News and Media, November 2009

Beyond the post-antibiotic apocalypse

When the University of Nottingham opened its new Centre for Healthcare Associated Infections in 2007, one of its senior microbiologists, Professor Richard James, said of the rising threat of superbugs: 'Quite frankly, the impending crisis on the horizon can be called the "post-antibiotic apocalypse".' James was far from being the first or last to employ the metaphor of doom in his warnings about MRSA and other drug-resistant bacteria. However, according to a new analysis by James's colleague, psycholinguist Professor Brigitte Nerlich, whilst the invocation of apocalyptic metaphors can certainly grab attention, this discourse is ultimately counter-productive because the fear that is provoked stifles behavioural change among the public (http://bit.ly/aZp70).

Writing in the latest issue of the Public Understanding of Science, Nerlich, who is Professor of Language, Science and Society, said that this lesson has already been learned in relation to climate change, where campaigners have shifted emphasis away from doom-laden prediction to encouraging constructive behavioural change. 'Talk of a post-antibiotic apocalypse has its merits in galvanizing policy makers' and funding agencies' attention, but might be less well suited when trying to change ordinary people's and ordinary policy makers' behaviour,' she said.

Nerlich's analysis was based on a search for the words 'antibiotic apocalypse' among news outlets between 1995 and 2007. She found 17 articles in local and national newspapers, most of them published in 2007 after the opening of the new research centre at Nottingham University. Nerlich told us that she originally conducted this research two years ago and that the situation has since grown more complicated – for example, in relation to climate change, some have argued that the avoidance of alarmist discourse can mislead the public into thinking that there is uncertainty or a lack of consensus over the risks ahead. Also, the latest figures for England show that rates of MRSA are currently falling, although it's not entirely clear why. But Nerlich told us that she's still concerned that alarmist messages can lead to cynicism rather than behaviour change. 'I think it's important to provide people with ways of "behaving" that they can control, that they have control over. This is not the case if they think "we are all going to die!!!"'

What about the ongoing threat of swine flu? Has the UK government struck the appropriate balance between alarmism and constructive information? 'I first thought the government was getting it right by pressing home the message about hygiene, thereby giving people some control over their action, which is not so easy to achieve if you see the bacterial or viral "enemy" as overwhelming your defences so to speak,' Nerlich told us. 'However, there have been some panic-inducing alarmist headlines too which I think were counterproductive, such as that there would be 100,000 cases a day at the end of August.'
 

BMA book prizes
A book about cognitive behavioural therapy, co-authored by psychologist Dr Monica Ramirez Basco at the University of Texas with three colleagues, has won the British Medical Association's  2009 book prize in the mental health category. According to its publishers, Cognitive-Behaviour Therapy for Severe Mental Illness: An Illustrated Guide is a practical, 'how to' guide for using cognitive behaviour therapy to treat some of the most common and difficult to treat psychiatric conditions. Also highly commended by the BMA were several books by UK authors: What is Mental Disorder? by Chartered Psychologist Dr Derek Bolton; Persecutory Delusions: Assessment, Theory, Treatment co-authored by Chartered Psychologists Dr Daniel Freeman and Professor Philippa Garety, together with Professor Richard Bentall; and the second edition of Cognitive Neurorehabilitation, co-authored by Chartered Psychologist Professor Ian Robertson with two colleagues.

NHS innovator awards
Society member Brigitte Squire, of Cambridgeshire and Peterborough NHS Foundation Trust, has been nominated for the NHS Leadership Awards in the 'Innovator of Year' category. The award aims to highlight and reward NHS staff who have spearheaded new initiatives to improve clinical outcomes. 

Brigitte is described as 'a consultant clinical psychologist on a mission – to involve local people in a highly successful therapy for anti-social teenagers'. For the past eight years, she has driven the commissioning and progression of ISSP (Intensive Supervision and Surveillance Programme) and MST (Multisystemic Therapy) Standard within the Cambridgeshire Youth Offending Service.

Trust research over two years on teenagers in the intensive home-based family intervention programme revealed that a high percentage of young people who faced custody or care remained in their own homes; continued in education; and did not reoffend within two months of finishing MST.

