because women are discharged quicker, maybe because of gendered family responsibilities and greater risk being attributed to men by professionals (Pilgrim, 2012).

As for the coercive wing of the mental health industry, not only are men overrepresented in secure facilities but women have been completely removed from most high-secure facilities after successful feminist campaigns. This begs an interesting question: if high security is considered to be too inhumane for women, then why is it legitimate for men to remain in such a brutal environment? If psychiatric oppression is indeed gendered then it would seem that now men, not women, have more to complain about, if coercion is our defining focus. And if we only study women and not men in community samples, then we will generate evidence unevenly (Brown & Harris, 1978). The latter was intended to be a study of social class and depression not women and depression but for methodological convenience only female respondents were then used.

Single social variables as predictors of mental health status are problematic, but if we do focus on them then social class and age are much better predictors than gender, with race hovering ambiguously in the hierarchy of determinants. The reason that single-variable determinants and their implied ideological special pleading are problematic is that in open systems a multiplicity of generative mechanisms intersect and lead to variegated outcomes (including clinical silence). Even just two variables studied in interaction inflect the evidence. For example, overall women seek help in primary care more than men, but in the US ethnic minority women (like white men) under utilise that service (Rogers & Pilgrim, 2005).

If we are to look seriously at the social patterning of diagnosis and service utilisation, then intersectional reasoning is required. Also, within-group differences in these intersections might be accounted for by variables little used in traditional epidemiological research, even its socially informed wing. In particular, traumatised groups (from childhood abuse, school bullying, war zones, intimate violence and regimes of torture) are significantly overrepresented in clinical samples, including those with a diagnosis of psychosis (Varese et al., 2012). 'Traumatised victims' as a single social variable is a more robust predictor, than gender, of mental health status, if we opt to use it as such. Intersectionality and intragroup differences accounted for by trauma should be our guides hereafter to researching the social patterning of mental health problems. But if gender is still considered to be important for mental health researchers, then the above arguments supporting  the cautions of Seager et al. warrant due consideration.

David Pilgrim
Professor of Health and Social Policy
University of Liverpool

References
Brown, G.W. & Harris, T.O. (1978). The social origins of depression. London: Tavistock.
Busfield, J. (1988). Mental illness as a social product or social construct: A contradiction in feminists' arguments? Sociology of Health and Illness, 10, 521–542.
Pilgrim, D. (2012). Final lessons from the Mental Health Act Commission for England and Wales: The limits of legalism-plus-safeguards. Journal of Social Policy, 41, 61–81.
Rogers, A. & Pilgrim, D. (2005). A sociology of mental health and illness (4th edn). Buckingham: Open University Press.
Showalter, E. (1987). The female malady. London: Virago.
Varese, F., Smeets, F., Drukker, M. et al. (2012). Childhood adversities increase the risk of psychosis: A meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin, 38(4), 661–671.

 

As a headline in The Psychologist once put it: 'Studying sex differences – not for the faint-hearted!' (June 2012, p.418). We knew this when we set out on a journey, described in our book The Stressed Sex, to answer what we consider two very important questions: Who is more likely to develop mental health problems – men or women? And if there are differences between the sexes, what are the causes? Although on a controversial topic the reception for the book over the past year has been very positive. Until, that is, the letter by Seager and colleagues (March 2014).

These six psychologists list evidence of particular mental health problems where men have greater difficulties than women, add a dose of anecdotal evidence, and conclude that men and women must have equal rates of mental health problems. This is exactly the type of selective approach we sought to avoid in The Stressed Sex. It is simply not in dispute that men have problems too. In our article ('The stressed sex?', February 2014) we write that there is a 'worryingly high rate of psychological problems across the population as a whole: that is, for both men and women'. Our point is that, when you consider mental health problems together, women outnumber men. In other words, this is not a debate about specific disorders but rates of mental disorder in toto. (Incidentally, in the book we show that this applies even when a non-diagnostic approach is taken.)

Take for example the study Seager and co. cite concerning a national epidemiological survey (Martin et al., 2013). Here, in a new analysis, gender differences in levels of depression are (unsurprisingly) reduced when problems such as anger and substance abuse are included in the diagnosis. But to understand overall rates of mental health problems one must look to the data on all problems, not just a selection. When this is done the findings from the same survey are clear: rates are higher for women than men (Kessler et al., 2005).

