‘Maybe more psychologists need to become outsiders’

What inspired you to pursue Psychology at Edinburgh University, and how did your time there shape your perspective on the field?

I went up to Edinburgh with seven A-levels. I thought I'd like to be a psychiatrist. Unfortunately for my parents' aspirations for me, when I got to Edinburgh, there was a lady corpse waiting for me to dissect, which did not appeal, so I wandered over to the Psychology Department and, a term late, signed on for a four-year M.A.(Honours) course.

The Psychology Department was a good place to be, as the emphasis was more on teaching and less on research. There were 28 of us in my year and we could knock on any lecturer's door if there was something we didn't understand.

The Department was very up on new trends. So, we were told of Chomsky's developments in psycholinguistics; about Kuhn's rewriting of how science progresses; and Kelly's Personal Construct Theory (PCT).

There was plenty of time to follow your own interests and three years of philosophy was compulsory. I also enrolled for the first two years of Sociology, as it seemed important to understand the wider society. 

Edinburgh was a stimulating period of my life. I left with an excellent grounding, a First and a wife. 

Can you share what drew you to community psychology during your early career in Newham, and what it was like working in the East End at that time?

Whilst I was at Edinburgh, I did my research thesis on PCT and I corresponded with the educational psychologist, Dr Tom Ravenette in the Mental Health Department of the London Borough of Newham. He told me that they wanted a psychologist and encouraged me to apply.

The East End was an exciting place to be. Ronald Laing, famous for his anti-psychiatry The Divided Self(1959), was at Kingsley Hall, in Bromley-by-Bow, and Wilmott and Young's (1957) Family and Kinship in East London came out of the Institute of Community Studies in Bethnal Green. There were also the Kray Twins in the Blind Beggar, Whitechapel…

My first three years, then, were in the Mental Health Department, learning my trade. I qualified as a Clinical Psychologist in 1971.That same year came the implementation of the Seebohm Report, creating Social Services Departments. 

Building a pioneering team in community psychology is no small feat. 

I was in the right place at the right time. The 1970s were growth years for Social Services. The big mental hospitals were being run down, and Community Care was replacing them. Newham was building a large day centre or a hostel complex almost every year; and we had over 700 old people in our residential homes. The Director of Social Services found my skills useful and so more psychologists were recruited to support the burgeoning services. I was very fortunate with my appointments – Anthea Sperlinger and Alison (then Cooper, now Bender) were key in building up the department.

Although we were clinical psychologists, the job title was 'Psychological Adviser', and our ID cards said something like 'authorised to assess need for provision of council services'. So, our brief was wide, with plenty of opportunity to innovate and for preventative work. I think we were pretty unique at the time.

We worked on three levels – with the individual client, with staff, and with the institutions. So, we could be treating an agoraphobic; training staff to run groups; or working out how best to make the day centres, hostels and homes therapeutic, rather than places of containment. At all levels we worked with other social services staff and shared our skills – 'skills transmission'. We worked at the interfaces – for example, sitting on the panel that scrutinised applications for older people to be admitted to council care homes, to ensure that clients' wishes were respected as far as possible, and admissions were not just nodded through. Social workers were interested in mental health issues and learning how we were trying to help their clients, so cooperation was good. Day care and residential staff welcomed the opportunity to develop their skills.

A key aspect of working in the local authority was accountability to the local people. Our Director met regularly with the council's Social Services Committee: elected representatives of the people who were paying our wages. We had always to be ready to justify the work that we were doing. 

Innovation was expected and valued, so we could be flexible and responsive. For example, when the AIDS epidemic hit, Alison very quickly set up training for home helps about HIV and averted the threat of them withholding their services out of fear.

In 1976, as a result of interest in our work, I published Community Psychology.

You moved to the South West in 1988, to the post of Consultant Clinical Psychologist, to build up Psychological Services for Older Adults, within an NHS Trust. How did this service differ from the conventional approaches at the time?

Once again, it entailed a wider approach than just clinical work, as we used a skills transmission model. Our clients were an interesting group of people, as the men had served in the 1939 War and the women subjected to the heavy bombing of Plymouth. As a naval town, the women brought up the children, with the men coming back for a few weeks from three-year tours of duty, a set-up that caused stresses.

I was helped immensely by having a series of good assistants trying to get their feet on the clinical ladder.

A focal point was the British Psychological Society's Psychologists' Special Interest Group for the Elderly – now FPop. I preferred the old acronym which was pronounced 'Siege'. I edited the PSIGE Newsletter for a few years.

The Annual Conference was where the Plymouth assistants most often presented their research, examples being: the relationship of internalised and external ageism; how people would give more to a dementia charity when the advert showed an incompetent person rather than when it showed competence; 'This is Me', a booklet with the basic facts of your life and your likes and dislikes that you had ready in your bag for when you went into hospital to give to staff to make you a person, not just a name above a bed; and many others.