The initial project proved so successful Brigitte encouraged the government to establish 10 further UK sites. A second generation of MST for Child Abuse and Neglect is about to be launched and piloted by the Trust and Cambridgeshire County Council with Brigitte at the helm in collaboration with the Medical University of South Carolina.

The awards ceremony takes place on 25 November in London.

 

Walking in circles
After hiking for half a day, the three students in the Blair Witch Project horror film end up back where they started, having apparently walked in a loop. Indeed, the idea that humans walk in circles when they're lost is a well-worn plot device and urban myth. Now, at last, scientists have tested whether this really happens.

Jan Souman at the Max Planck Institute for Biological Cybernetics and colleagues used GPS technology to plot the routes walked during several hours by six participants in a German forest and three participants in the Tunisian Sahara desert, after they were instructed to walk in a straight line. Souman's team found that, without the sun as a guide, humans walking in unfamiliar territory really do go round in circles (Current Biology: http://bit.ly/10A0fp).

Apart from two participants who walked in a forest on a sunny day, and the one participant who walked in the desert by day, rather than by night, the students all ended up walking in circles.

Previous explanations for why lost humans walk in circles have referred to a mismatch in leg strength or length. However, the researchers rejected these explanations – a test with blindfolded participants showed no systematic tendency to veer in one direction rather than the other, and no association between leg strengths and directional bias.

'The fact that participants often walked in circles instead of following a random zigzag path suggests that the veering from straight ahead was caused by a change in their subjective sense of straight ahead rather than by random noise in either the sensory input or the motor output,' the researchers said.

The fact that participants were able to use the sun to help them keep a true course suggests that humans, like honey bees and pigeons, are able to compensate for the sun's movement when judging their direction. 'Ironically, in the age of ubiquitous navigation systems in airplanes, cars, and even mobile phones, we are only beginning to understand how humans navigate through their environment, exploring uncharted terrain,' the researchers concluded.

IN BRIEF
The National Institute for Health and Clinical Excellence (NICE) has published new guidelines on promoting young people's social and emotional well-being. The advice is aimed at commissioners and providers of services to young people in secondary education, as well as professionals working in children's and youth services. Professor Mike Kelly, Public Health Excellence Director at NICE said: 'A range of factors affect how young people feel, including their individual family background and the community they live in, so different agencies need to work together to agree effective strategies.'
I The guidelines are available at http://guidance.nice.org.uk/PH20

Dr Christian Jarrett, staff journalist on The Psychologist and Research Digest editor, has won the Guild of Health Writers Writing Award for 'Best trade and specialist publication feature'. He was nominated for his article 'When therapy causes harm', in January 2008's Psychologist.

The press release also mentioned Christian's feature on the psychology of space exploration, and judge Justine Hancock said: 'I was particularly impressed by the work from the trade and specialist publications – it deserves a wider audience.'

A record number of entries were received from journalists, with over 300 items submitted by more than 100 health writers vying for prize money of £6000. 'Journalists are especially keen to win a Guild Writing Award because they are judged by fellow professionals and experts,' said Paul Dinsdale, chair of the Guild of Health Writers. The winners were announced at a presentation at Chandos House, London on 13 October.

Torture and interrogation
Lurking beneath the leaked reports of psychologists' involvement in Bush-era coercive interrogation techniques is the largely unchallenged notion that, notwithstanding its moral repugnance, psychologically informed torture can help with the extraction of important security information from prisoners. In a new paper, however, psychologist Shane O'Mara at Trinity College, Dublin reviews contemporary scientific evidence showing that the opposite is true – coercive interrogation is likely to be counter-productive (Trends in Cognitive Sciences: http://bit.ly/IkXA1).

The apparent aim of many of the coercive techniques – such as sleep deprivation and waterboarding (simulated drowning) – used previously at sites like Guantanamo Bay, is to raise stress levels in a detainee thereby, so the logic goes, increasing their willingness to disclose sought-after information. But O'Mara highlights an extensive literature showing that prolonged and extreme stress actually depresses memory functioning, and can even cause atrophy in brain regions crucial to memory, including the hippocampus and prefrontal cortex. 'Stress hormones provoke and control the "fight or flight" response…that, if overly prolonged, can result in compromised cognitive neurobiological function (and even tissue loss) in these brain regions,' he says.