The question of whether men are simply unwilling to report mental health problems is often raised in discussion of these issues, and it's one we explicitly address in The Stressed Sex. We believe it probably plays a role, but there are many compelling reasons to believe that the difference in overall rate of psychological illness is genuine. Moreover, epidemiological surveys seek to minimise such reporting problems.
In the end, of course, self-report is the only way to find out whether someone has a problem – and it's possible that women are also underreporting: the research simply hasn't been done for either gender. It's worth noting, by the way, that the study by Pierce and Kirkpatrick (1992) did not simply find that men underreported their fear; it also discovered that rates of fear were higher among women, even after male bravado had been taken into account.

For Seager and co. to dismiss a discussion of possible gender differences by evoking the spectre of the 'hysterical female' displays a worryingly limited view of the causes of mental health problems. Clearly, the number of people of both sexes affected by these conditions is too high. But if they think the gender inequalities in society have no consequences for women's mental health, or that these consequences should be ignored or hidden away, then we must disagree.

Daniel Freeman
Professor of Clinical Psychology
University of Oxford
Jason Freeman
Psychology writer and editor

References
Freeman, D. & Freeman, J. (2013). The stressed sex: Uncovering the truth about men, women, and mental health. Oxford: Oxford University Press.
Kessler, R., Chiu, W., Demler, O. & Walters, E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617–627.
Martin, L., Neighbors, H. & Griffith, D. (2013). The experience of symptoms of depression in men vs women. JAMA Psychiatry, 70(10), 1100–1106.
Pierce, K. & Kirkpatrick, D. (1992). Do men lie on fear surveys? Behaviour Research and Therapy, 30, 415–418.

 

Call for formation of a Royal College of Psychologists

The British Psychological Society has been at the centre of our profession for more than a hundred years, providing a focus for our work and an invaluable channel for communicating with each other. But at a time of regulatory upheaval within our profession we believe the BPS risks losing influence and becoming marginalised, which is why we are asking you to support our plan to reform the Society so it can meet the challenges of the 21st century. To achieve our aim, we want to establish a Royal College of Psychologists.

This is not a radical step: the BPS is already 'Royal'. The Queen granted a Royal Charter to the BPS in 1965, but in the intervening years we doubt whether it has taken full advantage of the opportunities presented by the award. Our belief is that the profile of our entire profession will be enhanced in the eyes of the public, government and business by establishing and using the title of Royal College of Psychologists. It will also bring the BPS into line with many other organisations that already proclaim their equivalent status, such as the Royal College of Physicians, the Royal Institute of British Architects, and the Royal College of Psychiatrists.

We feel this enhanced title will galvanise the organisation, arrest the slump in recruitment, provide a strong reason for existing members to remain in the organisation and attract new members. The latest data from the BPS shows that after more than 70 years of growth, the total number of members has been stagnating at around 49,000 since 2011. Furthermore the number of student members has been falling. Without a steady stream of new recruits, overall membership levels could soon slip into decline, which could be difficult to correct and would bring about financial strain.

To understand better the mood, we sampled opinions of colleagues and have found a marked degree of dissatisfaction regarding the BPS. In an online survey of 456 psychologists (including 374 BPS members) we found that most believe the BPS neither provided value for money nor met their professional needs.

Some respondents questioned the continuing relevance of the BPS, after the statutory regulation of psychologists was entrusted to the Health and Care Professions Council in 2009: 'My practising licence is issued by the HCPC, and I allowed my membership of the BPS to lapse three years ago', said one respondent. Another wrote: 'I maintain my membership of the BPS because it's what I've always done, and I don't know if I have to, to maintain my HCPC registration…in the last few years, the BPS has been positively destructive to the profession of psychology'.

Other respondents told us they felt the BPS was lacking effectiveness as an advocate for the profession. 'It's poor at making a stand, representing the profession, and making any sort of decision', said one psychologist. While another commented: 'I don't believe the BPS can meet the professional representation needs of psychologists with its current configuration.'

By contrast, our respondents were overwhelmingly enthusiastic about the formation of a Royal College of Psychologists, 90.4 per cent supporting the idea. Among the main reasons given in support were that a College would act 'as a unified voice' to safeguard the professional integrity of all psychologists, as well being an active advocate for how psychologists and their work are perceived. It would also act as 'the definitive authority' in the eyes of the public, both at home and abroad.

The great majority of respondents (84 per cent) also believed a Royal College would play a valuable role in protecting the needs of psychologists. So we in the Campaign also wish to protect the title 'psychologist'. We want to establish the right of all psychologists to be equitably registered, and to lobby the government towards these goals.
How do we hope to achieve Royal College status?

