News and media, December 2008

A blueprint for mental capital and well-being
The media spotlight shone brightly on the psychological needs of the nation once again in October, this time thanks to publication of the latest report from the government's Foresight programme – the Mental Capital and Wellbeing project (tinyurl.com/6c2fdt). Led by psychologist Cary Cooper of Lancaster University, and with the involvement of psychologists Usha Goswami, Felicia Huppert and Barbara Sahakian of the University of Cambridge, the report makes a plethora of recommendations to government, including in the areas of learning difficulties, work and old age.

Two years in the making, the report draws on over 80 commissioned scientific reviews and received input from over 400 experts from a range of fields. A lifespan approach is adopted, with the report's authors attempting, for example, to predict the long-term consequences of  a failure to recognise a person's dyslexia or dyscalculia in their early childhood. 'Think about mental capital being in  a sense like a bank account of the mind, which you're debiting and crediting through life,' Cooper told us. 'Even pre-birth, your mental capital is affected by the diet and behaviour of your mother in the womb, all the way up to when you die.'

Another focus of the report is on absenteeism and presenteeism at work. The latter refers to people who go to work stressed out – they're scared they'll lose their job if they don't. However, because they're stressed or mentally unwell, they're not contributing added value to products and services. 'Presenteeism costs the nation £900 million every year and we're going to see more of it during the recession,' Cooper warned. 'We're going to need more and more psychologists doing work in this area.'

The report also highlights the future costs and benefits to society of an ageing population. By 2071, the UK Office of National Statistics estimates that the number of people aged over 65 years will have doubled to nearly 21.3 million, while the number of people aged 90 plus will have tripled to 9.5 million The report states: 'Although the impacts of population ageing are most often seen negatively, in terms of a "burden" of rising costs, an authoritative study [tinyurl.com/5m8ae2] of the costs and benefits of improving health estimated the contribution to US economic wellbeing of the increase in life expectancy since 1970 to have been $73 trillion, or about $2.6 trillion per year.'

Of course, any benefits to society of an ageing population depend greatly on older people remaining as mentally and physically healthy as is possible. '[T]he pressing and growing problem of cognitive ageing presents special challenges,' the report warns. 'Among these are the facts that: the assessment of change is technically difficult and demands unusually burdensome studies; most studies are observational; the influences in cognitive ageing are heterogeneous, demanding collaboration amongst biomedical, physical and social scientists; and some of the theoretical constructs in the field require further clarification.'

'This [report] is the first time any government, anywhere in the world, has done anything like this,' Cooper said. 'This is wonderful for psychology. It's showing the real importance of psychologists: I'm talking educational psychologists, clinical psychologists, occupational psychologists and health psychologists. There's recommendations for every single one of them in this report, about early detection, about treatment, it's all there. This is a blueprint for how psychology can improve the mental capital and well-being of our population. We've been given a real fillip, I think, in this work

New NICE guidelines on ADHD

Parental training and psychological interventions are at the heart of new National Institute for Health and Clinical Excellence (NICE) guidelines on the diagnosis and management of ADHD, published in September.

Specifically, drug treatment is not recommended for pre-school children with suspected ADHD, nor for older children and adolescents with moderate ADHD. Instead, the parents of children and adolescents with ADHD should be offered a group training programme based on the principles of Albert Bandura's social learning theory. There should also be the option of group psychological treatment or social skills training for the child or young person, and the option of individual psychological therapy should be considered for older adolescents.

The new guidelines do recommend drug treatment as the first-line intervention for children and young people with severe ADHD and for adults with ADHD. However, such treatment should always form part of a comprehensive care package that includes psychological and educational components. In particular, adults who don't want a drug treatment should be able to access psychological help instead.

Other notable aspects to the new guidance include: a call for multidisciplinary specialist ADHD teams and/or clinics to be established; a recommendation that teachers with necessary training should provide behavioural interventions in the classroom; an unequivocal statement that dietary fatty acids are not recommended; and a recommendation that GPs do not initiate drug treatments for ADHD, although they may continue prescribing and monitoring such treatment once started by a suitably qualified expert.

Paul Cooper, a chartered psychologist and Professor of Education at the University of Leicester, told The Psychologist that the new guidelines are to be welcomed for the way in which they locate the use of medication in the treatment of ADHD within the context of a multimodal approach, and for stressing the primacy of social and psychological interventions for young children. 'It is a pity, however, that recommended educational interventions are restricted solely to behaviour management strategies,' he said. 'A more educationally informed approach to ADHD would emphasise the ways in which teachers can exploit the cognitive features of ADHD for pedagogical purposes, thus reframing aspects of ADHD as differences in cognitive style rather than deficits. This should be an important focus for future research.'   

