More letters…

Stopping sex offending

I have been so delighted to read the correspondence in The Psychologist about working with sex offenders (Hossack, October 2014; Duff, Pilgrim, November; and MacLeod, January 2015). However, there is one inaccuracy in the correspondence that I would like to put right, and that was in MacLeod's letter:
'As I see it, the main stumbling block for unconvicted and would-be offenders seeking psychological support lies in our mandatory reporting laws. These laws bind social, medical and mental health professionals into compulsorily contacting police if they believe that a crime has been committed or is likely to be committed, superseding all confidentiality clauses.'

It is true that anyone working for the NHS or social services is under a duty to report suspected child abuse; yet this is not a legal requirement, it is something that employees agree to through their contract of employment. For those practitioners working in private practice there is no legal obligation to report. Psychologists and psychotherapists may feel that ethically they need to report, but that is a different matter, and brings some element of choice with it. This means that, here in the UK it is legally possible to provide confidential therapy to those who are at risk of offending, or re-offending. In fact there are many therapists doing just that, making their own risk assessment and then working with the client if they feel able to.

There is no law that stops someone in private practice from seeing a client they know has broken the law around sexual behaviour. The only time a counsellor or psychotherapist is legally required to breach confidentiality is if a client is making money through drug trafficking (Drug Trafficking Act 1986), you have a belief or a suspicion that they are engaged in terrorist activities (Terrorism Act 2006), if you know someone is unsafe to drive (Road Traffic Act 1988), or they are money laundering (Money Laundering Regulations 2007).

Indeed, one colleague wanted to check this, so contacted the Home Office for clarification. The reply from the Criminal Law Policy Unit stated: 'With regard to your question: If a client confides in you during the course of therapy that they had been viewing child pornography on the Internet, whether you would be obliged to disclose this to the authorities. There is no specific requirement in The Protection of Children Act 1978.'

This knowledge has enabled the organisation StopSO, the Specialist Treatment Organisation for the Prevention of Sexual Offending, to spread in the UK. StopSO is a not–for-profit organisation, that has a network of therapists who are willing and trained to work with sex offenders, and welcomes new members providing they have the appropriate therapeutic qualifications. StopSO offers training to enable those experienced therapists in private practice who feel ready to engage with this client group, a way to prepare themselves. Through StopSO psychologists and psychotherapists can also access specialist supervision where necessary.

If we can treat one person successfully then we may save many people from becoming victims. Good therapeutic intervention for sex offenders is a child protection issue!
Juliet Grayson
UKCP Registered Psychotherapist

Social and material causes of distress

We welcome the recent debate between John Cromby and Vaughan Bell on whether understandings of mental illness are mired in the past (January 2015).

We agree that it's time to do away with the unhelpful assumption that psychological distress is mental illness with primarily biological causes. We feel it is important to point out, however, that at no stage did John Cromby say that biology plays no role in psychological distress, only that it is often not the primary causal influence. Vaughan Bell's response appeared as though he had taken John as denying any role for biology at all. But as long as we consider biology to be the fundamental cause of distress, antidepressant and antipsychotic medications will continue to be the go-to remedies. However, such medications frequently cause real mental and physical harm, including exacerbating rather than alleviating distress.

We also believe that overly 'psychologised' approaches can be equally unhelpful. For example, the over-prescription of cognitive behavioural therapies – a case convincingly argued by Peter McKenna and Keith Laws in a recent Maudsley Debate (tinyurl.com/kmbp3en) – as a treatment for distress again reflects the misplaced assumption that the causes of distress are to be found within the person. Just as biological explanations wrongly attribute distress to neural or hormonal imbalances, psychological explanations wrongly point to 'faulty thinking patterns' or 'maladaptive behaviours' as the source of psychological suffering.

John Cromby's argument that it's time to more adequately address the social and material causes of distress, and the structural inequalities that give rise to psychological suffering, makes perfect sense. Thus the call for a more sophisticated approach to understanding and alleviating psychological distress in the 21st century is prudent and timely.
Nick Caddick & Martin Willis
Loughborough University

No right to be forgotten for PhDs?

Ten years ago, I was one of several researchers targeted by a small group of cyberbullies. The main bully was convicted under the Harassment Act and the bullying stopped. I thought it was all over but have recently found that colleagues who Google me now find the old posts and without knowing the context, jump to conclusions. There's no warning that the URL was part of a campaign of harassment and that the author was convicted, so those who don't know me assume that the criticisms of my professionalism were made by a rational and well-informed individual. They've stopped asking me for my opinion, and any reputation I had as a competent and honest psychologist has been severely damaged.