The principal aim of our campaign has been to gain enough support to petition the BPS to work towards the status of a Royal College, by mandating a decision to create a College of Psychologists. Once that has been achieved we would seek to secure Royal patronage. Our Campaign has already recruited 1000 psychologist supporters (a number which equals over 2 per cent of the BPS membership) and a number of highly eminent psychologists have become patrons. So we have already achieved well over the number needed to require the BPS to act, although we would still like many more members to back our campaign (please visit our website www.rcpsychol.com).

There is also a historical precedent for what we are proposing. At its inception in 1901, our organisation was called the Psychological Society, but within five years, the founders felt compelled to change the name to the British Psychological Society as a protective measure in response to a rival group of non-academics who had set up their own version of the Psychological Society. By the same token, we wish to establish a Royal College of Psychologists to protect and enhance the professional standing of the membership, be they academics, practitioners or teachers. We believe this move is in accord with both the intentions and actions of the Society's founders.
Dr Maxwell J. Benjamin, Professor Robert Bor, Dr Joel Dawson, Madeleine Devon, Dr Clare Eldred, Peter Farnbank, Professor Emeritus Peter Farrell, Dr Alex Linley, Professor A. Malik, Dr Denise McCartan, Dr Mathew McCauley, Karen Moore, Garret O'Moore, Annabel Poate-Joyner, Dr Seema Qurashi, Dr A. Michael Rennie, Professor Peter Saville, Martin Shankleman, Clive Sims, Dita Stanis-Traken, Dr James Thompson, Dr Mark J. Turner, Professor Barbara A. Wilson, Hatice Yildiran

Editor's note: A full response from the Society will be published in the May issue of The Psychologist.

Guest Column – The real world 

With the Black Sea region, or rather Crimea, Ukraine and Russia, currently dominating the news, I (Stephen) am reminded of 1987, my first conference of the European Association of Social Psychology held in the Black Sea city of Varna. I was sitting reading by a swimming pool and wondering why so many people were giving me dirty looks and a very wide berth. Then I realised. The book I was holding was titled Male Fantasies. The front cover sported a lurid picture of a naked man on a stallion with swastikas in the background. I hastily put it away.

But, far from being salacious or disreputable, Male Fantasies actually presents an important analysis by the German literary scholar Klaus Theweleit of the German Freikorps — the ultra-reactionary nationalist paramilitaries who paved the way tor the rise of Nazism. It analyses the toxic combination of damaged national pride and wounded masculinity that arose from the post–World War I settlement imposed on Germany at Versailles.

As the paramilitaries asserted their power, they benefited from the inability of a weak state to contain the violence. Many dreamt of national redemption centred on the expression of masculine power. 
In 1934 American sociologist Theodore Abel ran an essay competition asking Nazi Party members to explain why they had joined. One theme ran throughout, carved in stone on a monument in the hometown of one member: 'We eagerly await the coming of the man whose strong hand may restore order'.

In his 2013 book Fascist Voices Christopher Duggan shows that many Italians, like Germans, felt cheated and weak after 1918. Mussolini embodied their redemption: the strong man who would create a third Rome. He loved to be pictured, stripped to the waist, performing manual tasks. His torso and his jutting jaw became metonyms for the idealised nation.

Indirectly, this takes us back to the Black Sea, to Crimea and to Russia – or at least to Vladimir Putin who is central to the current drama there. What are his motives? What might he do next? And why does he have such political freedom? 

In part at least, Theweleit's book provides important answers. After the collapse of Communism in the 1990s the West was seen to impose its interests and its values on Russia. As a result the country was seen to be humiliated and diminished, losing its stature in the world and its identity. At the same time, the slapstick administration of Boris Yeltsin was seen to accelerate this decline. This constituted the perfect storm – the combination of conditions that energise potential patriarchs and that render patriarchy more attractive.

Tapping into this dynamic, it is clear that Putin knowingly affirms his embrace of the Russian 'family' by challenging his critics through the brute assertion of aggressive, homophobic, patriarchal force. 
That much, at least, he shares in common with other redemptive ultra-nationalists in history. We have to hope that he hasn't also adopted their belief in war as a redemptive tool to reforge the national character.

But perhaps the most important implication of all this is not for our understanding of the autocrats themselves – whether in Germany or in Russia. It is for our understanding of ourselves. When will we understand that a sense of the superiority of our economic, political and moral values, and our imposition of these values on those who have been defeated, will only empower those who negate all that we believe in. When will we realise that the triumphalism of the West is 
a harbinger of our profoundest problems?