Although we were working within the framework of memory difficulties being due to 'Alzheimer's', we never closed a case, and my assistants supported the families. always offering ongoing support and regular face-to-face contact.

I think what we were doing was showing that work with older adults, including those living with dementia, could be exciting and innovative; and that you could inspire staff to see that. I wrote up all our research and theorised about the psychological components of living with dementia in Explorations in Dementia (2003).

Can you tell us more about your 1999 book with Rik Cheston, Understanding Dementia: The Man with the Worried Eyes and its impact on the field? 

I can't remember how I met Rik Cheston, then Consultant Clinical Psychologist, Avon and Wiltshire, but we started writing papers together on the social and familial context of people diagnosed with dementia. We questioned how useful the disease framework was; and explored how people who were suffering cognitive difficulties were trying to understand and verbalise those difficulties and trying to communicate the very frightening things that were happening to them. Rik had a striking ability to empathise, 'bearing witness', and make sense of what people with cognitive difficulties were saying and he was very strong on the metaphorical meaning of the stories of incidents in their lives. 

So, we combined the contextual and the personal constructions in our book, which included accounts of Rik's therapeutic work. And it sold well, especially in Australia! But unfortunately, the tide was turning, and therapeutic approaches got washed away by the excitement about new anti-Alzheimer's drugs, especially Aricept, supposedly the forerunner of even more effective drugs. Since the government believed this hype, what was the point of expensive, time-consuming psychotherapeutic approaches?

As the century turned, an even bigger problem was the centralisation of decision-making in Westminster and hence in the senior management of the NHS. The aim was to get the cuts implemented and services available to old age psychiatry were slashed. 

Wards for older adults with mental health problems were being closed, along with day hospitals and day centres. I watched with horror the closure of the respite care beds. So many carers had told me that the respite of two or three weeks a year was what kept them going. It was incredibly short-sighted, as it meant the carers gave up earlier.

Quality services were not valued by management. Nor was anyone who tried to maintain professional standards. They were pushed out and replaced, if their posts were replaced at all, by staff who understood that their role was purely to be service providers. An astonishing number of excellent senior people from across the mental health professions were culled – edged or pushed out in a traumatic way, often having to sign Non-Disclosure Agreements and so not feeling able to group together and fight back. It was a frightening and very damaging time, and I am not sure that clinical psychology has ever really recovered.

In those days, if you had 'mental health officer' status, you could retire early. I did and I left the NHS in 2002.

What led you to write your recently published book, A New Understanding of Dementia: A Guide?

I never lost my interest in understanding 'dementia' better. I set up a support group for people diagnosed with Dementia in Cornwall run by an O.T. and a psychiatric nurse, now both high up the mental health hierarchy. 

Across the years I watched on, as services for older people starting to worry about 'getting dementia/ demented' remained at near zero. There were no effective drugs, and the Memory Clinics were diagnosing but offering no follow-up. So, I felt I had to get back up to speed and started reading more intensively. Peter Whitehouse, an American medical academic, in The Myth of Alzheimer's (2008), was clear that the dominant narrative was shaky. 

What is this 'dominant narrative' about Alzheimer's?

The dominant narrative holds that most people, as they age, will get a disease called 'dementia', now often called 'Alzheimer's', which will slowly destroy their memory and their identity, and lead to their death. It is 'dominant' in our society as it is continually referred to as self-evident, by government, drug companies, Alzheimer's charities, the media and by many scientists in the field.

The pathogens supposedly responsible for this disease are plaques and fibrils. But half of cognitively competent old people show plaques and fibrils at autopsy; and half of old people who are diagnosed with dementia do not have high levels of plaques and fibrils, a finding replicated many times, most notably in David Snowdon's study of nuns, Aging with Grace.

So, plaques and fibrils, and the much-vaunted Amyloid Cascade hypothesis, despite the huge amount of publicity that they are given as the cause of 'Alzheimer's', are clearly not the key pathogenic process. 50 to 80 per cent of people diagnosed with Alzheimer's at autopsy show evidence of cerebral vascular damage, which looks to me as if it should be the main target of investigations.

Can you elaborate on the self-help techniques you describe in A New Understanding of Dementia? What makes them effective in preventing or delaying cognitive losses?

The dominant narrative has obscured the fact that longitudinal studies, by the likes of Patrick Rabbitt and K. Warner Schaie, show that cognitive decline in old age is slow, selective and highly variable across people. What we need to do is to help older people look at how they can ameliorate the problems of old age: how they can lengthen their healthspan – being able to enjoy life.