I asked Google and Bing to remove the links to the posts as they fell under the European Court ruling and later guidelines; that is, they were old, defamatory, caused distress, allegations were untrue, most arguments were irrelevant (they had linked me to a trial that I was not involved in) and I was not a public figure. Google rejected my request, stating that as I was a professional and that my potential patients and clients needed to know. It was, in their view, in the public interest. I pointed out to them that I didn't have potential patients or clients as I had retired.

Bing never responded.

The UK regulator, the Information Commissioner's Office (ICO), rejected my complaint because I have a PhD, which in their view makes me a professional engaged in a professional debate. Like Google, they felt that the public would benefit from being aware of the conflicting views amongst health professionals. The inaccurate information about me and my work that dominated the posts was dismissed as a professional disagreement and the authors had a right to freedom of expression as enshrined in the Human Rights Act.

The 'debate' was not about the causes or treatment of an illness and it was not a professional disagreement. None of the bullies were colleagues engaged in research into the illness and none had published in a scientific journal at that time. Three of the four were not patients with the illness in question. Some of their 'evidence' about me had been fabricated. I sent the ICO evidence from others who had been targeted, showing that there had been a campaign by individuals who cared little about accuracy, let alone science.

On their website the ICO notes that it will consider links to comments that constitute hate speech, slander, libel or similarly offensive content targeted at the complainant. This was true in my case, but the fact that the main bully was convicted under the Harassment Act wasn't relevant as harassment is 'not covered by the DPA' (Data Protection Act). I was advised to sue the authors under sections 10 and 14 of the DPA. Independent legal advice recommended I avoid a court case as it was a minefield, and while I had been defamed the freedom of expression argument tends to protect cyberbullies.

The message I wish to convey is that having a PhD in psychology excludes you from the EU Court's ruling and we therefore don't have the right to be forgotten. My case also means that we need to be more careful what we write and say, because the village gossips can now spread their bile all over the world in a matter of seconds. And as I learnt to my cost, the assumption that intelligent people can distinguish between fair comment and cyberbullying may not be valid.
Name and address supplied

Anonymous contributors

I have just read a piece on your Research Digest blog that was attributed as: 'Post written for the BPS Research Digest by Neuroskeptic, a British neuroscientist who blogs for Discover Magazine.' I have no issue with what was said in the piece, but I am concerned that this is being published anonymously. It is vital that the reader is able to place the published material in the context in which it is written. To appraise a piece, it is helpful to the reader to know something of the previous work the author has published and whether there are particular views held by the writer, on theory for example, that might flavour or bias the piece.

There is then the issue of declared conflict of interest, about which the reader would be more reassured if the author was named. I am all for 'disseminating psychological science far and wide' but it is a central tenet of such science that the provenance of a finding or an opinion is attributed.
Jim Stevenson
Emeritus Professor, School of Psychology, University of Southampton

Editor's reply: The Psychologist and Research Digest policy is that we are comfortable publishing anonymous writers in principle, although each case is judged carefully. In the case that prompted your letter, the author is a British neuroscientist who the Research Digest editor and I have met and know the identity of. This person has published in The Psychologist and Digest, on a widely read blog, and even in scientific journal articles under this pseudonym. This enables the reader to appraise the work and place it in context as much as a real name would. Increasingly in the 'blogosphere' psychologists are, for whatever reason, choosing to write anonymously, and we feel that decision should be respected unless there is a good reason to avoid it; for example, if there was the sense that an author was choosing to hide behind a cloak of anonymity in order to express particular views.
However, we will revisit the policy at the next meeting of the Psychologist and Digest Editorial Advisory Committee.

Outsider psychologists

I picked up my copy of The Psychologist when it arrived this morning and randomly opened to page 111 where there was an image of an elderly white couple. I immediately thought 'How many images of black people appear in the magazine?' Then stumbling across Jeune Guishard-Pine's letter 'Where have all the BAME psychologists gone' prompted several musings for me.

As a former social worker, entering the psychology arena has been like stepping into a 'timewarp' in relation to how black and ethnic minority people are (not) represented in the mainstream literature of psychology as a whole. Is it, I ask myself, that psychologists do not view themselves as 'agents of change' on a social level compared to (old school) social work practice that had at its core value's of inclusion and challenging injustice and inequality?

As a black woman I have found that belonging to a profession where images of myself and issues that speak to my experience are made explicit alongside issues pertinent to white, middle-class people gives me a sense of validation and inclusion. I am sad to say, unlike my experience of being a social worker where I could own my professional identity in a professional home, I have struggled to do so since qualifying as a psychologist. What this has meant is I have a sense of apathy about getting involved. In fact I have joined the APA black psychology section, which goes some way to providing some affirmation despite the cultural difference that exists.