Steve Reicher is at the University of St Andrews. Alex Haslam is at the University of Queensland. Share your views on this and other 'real world' psychological issues – e-mail [email protected]. An archive of columns can be found at www.bbcprisonstudy.org

Height of difficulty 

I refer to your article in the February issue, 'Improving aircraft safety'. The aircraft sensitive altimeter – in RAF parlance – the Mk 14 was the original instrument with three straight pointers that had the potential to be misread. The shortcomings were recognised and the instrument was modified after many years with different pointers to overcome the problem. Your Figure 1 shows one of the modified instruments with a changed 1000 feet pointer.

In the original three-pointer instrument (pictured above), the figures on the dial represent; for the longest pointer units of 100 feet, the intermediate pointer units of 1000 feet and the shortest pointer units of 10,000 feet. The problem arose when flying at about 11,500 feet the short pointer was hidden behind the intermediate pointer so the pilot of a rapidly descending aircraft, in cloud, at night with minimal lighting could not be sure if his altitude was 11,500 feet or was just 1,500 feet. I know – it happened to me one dark and stormy night. Though I would have been descending at about 3000 feet per minute and passing through 12,000 feet, I hauled back on the controls, levelled off and then did a double take that I was at a safe altitude and was not about to get my feet wet in the North Sea.
Kenneth Foster
Luncarty, Perth

 

Media ethics advice

It is encouraging to read in Sian Williams's article ('Voices of the vulnerable', March 2014) of the care and thoughtfulness that she brings to her journalistic and broadcasting work. She highlights the dilemmas that psychologists face when we engage with public media, when anonymity for the 'participant' is rarely possible, and the consequences of media exposure are often hard to predict.

Because the issues that Sian raises are basically around ethics, the Society has put effort into supporting psychologists, especially those new to working with public media, by offering guidance, support and training, from an ethics perspective as well as the basic practicalities, to protect the rights and well-being of others participating in productions where psychologists are involved. There is a set of guidance notes accessible to members via tinyurl.com/p4qpppq, and practical advice on interviews is offered.

We also have a support service, via the Media Ethics Advisory Group, for situations when members need help with negotiating ethically sound ways of working with media producers. The Group also engages with broadcasters, advising on ethics protocols for programmes in the early pre-production phases, and on issues that may arise during production. The questions that Sian helpfully offers in the journalists' checklist in her article are among those that we recommend psychologists ask of media producers, but we have also seen it as increasingly important for psychologists to clarify the ethical need for involvement in the editorial process, since so much can change in terms of the messages conveyed when recorded materials are edited and framed.

John Oates
Chair, BPS Media Ethics Advisory Group 

Dementia – work being done

I write in response to Sandie Hobley' s letter ('Dementia – work to be done', February 2014).

There exists a phenomenal amount of psychological research, knowledge and development about what needs to be done effectively across all areas of dementia care. There is enormous potential for further work and the active, internationally renowned, cited work of members of the Faculty of the Psychology of Older People (FPOP) and its colleagues demonstrates this – please see www.psige.org.uk for an overview. We, as a Faculty, as individual psychologists, as advocates for the care of older people and as part of the broader 'dementia' network welcome all opportunities and suggestions to increase this work, be that through greater research funding, opportunities
for graduates, policy change or greater recognition of need.

The 'some sort of subsection' mentioned must refer to FPOP, and it is truly disappointing that our profile is apparently so low amongst some BPS members. We take heed as regards the absence of our work within The Psychologist and within the BPS more broadly, but in terms of making an effort to raise psychology's profile in dementia services – I can assure you that as FPOP (previously PSIGE) this has been our focus, along with raising psychology's profile in all aspects of older adult services, for the past 30+ years. This is an 'old' and very active subsection of the Division of Clinical Psychology. With a fee of only £30 per annum, Hobley may like to consider joining.

Dementia is at the forefront of people's minds currently – the problem and finance saturated storyline is concerning but we recognise the need to push for greater psychological understanding. Over the past four years FPOP has created a dedicated dementia work stream to draw together and lead on psychological developments. Please follow the link tinyurl.com/q3dwfcn to see the latest publications and plans on interventions around diagnosis and therapy and how the best alternative to antipsychotic medication is good psychological care.
We agree that it is disappointing that psychology and its potential to offer so much for people with dementia and carers has held a low profile with governments, but just recently we have met with Health Education England to consider needs for training and policy change; we have contributed to guidance on commissioning older people's services – see tinyurl.com/qgpu8f4. Scotland (http://tinyurl.com/q89kpjh), Wales (http://dsdc.bangor.ac.uk) and Northern Ireland (tinyurl.com/nthz84p) are also active in their contributions.