The full guidelines can be accessed online at tinyurl.com/3zr2hm
 

Recognising missing children
Changes in levels of cleanliness and facial expression can interfere with people's ability to recognise a child's face. Vicki Gier at Mississippi Sate University and David Kreiner at the University of Central Missouri, who made the new finding, said their work could have implications for missing children campaigns.

Dozens of undergraduates viewed the faces of 60 children. Ten minutes later, after completing an irrelevant distraction task, the undergraduates viewed 60 more faces and had to say for each one whether it had appeared earlier or not (40 had, 20 were new).

Crucially, the students' accuracy and confidence were significantly affected by whether the cleanliness and emotional expression of a child's face was the same or different in the two presentations. If the same face was shown clean and happy, or dirty and miserable, on both presentations, accuracy was 79 per cent or 92 per cent, respectively. By contrast, faces that appeared first clean/happy and then dirty/miserable were only correctly recognised 11 per cent of the time, while faces that were first dirty/miserable and then clean/happy were correctly recognised just 26 per cent of the time.

The findings were replicated in a second experiment that increased the gap between the first and second presentation of the faces to up to 12 weeks. The effect of a change in appearance on confidence grew the longer the gap between presentations, while accuracy was affected by an appearance mismatch just the same regardless of the gap length. Campaigns to find missing children often use recent school photos in which the lost child appears happy and clean. The researchers warned their findings suggest that if an abducted child is in a dirty, bruised and unhappy state, the chances of him or her being recognised from their school photo are likely to be slim.

Writing in the journal Applied Cognitive Psychology (tinyurl.com/6hx4bn), Gier and Kreiner advised: '[P]erhaps parents should have both types of pictures (clean with positive affect and dirty with negative affect) available. If both types of facial appearance are shown to the public or possible eyewitnesses, based on the current study, the chances of recognising the child may increase.'

The long and short of it

Long-term psychodynamic psychotherapy (LTPP) for the treatment of complex and chronic mental disorders is more effective than a range of short-term interventions, including cognitive therapy. That's according to researchers in Germany who have conducted what they believe to be the first ever meta-analysis of studies in this area. The news comes against a backdrop of controversy concerning what some clinicians have claimed is the government's over focus on short-term, largely CBT-based, interventions as part of their Improving Access to Psychological Therapies programme.

'[L]ong-term psychotherapy is associated with higher direct costs than short-term psychotherapy,' Falk Leichsenring and Sven Rabung wrote in JAMA (tinyurl.com/54t4re). 'For this reason, it is important to know whether the benefits of LTPP exceed those of short-term treatments. In this meta-analysis, LTPP was significantly superior to shorter-term methods of psychotherapy with regard to overall outcome, target problems, and personality functioning.

'Leichsenring and Rabung identified 11 randomised controlled trials and 12 observational studies published since 1984 that met their strict methodological criteria – treatments had to have lasted at least a year, or for at least 50 sessions; to have involved identification of transference and resistance in line with Gunderson and Gabbard's definition of psychodynamic psychotherapy (tinyurl.com/5t7mkw); and reliable outcome measures had to have been used.

Overall, the 23 studies involved 1053 patients who received long-term psychodynamic psychotherapy and 257 patients who underwent comparison treatments. The patients were diagnosed with a range of chronic and complex conditions, including personality disorders and chronic depression.

Professor Tony Roth, Joint Course Director of the Doctorate in Clinical Psychology at UCL, told us he welcomed the study in the sense that he is keen to see psychodynamic approaches develop their evidence base (see his review of the evidence at tinyurl.com/5eaayb). In this regard, he said, a randomised controlled trial by Anthony Bateman and Peter Fonagy (tinyurl.com/5qhaqv) had been 'fantastically helpful'.

However, Roth said the current meta-analysis had set up a 'straw-man', adding:  'I don't think anyone would argue that if you've got a condition like borderline personality disorder, that you'd give short-term CBT. It's being set-up as if there's some oppositional issue – for most people, I don't think there is.'

Moreover, Roth pointed out that the meta-analysis actually identified very few studies that compared LTPP with shorter-term treatments (in most cases the comparison was with 'treatment as usual'), and not one compared LTPP against CBT. 'This study is a polemic really. It's not unhelpful polemic – it's reminding people that if you look around, there is an evidence base. What's less scientifically justifiable is when people want to over-egg the pudding. That's really what's been done here and it provokes unnecessary arguments.' 

 

Play on emotion
There's still time to catch the psychology-themed play On Emotion, showing at Soho Theatre in London until 20 December (tinyurl.com/5qejf4). The play is the result of a second collaboration between clinical neuropsychologist Paul Broks and director Mick Gordon – the first being On Ego, which explored the nature of personal identity.