I can admit in answer to Jeune's question of 'Who would bother to fill in this form?' that I was certainly one of those who couldn't be bothered, for some of the reasons stated above – not least of all the deathly silence that exists within the profession in relation to these issues. Truth is I feel like an 'outsider psychologist'.
Margaret Jordan CPsychol
Clinical Director

Population pressures

Graham Pluck's urgent article on street children (January 2015) makes the next questions for psychologists – Why are they homeless and what can be done to stop it? Are they part of the problem of families with children they do not want or cannot care for? The refugees from Africa to Europe seeking jobs, and the people daring desert crossings to reach the United States are also part of the problem.

Why are there such large families with unwanted children or teenagers who cannot get jobs? Now that modern medicine and hygiene prevents high child mortality, large families in poor countries mainly survive, and can help parents by working as children until they seek to become parents too.

What can be done about political and religious pressures to have large families?
The West sees a problem in Western small families, but the world problem is in a population explosion that is greater than can be sustained. China's solution was one-child families, but two-child families seem better for all concerned.

This is a complex question for psychologists to attend to.
Valerie Yule
Mount Waverley, Victoria, Australia

Editor's note: We do in fact have an article in the pipeline on just this issue.

Addressing experiences of brain injury

I read with dismay, coupled with some sympathy, Niamh Lowe's experiences at the hands of neuropsychologists ('Viewpoints', February 2015).

Having worked as a neuropsychologist for over 15 years, I am only too aware of the possibility of appearing cold, clinical and lacking in empathy for a brain-injured person when conducting an assessment. Formal tests present a considerable challenge to testees, and they often appear completely irrelevant to the individual's needs. Results are often withheld and feedback on test performance is often lacking. Testees themselves often know that they're performing poorly in spite of encouragement, and these factors can have a demoralising effect on the individual at the very time that they need optimism and hope.

In the private sector I am fortunate to be able to delay formal testing until I have got to know the individual and relatives. In this way I can form a picture of what the person was like before the brain injury and how far away from that premorbid person they currently are. I do, however, conduct a wide range of formal tests and always feed back results, together with reassuring explanations and realistic hopes for recovery. In addition, I invariably address issues such as anxiety, depression, low self-esteem, self-efficacy, recovery, locus of control, and attitudes towards and acceptance of disability. These have been formalised in a 55-item questionnaire known as the Nottingham Adjustment Scale (NAS), a reliable and valid instrument that we developed at the Blind Mobility Research Unit way back in the 1990s.

Although I never imagined for one moment that I myself would employ this research tool in clinical practice, I have found it invaluable in addressing the psychological and emotional factors alluded to by Niamh. The scale has been translated into a number of languages, and the factor structure has stood up well, suggesting that the experience of acquiring a disability may be a human universal independent of the actual disability itself. The scale enables one to evaluate psychological progress as rehabilitation proceeds and to compare the effectiveness of various interventions. Copies of the NAS may be obtained by e-mailing me.
Dr Allan Dodds
Bramcote, Nottingham
[email protected]

Thinking in context

Dr Alan Dodds response (Letters, February 2015) to our article 'The "strange death of Radical behaviourism' repeats the often cited, but nonetheless incorrect view that Skinner was not interested in cognitions. So to be absolutely clear on this point, in spite of various misrepresentations to the contrary, Skinner and radical behaviourism have always considered thoughts and feelings as important psychological phenomenon that must be included in any scientific analysis of the human condition. Watson didn't, but Skinner did. It's that simple really. Asserting the contrary in the face of the evidence is not likely to add to the quality of any discussion.

There is a more interesting issue in Dr Dodds's response, however, and it relates to using quotations or anecdotes out of their broader context. We don't know the interview with Skinner that Dr Dodds refers to and do not dispute the words used, but we do question the meaning he ascribes. One of Skinner's central criticisms of the cognitive theories advanced during his day was that they frequently took common metaphors and turned them into explanatory models. Consider the metaphor of 'thoughts going through our heads' that Dr Dodds refers to. Do thoughts literally go through our heads? If so, what is actually moving and through what? For Skinner phrases like these were everyday metaphors for thinking and not the basis of a scientific understanding of cognitive processes.

So when asked if thoughts were going through his head, he may have provocatively said 'No' because it was just a metaphor for the experience and not a scientifically precise statement. Skinner frequently made this type of argument. Had the interviewer asked Skinner if he 'thinks' he would almost certainly would have replied 'Yes' (as all radical behaviourists would, though he probably would have also gone on to deconstruct what we mean by thinking too!)