For obvious reasons there have been few legitimate investigations that have directly tested the effects of torture on detainee behaviour and memory. However, O'Mara highlights an unusually pertinent paper published by Charles Morgan III and colleagues in 2006 in which they tested working memory and visuospatial performance in special operations personnel undergoing survival training. The researchers found that personnel tested during the captivity phase of training (involving food and sleep deprivation and stressful interrogation) were significantly impaired compared with their colleagues who were tested before or after the captivity training phase (Biological Psychiatry: http://bit.ly/1SXIg2). The clear implication is that prolonged torture is likely to impair the ability of terror detainees to recall information.

An oft-cited defence of the use of torture is the 'ticking time bomb' scenario in which extraction of information from an alleged terrorist has the potential to save innocent lives. O'Mara points out, however, that torture is as likely to elicit false as true information in such situations. In fact, he reasons, given that frontal lobe disorders are associated with confabulation, and given that prolonged stress is harmful to frontal lobe function, torture could actually increase the likelihood that false information will be elicited.

O'Mara also argues that our understanding of classical conditioning further suggests that torture will be ineffective. The behaviour that the detainee will come to associate with a cessation of torture is talking in general, not uttering the truth per se, unless the captor has some way to verify their proclamations. The detainee will learn that so long as they talk, the torture stops. Similarly, O'Mara surmises that most interrogators, unless they are psychopathic, will find administering torture stressful and will seek out reasons to stop. Provoking the prisoner to say anything, not necessarily the truth, so ending the torture, is therefore likely to become the torturing interrogators' subconscious, and ultimately futile, aim.

'[C]oercive interrogations involving extreme stress are unlikely to facilitate the release of veridical information from long-term memory, given our current cognitive neurobiological knowledge,' O'Mara concludes.

Packaging the message on smoking
Consumers tend to perceive so-called 'low tar', 'light' or 'mild' cigarettes as being less harmful to health than apparently stronger versions, even though the reality is that they are just as harmful. Consequently, numerous countries, including the UK, have banned the use of the terms 'light' and 'mild' on cigarette packaging. However, a new study by researchers in Canada suggests that these restrictions do not go far enough (Journal of Public Health: http://bit.ly/3f0CbB).

David Hammond and Carla Parkinson at the University of Waterloo presented hundreds of smokers and non-smokers with pairs of contrasting cigarette packets. Participants not only made the mistake of believing that packets described as 'light' and 'mild' carried fewer health risks, but also tended to rate packages with the terms 'smooth' and 'silver' as being safer and as delivering less tar. Packaging and symbols in a lighter colour and filter imagery were also associated with a reduced health risk. Non-smokers showed the same general patterns of response, but the results were most striking with smokers, presumably because they have an incentive to believe in the relative safety of some brands. 'In addition to broadening the list of prohibited words on packs, the removal of colour and other design elements – so-called "plain packaging" – may also be required to eliminate misleading information from packaging,' the researchers said.

Childhood body satisfaction
North American researchers have performed one of the first-ever investigations into body satisfaction among pre-adolescent children, finding that 7.3 per cent of 2159 Canadian girls aged 10 to 11, and 7.8 per cent of 2095 similarly aged Canadian boys, said that they 'never' or 'almost never' liked the way they looked.

Bryn Austin at the Children's Hospital in Boston and his colleagues found links between the children's body mass index (BMI) and their body satisfaction, which they said could prove useful in tackling rising childhood obesity levels. Prior longitudinal research has found poor body satisfaction at baseline to be associated with unhealthy eating and exercise behaviours years later. 'Body satisfaction is emerging as a potentially valuable leverage point for public health efforts
to address childhood overweight,' they said.

Gender differences emerged, with girls' poor body satisfaction rising linearly with BMI whereas boys were more likely to say they didn't like the way they looked if they were either overweight or thin. Among girls only, poorer body satisfaction was also associated with living in a rural area and with their mothers being less educated, although the reasons for these links are unknown.