'On Emotion is the first of a planned trilogy of plays mapping the hinterlands of emotion and magical thinking,' Broks told The Psychologist. 'We always start with a question, in this case: "Are we the puppets of our emotions?" We then interrogate the question applying the tools of theatre to contemporary psychological issues. In On Emotion a cognitive behavioural therapist becomes emotionally enmeshed with his puppet-maker client, exposing fissures in his relationship with his daughter and autistic son in the process. We use puppets as well as actors, poking and probing the mind's thin partition between reality and imagination.'
A trailer can be viewed online at tinyurl.com/6dqc8z

 

More choice, less trust?
Psychologists have warned that government plans to increase healthcare choice could have a detrimental effect on patient trust. Carolyn Tarrant of the University of Leicester, with Society member Andrew Colman and Tim Stokes, surveyed 243 patients about their last GP consultation, their anticipations for future care and the trust they have in their doctor.The strongest predictor of trust was 'interpersonal care', as indicated by a doctor's demonstration of patience and concern, followed by past experience of cooperation with a doctor, and expectation that the same GP would provide follow-up care.

Writing in the British Journal of General Practice where their article is in press, the researchers said their findings indicate that government plans to increase access and choice (via walk-in centres and polyclinics), at the expense of ongoing interpersonal continuity, could harm patient–doctor trust.

'Ways of minimising this in primary care could include encouraging GPs to ask patients to come back to see them again personally,' the researchers advised, 'and putting practice systems in place to ensure that this is made easy for the patient (for example, flexible appointment booking systems).' 

 

No hiding from cbt plans
Christian Jarrett reports from the joint British Academy/British Psychological Society Lecture held at the London School of Economics on 17 October 

This year's lecture was delivered by Professor David Clark – one of the country's leading experts on CBT, and clinical adviser to the government's Improving Access to Psychological Therapies (IAPTs) programme. As well as providing an eloquent survey of the rationale and evidence for a cognitive approach to treating anxiety disorders, Clark also took the opportunity to answer some of the criticisms frequently aimed at the evidence for cognitive-based therapies.

Some critics have argued, for example, that the evidence for the effectiveness of CBT derived from randomised controlled trials does not translate into the messiness of the real world. Responding to this charge, Clark described how his team trained local NHS staff in Northern Ireland to provide brief CBT to people suffering from PTSD in the wake of the Omagh terrorist bombing. There were no exclusion criteria or other restrictions that you'd expect in a controlled study and yet the improvements experienced by the patients were as significant as shown in research settings (tinyurl.com/58vxkt).

Another common criticism is that, during trials, therapists are more effective when delivering CBT, as opposed to a comparison treatment, simply because of their enthusiasm for CBT. Yet Clark pointed to a study that showed cognitive therapy (CT) was just as effective whether delivered by a Frankfurt based centre with a CBT bias or by a centre in Freiberg with an orientation towards interpersonal therapy. Yet another charge levelled at CBT is that outcomes in therapy have much more to do with the therapist delivering the treatment than the type of therapeutic approach they use. However, Clark said that in CBT/CT trials, the treatment effects related specifically to the therapist were modest, and were anyway mostly explained by levels of training.

What about the IAPTs plan to open up clinics to self-referrals? Clark said critics have claimed the doors will be knocked down by a rush of Guardian-reading folk from the chattering classes. But that wasn't the experience at the IAPTs trial site in Newham where patients who self-referred were more often from an ethnic minority background (than GP referrals), were equally severe, more chronic, but just as likely to recover.

All in all, Clark argued that the evidence for the cognitive-based treatment of anxiety disorders is overwhelming. Across all the RCTs testing CT as a treatment for social phobia, panic and PTSD, 82.5 per cent of patients have shown a significant recovery (4/5 have lost their diagnosis), with just a 2 per cent drop out rate.

It's just as well the evidence base is strong. Clark reminded the audience that when Health Secretary Alan Johnson announced the government's increased funding of psychological therapies last year, he claimed that 900,000 more people will be treated and that 450,000 will 'be cured'. As Clark observed, that's quite some expectation for psychologists and other therapists to meet. And there'll be no hiding the results of the IAPTs programme, as integral to the scheme is the idea that patient progress will be recorded on a weekly basis.

APA letter to Bush
Following the American Psychological Association (APA) vote to prohibit members from involvement in interrogations or other operational procedures in locations that violate international law or the US Constitution (see November news), APA President Alan Kazdin wrote to President Bush to inform him and his administration of the new policy and its implications. Kazdin's letter ended with this plea: '[T]he American Psychological Association strongly calls on  you and your administration to safeguard the physical and psychological welfare and human rights of individuals incarcerated by the US Government in such detention centers and to investigate their treatment to ensure that the highest ethical standards are being upheld.' Read the full letter at  tinyurl.com/6xfy8v