Our academic clinical psychologist colleagues are adding significantly to knowledge in this area and have contributed to recent developments in the UK government research agenda. Clinical psychologists are leading studies funded through the NIHR HTA dementia-focused call and ESRC/NIHR dementia large grants call (e.g. at Bangor, UCL and Worcester)

As a community of older adult psychologists we would welcome the opportunity to work with well-trained, well-resourced graduates to improve well-being for people with dementia. Part of the puzzle is how to encourage graduates to this specialty – this is not simply an issue of economic opportunity, supply and demand because working with older people with dementia is challenging, exhausting, complicated but an ultimately rewarding and privileged role.

Becci Dow
Chair, Faculty of the Psychology of Older People (FPOP)

Misdiagnosing the unexplained

Richard Brown's article ('Explaining the unexplained', December 2013) relates some current thinking about medically unexplained conditions (MUS); however, there are areas that were not explored in sufficient depth. This is important as they underpin Brown's stance towards MUS especially those involving contested conditions such as myalgic encephalomyelitis and fibromyalgia, where patients' experiences can collide with medical and psychological opinion.

Brown's assertion that misdiagnosis is rare requires challenge. As the Chair of a UK-based myalgic encephalomyelitis self-help group with 260 members in the North West of England, I have been made aware of at least 18 different misdiagnoses in 12 different patients recently.

I wonder how many more patients are misdiagnosed with treatable, identifiable pathology. Furthermore, there appears to be a pattern of circular thinking around the concept of 'rarity'. If a condition is perceived as rare the patient is presumed that they can't or probably don't have it, so they are not checked for it, thus the patient is not diagnosed with it, so the condition remains understood to be rare and remains underdiagnosed. And so it goes on. This raises the issue of who gets to decide which patients receive the screening for the so-called rare disorders? The power to act does not reside with the patient, who is essentially powerless. On occasion this can be overcome, if they have sufficient support, by determination and a deep well of financial resources.

I suspect it can be tempting for a medical practitioner when they run out of coherent ideas and fail to find evidence to rectify patients' symptoms with medical diagnosis to push the responsibility back towards the patient by psychologising their symptoms (Goudsmit, 2002). This process probably helps to preserve medical authority and control; protecting professionals in the short term from uncomfortable emotions.

Patients can be given the impression, consciously or otherwise, that their symptoms and suffering are not of worth; that they are derived from within themselves via a self-generated, autopoietic mechanism (Deary et al., 2007), which they have the power to overcome. This self-blaming and shaming approach can silence patients discouraging them from further medical interaction and, I would suggest also, additional emotional and social support. Together it is clear that this can have tragic consequences for patients and their families.

I would urge anyone working with patients to take time to reflect on the impact of undermining the validity of patients' experiences via psychologisation and to explore more meaningful aspects of patients' distress, which may in the longer term reap greater benefit.                

Joan Crawford
Chair – Chester MESH
Trainee counselling psychologist
 
References
Deary, V., Chalder, T & Sharpe, M. (2007). The cognitive behavioural model of medically unexplained symptoms. Clinical Psychology Review, 27, 781–797.
Goudsmit, E.M. (2002). The psychologisation of illness. In J. Brostoff & S.J. Challacombe (Eds.) Food allergy and intolerance (pp.685–693). London: W.B. Saunders & Co.

 

Mum's not the word

I really do despair about the state of knowledge, and ability to put forward an evidence-based argument, in those who go on to classify themselves as 'psychologists', and the perception of psychologists by the media and general public. In my periodic viewing of BBC Breakfast News since November, I have seen five psychologists interviewed about a variety of topics. Four of them were women and, in all four cases, the news presenters felt the need to point out that the women were also mothers. The male psychologist, Geoffrey Beattie, on at the same time as one of the female psychologists who was introduced as 'also a mother', had no such statement.

But what concerns me too is when the psychologist, as I have also seen, does not give her opinions based on psychological research, rather based on her personal experiences as a mother.

From this, albeit small, sample, I am left with two impressions. (1) Female psychologists' opinions about human behaviour are not valid unless they are mothers. Apparently, being reproductively successful blesses you with knowledge and wisdom that those of us less fertile, or with no interest in having children, lack. Quite frankly, I don't understand why the BBC felt the need to seek out psychologists to interview as, apparently, the opinion of anyone with children would have been equally relevant. (2) The impression that psychologists are conveying to the general pop