I wrote a small self-help manual, called Taking the Fear out of Dementia and got it into libraries in Cornwall. Then I settled down to research and write a much more substantial book, A New Understanding of Dementia: A Guide, which aims to free the older person from despair, and therefore be able to see their position within their lifecycle, and to handle the difficulties they are experiencing. 

I encourage readers to insist on having a good work up from their GP to exclude any treatable underlying physical or psychological causes of their difficulties. Evidence is piling up about the importance of risk factors known to increase the likelihood of cognitive difficulties in old age and the techniques proven to help – a healthy diet, exercise, socialising and learning how to reach calm – so I describe these factors and possible ways of improving one's physical and, intertwined, cognitive health.

I then move onto Problem Analysis and Problem Solving, which is a form of Cognitive Rehabilitation, which Linda Clare and her colleagues at Exeter University show can achieve positive results. I take the reader through how they can work out the context of their difficulties, develop strategies to alleviate them. and how to monitor progress.

I have taught this as a fortnightly six two-hour sessions course for U3A members, and it was well received. 

What role do you think psychologists should play in public health discussions about aging and cognitive health?

Well, there is absolutely no point in them going along with the present situation of therapeutic nihilism and lack of preventative work. Tacking prevention onto Memory Clinics would require real investment, but is the wrong place to start, as it's too late in the process. 

You know, when my wife, Alison, heard about this interview, she said 'the thread through your life is that, as the child of refugees, you were an outsider'. Although sometimes lonely, an outsider can be more able to challenge the status quo, being freer from cultural norms and biases. Maybe more psychologists need to become outsiders – step away from a circumscribed role and search out local groups in need of support and focus on them. 

Sorting out social care would cost billions, so my advice would be to mind the reality gap and stay well clear of consultations and committee reports. You can't achieve anything that will change the situation, and you'll get caught up in the collusive web.

Challenging the dominant narrative is a rather lonely business. If you are going to challenge a paradigm in your field, you need a strong conviction you're right, to be fairly buoyant and have a support system. 

Over the course of your career, what has been the achievement you have been most proud?

I have been in at the beginning of the careers of some very talented people – being able to give them the opportunity to explore ideas, to present them at conferences and to develop their skills gives me pleasure to look back on.

Reflecting on your pioneering work and research, what legacy do you hope to leave for future psychologists?

In terms of applied psychology, the opportunities I had in Newham no longer exist. I was basically a service planner. I was asked to use psychologists in the best way of helping distress in the local population – pretty well a blank sheet to plan services.

In Plymouth, the parameters of the service for old people were much more fixed. You might say I was a service developer – I was asked to utilise psychology within those parameters.

I see present day clinical psychologists as service providers. They are told the area they are to work in, and often, implicitly or explicitly, what methods to use, how many clients they should be seeing for how many sessions, what the outcomes should be, etc. 

If they could break away from this and innovate with community groups it would be wonderful, but I don't really know how feasible this would be now.

For aspiring psychologists, what advice would you give about entering the field, particularly in the areas of aging and dementia?

Psychology is a beautiful and important area, but what is unclear is what any finding means in terms of its range of applicability and the time it will be valid for. For example, what does the advent of the digital age, the internet, the mobile and the smart phone mean in terms of earlier findings?

This problem can be at least partly solved if we understand that there is only one, a single unitary social science, a Russian doll series of Anthropology (culture), Sociology (society) and Psychology (the person). History should be in there as well. 

If you like images, culture is the airship, history the flight recorder, sociology the groups inside the airship, and psychology the individuals. We can see this single social science as moving through time and space, so constantly changing. Psychology students should have a grounding in these interlocking perspectives.

Career advancement in psychology is not a cooperative system but is based on individual aspiration. You find a small area and you colonise it. Aspirational individualism rules. 

It sounds like you would prefer a radical alternative.

We need a much greater sense of urgency concerning the major problems – the planet-endangering problems – that British society is facing. At a conservative estimate we've got five years to get a real handle on these problems.

Of course, psychology has considerable expertise to bring to bear on these issues, for example, regarding the transmission of information, disinformation and misinformation, building trust between and within groups; etc. Teaching would focus on the theory and practice of influencing and achieving change in the key areas.

More widely, all research should be focused on understanding the present situation, and the changes needed, and examining the effects of efforts to achieve these changes.

If students only enrolled on courses that embodied such principles, the rest, however prestigious, would soon fall in line in order to maintain their student numbers.

We must encourage people, including ourselves, to care for and relate to each other and work together on more rational solutions for a better, more generous and future-orientated society.

Five years…

• Mike Bender's A New Understanding of "Dementia": A Guide is available from Agewise Books. On this website also are a longer version of this interview; and more detailed discussion of the scientific status of 'Alzheimer's Disease' in two papers: 'The Natural History of Dementia' and '"Alzheimer's Disease": A report from the Trenches of Paradigm Change'.