There is a more interesting debate to be had about the use of metaphors in our theories that is being missed when we selectively present quotations or anecdotes about Skinner out of their wider context.
Freddy Jackson Brown
Duncan Gillard
Bristol

Brown and Gillard ('The "strange death" of radical behaviourism', January 2015) make an excellent case that one should not ignore theoretical approaches, such as behaviourism, merely because many have declared them 'dead'. Yet, one might argue that the assumptions of behaviourism are still alive and well within contemporary cognitive approaches. Cognitive researchers still subscribe to a model that a stimulus in the environment leads to a response, albeit through various intermediate 'mental processes'. Maybe psychologists should pay more attention to a 50-year-old theory – perceptual control theory (PCT) – that has not even yet been regarded as 'alive' by mainstream psychology, never mind 'dead'.

PCT proposes that behaviour is the process of controlling sensory input within a closed loop. So, when we see a 'response' following a 'stimulus', this is actually the emergent attempt by the organism to maintain its desired sensory goals (e.g. to keep a glass of beer steady on a swaying ship!), despite the ongoing disturbances in the environment. Because behaviour emerges dynamically, it cannot be learned in the way that Skinner described; only the parameters of the control system that utilise behaviour can be modified.

Returning to the recent article, Brown and Gillard draw the analogy with Darwinian evolution to explain selection of behaviour within a lifetime, but they do not extend the analogy to the distinction between genotype and phenotype. The phenotype is a complex product of the genotype and the environment, thus while it determines survival, it cannot be the unit of selection – this is the genotype. Similarly, from the PCT perspective (Mansell et al., in press), behaviour is a complex product of what the organism is attempting to do, and of the features of the environment that either permit this (e.g. a post on a swaying boat used to stabilise oneself) or disturb this (e.g. the movement of the boat). Clearly, none of these features of the environment that define and shape the behaviour as it is happening are passed on within the organism; yet the systems that utilise these are – these are known as control systems in PCT.
Warren Mansell
University of Manchester

Reference
Mansell, W., Carey, T.A. & Tai, S.J. (in press). Classification of psychopathology and unifying theory: The ingredients of a Darwinian paradigm shift in research methodology. Psychopathology Review.

Stubbing out smoking

I volunteer at Lancashire Care Foundation Trust (LCFT) where smoking, or rather, 'not smoking' is a hot topic! So I was pleased to read the article 'Stubbing out smoking in schizophrenia' by Theodore Lloyd (January's 2015), which posed the question 'What can mental health professionals do to help people with schizophrenia who smoke?'

In January LCFT went 'smoke-free'. A positive change for everyone; especially those with a diagnosis of schizophrenia and other serious mental illnesses (SMIs), as these individuals have a life expectancy that is 15–25 years shorter than the rest of the population, due in part to high prevalence of smoking (Bradshaw et al., 2014).

To successfully help people stop smoking, we must know what barriers might present themselves. Some common concerns that people with SMI have around quitting smoking are: possible effects on anxiety levels, loss of an important coping resource, the fact that smoking is strongly linked to socialising – people worry that stopping could have a negative impact on relationships, giving up something that is pleasurable and also the risk of a deterioration in their mental health (Kerr et al., 2013). Being aware and informed about the worries clients may have about stopping smoking means we are better placed to provide support.

It isn't just our clients who feel anxious at the prospect of stopping smoking. Ratschen et al. (2009) found ward staff were concerned about damaging the clinician–patient relationship, dealing with aggression when challenging patients who were smoking, increased risk of fire due to 'covert smoking' and the possible exacerbation of clients' mental health problems. Interestingly, however, none of the respondents could cite any incidents to justify their fears. A professional's own smoking status might also influence their health-promoting role and cause missed opportunities to engage clients regarding smoking cessation (Kerr et al., 2013).

Making Every Contact Count (MECC: see http://makingeverycontactcount.co.uk) encourages conversations about lifestyle change; focusing on diet, exercise, alcohol and tobacco. LCFT plans to conduct research into whether training staff in MECC changes the way they interact with clients. If behaviour isn't changed after training, the study will aim to identify barriers to change. This information coupled with what we already know about the barriers clients face when considering stopping smoking will hopefully result in more helpful and successful interventions.

I hope this goes some way towards an answer to the question Theodore poses.
Rebecca White
Manchester

References
Bradshaw, T., Davis, E., Stronach, M. et al. (2014). Helping people with serious mental illness to cut down or stop smoking, Mental Health Practice, 17(6), 14–20.
Kerr, S., Woods, C., Knussen, C. et al. (2013). Breaking the habit. BMC Public Health, 13, 221.
Ratschen, E., Britton, J. & McNeill, A. (2009). Implementation of smoke-free policies in mental health in-patient settings in England. British Journal of Psychiatry, 194, 547–551.