More letters… December 2014

Help for problem gamblers

I note in your news article in the October issue ('New gambling research centre') the comment from Dr Roberts that 'treatment facilities which primarily rehabilitate problem gamblers are very limited; in the UK the NHS does not provide treatment facilities, unless the individual has other disorders they might need treatment for'. Whilst this might be true of residential rehabilitation facilities, it is not true of all treatment modalities.

The National Problem Gambling Clinic has been treating problem gamblers within Central and North West London NHS Foundation Trust since 2008. In that time we have received several thousand referrals and successfully treated many of these individuals using an evidence-based cognitive behavioural therapy treatment delivered by clinical and counselling psychologists. However, despite greater numbers of gamblers developing problems in the UK – estimates currently stand at between 0.4 and 1.2 per cent of the adult male population (Health Survey for England, 2012) – we remain the only NHS service for problem gamblers in the United Kingdom. We also receive no funding from national or local public health resources, being supported partially by a grant from the Responsible Gambling Trust, a charity that collects a voluntary levy from the gambling industry for research, prevention and treatment of problem gambling.

We believe strongly that the NHS has a role to play in the treatment of problem gamblers, with or without comorbid difficulties, and are working hard to publicise the issue of problem gambling and to have it seen as a public health issue deserving of funding. Problem gamblers are a population of individuals from all walks of life who develop problems with a legally available and heavily taxed activity. We now have the knowledge and experience to deliver a successful psychological intervention, but without funding from public sources this intervention will remain at best peripheral and at worst nonexistent.

Dr Neil Smith
Consultant Clinical Psychologist

Dr Henrietta Bowden-Jones
Consultant Psychiatrist and Clinic Director
National Problem Gambling Clinic

 

Dangers of 'colour-blind' perspectives

The article 'Child protection and the Rotherham abuse scandal' (October 2014) missed a key point observed by Professor Alexis Jay in her official inquiry into the scandal: 'By far the majority of perpetrators were described as "Asian" by victims, yet throughout the entire period, councillors did not engage directly with the Pakistani-heritage community to discuss how best they could jointly address the issue. Some councillors seemed to think it was a one-off problem, which they hoped would go away. Several staff described their nervousness about identifying the ethnic origins of perpetrators for fear of being thought racist; others remembered clear direction from their managers not to do so' (Jay, 2014, p.2).

Strategic colour-blindness (purposely avoiding mention of a target's ethnicity to appear unprejudiced) potentially hinders eyewitness testimony (Egan et al., 2013). In the case of Rotherham, this phenomenon shamefully invalidated the experience of the marginalised and socially excluded victims, enabling the offenders to continue to believe they were above the law and that the victim's complaints were irrelevant. Fieldworkers and practitioners who sought to whistleblow were likewise invalidated by the management executive despite practitioners seeking to protect the vulnerable. Independent academic research exposed the systematic nature of the offences in 2003 and 2006, but the work was blocked (and research files removed) due to the uncomfortable issues it raised for those whose priority was possibly less about child protection and more about playing politics. The case series investigated by Professor Jay therefore continued for another seven years. In the high-handed unfairness this scandal exposed, persons who believe themselves of a socially progressive outlook who tried to bury the offences may have ironically assisted in raising the appeal of right-wing political parties who will do little to improve local community cohesion.

A common discovery in any inquiry into official agencies failing to protect the public is their failure to communicate directly. Moreover, in helping people change, 'ownership of the problem' is crucial. Both are clearly in operation here. I point out that while colour-blind perspectives seek to minimise and ideally ignore racial group difference to reduce racial bias (Apfelbaum et al., 2008), this does not respect and recognise the cultures and communities being homogenised, nor the basic reality that all communities have wrong-doers. As a practice point for readers worried that observing a client's heritage may somehow be prejudiced, note that when asked, persons of colour and minority prefer their personal identity, race and culture validated (Ryan et al., 2007).

Dr Vincent Egan
Associate Professor of Forensic Psychology Practice
University of Nottingham

References
Apfelbaum, E.P., Sommers, S.R. & Norton, M.I. (2008). Seeing race and seeming racist? Evaluating strategic colorblindness in social interaction. Journal of Personality and Social Psychology, 95(4), 918–932.
Egan, V., Gilzeane, N. & Viskaduraki, M. (2013). Strategic race blindness: Not so black and white? Journal of Criminal Psychology, 3(2), 127–135.
Jay, A. (2014). Independent inquiry into child sexual exploitation in Rotherham (1997–2013). Retrieved 15 October 2014 from www.rotherham.gov.uk/downloads/file/1407/independent_inquiry_cse_in_rotherham.
Ryan, C.S., Hunt, J.S., Weible, J.A. et al. (2007). Multicultural and colorblind ideology, stereotypes, and ethnocentrism among black and white Americans. Group Processes & Intergroup Relations, 10(4), 617–637.

 

Towards a comprehensive model of psychopathology

I have long ceased to take any unitary concept e.g. anxiety,… seriously that is not founded on basic factor analytic research – exploratory or confirmatory. …bivariate methods are as useless in finding wholes as is trying to eat soup with a fork… (Raymond Cattell, The Psychologist, January 1993, p.22).

I'm moved to write in response to the letters by Sue Gerrard and Richard Hassel ('The end of autism', November 2014), but not to get into the debate about autism. Several contemporary issues, such as the debate on psychiatric diagnosis and DSM-5, whether autism is a category or a series of dimensions, and genetic contribution to chronic psychological distress, appear to be related to a lack of meaningful application of psychological theory. It seems to me that there is a requirement for a comprehensive model of psychopathology based on psychological research. While this would be difficult to achieve practically, it is surely the method by which to address these major debates.

I have often thought that the process is essentially straightforward:
1.    Choose those phenomena that are considered in this culture at this time to be important because of outcomes we do not desire (e.g. 'depression' links to suicide and unhappiness; anger links to aggression, injury and death; poor social understanding in children links to social isolation, etc.). The dimensions to be included could be exhaustively agreed among the community of psychologists in the field.
2.    Develop measures for each dimension that achieve satisfactory reliability and validity, aiming to achieve high sensitivity and specificity.
3.    On achievement of acceptable valid measurement on all psychological dimensions that are considered currently important, use data-reduction techniques to identify the underlying factor structure of our working psychological constructs, and importantly, discard the invalid.
4.    Research those risk factors (not necessarily first causes) that load onto the negative outcomes on each underlying factor (e.g. attachment insecurity, socialisation of boys into aggression, lack of structured education for those with poor social cognition, etc.), seeking to address each through health and social care services.
5.    Feed back to policy makers, the public and other professions about the new basis of psychopathology in the above. Specify the relative power of known risk factors (allowing for unmeasured and unknown variance) that load onto outcomes, and what might be done to change these most efficiently.

A comprehensive model of psychopathology that is ambitious in scope but practical in usage does not emphasise debate about diagnosis or genetic causation. Current 'comprehensive' measures, such as the Millon Multi-axial Clinical Inventory, continue to have a basis in diagnostic systems that we now consider to lack sufficient validity.

Psychologists may then have to face up to an empirical model where current theoretical distinctions are debunked (e.g. merging of anxiety and depression into 'distress'). It is entirely possible that we achieve something like the DSM axes, but these will be based in sound bottom-up research. Health and social care policy may then have a basis in something like
a scientific consensus.
Dr Allan Skelly CPsychol AFBPS
Secretary, Faculty for People with Intellectual Disabilities
BPS Division of Clinical Psychology