Writing in the journal BMC Public Health (http://bit.ly/N1fGa), the researchers concluded: '[P]ublic health initiatives designed to improve body satisfaction along with promotion of healthy eating and active living in children as young as 10 and 11 years are appropriate and warranted.'

 

Analysis: Gender variant youth

As a 12-year-old British boy seeks to become the world's youngest gender reassignment patient (see http://bit.ly/1Qi6lB), Katrina Roen (University of Oslo) looks at the provision behind the headlines

Young people who express profound dissatisfaction with their birth sex have been making headlines. This is partly because of the sensational way that news media have often treated gender transition, but it is also because of recent shifts in psycho-medical practice facilitating some young people's transition.

Many transsexual adults have argued that their lives would have been more bearable if they could have accessed treatment earlier and, specifically, if they had been spared the experience of going through puberty and adolescence in what they felt to be the 'wrong' sex. Drawing on the DSM diagnostic classification 'gender identity disorder' (GID), psychologists and psychiatrists have developed interventions aiming, variously, to help children adapt to their birth sex and expected gender role or, more recently, to facilitate some children and adolescents to begin living in their preferred gender.

Cohen-Kettenis and colleagues in the Netherlands began a programme for facilitating early transition for a carefully selected group of young people. Early transition, in this context, means endocrinological interventions to suppress pubertal development. This is accompanied by careful psychological follow-up throughout adolescence with a view to supporting the young person concerned to participate fully in decisions about whether, after the age of 16, they might begin treatment with cross-sex hormones and then, after the age of 18, begin surgical gender reassignment. This clinical work is now at a stage where early outcomes are being reported and those outcomes look promising for the young people selected to take part. This work has received a great deal of attention worldwide, and early intervention has, reportedly, also become available at clinics in Boston, Toronto, Gent, Hamburg and Oslo.

There are clear indications that the approach being publicised by the Dutch clinicians is to be taken up more widely as endocrinological treatment guidelines cite puberty suppression as the appropriate course of action in cases judged to be psychologically suited to such intervention. This does not mean it is without dissenters. Many are concerned about the long-term implications of supporting adolescents to undergo such radical and irreversible changes. Many question the ethical foundation for this kind of intervention. There are ongoing criticisms of the construction and classification of GID, as well as criticisms that the diagnostic criteria are too loose to help distinguish between children who are likely to 'grow out of it' and children who go on to persist in their cross-gender wishes. As long as pubertal suppression and early transition are possible, no one can say what alternatives those selected for such treatment might have found if such a course of treatment had not been available. Some clinicians point out that young people who are severely unhappy with their sex of rearing engage in deliberate self-harm or attempt to kill themselves if not offered such possibilities for treatment.

According to reports from the Dutch clinical team, those who are selected for pubertal suppression have already entered puberty and have subsequently displayed increased gender dysphoria. Further, they are selected on the grounds of showing evidence of gender dysphoria from early childhood, not having other psychiatric diagnoses that could interfere with diagnosis or treatment, having adequate psychosocial support and typically strong family support, and being able to demonstrate an understanding of the effects and consequences of the treatment.

While psychologists play a key role in supporting young gender variant people, the actual role they play varies a great deal from place to place. Some clinical teams put a great deal of emphasis on psychological interventions aimed at helping the young person to accept and live with their birth sex (e.g. the three-stage intervention described by Kenneth Zucker). Some clinical teams emphasise the importance of not foreclosing questions of identity and allowing young people to explore gender fluidity (e.g. see Wren, 2000; Di Ceglie, 2008). Some clinical teams are working within a legal and medical framework where it is possible to facilitate selected young people through gender transition in the course of adolescence. In this case, psychologists play an important part in assessment and psychological support throughout the process, although the 'treatment' is medically oriented.

Cohen-Kettenis, P.T. et al. (2008). The treatment of adolescent transsexuals: Changing insights. Journal of Sexual Medicine, 5(8), 1892–1897.
Di Ceglie, D. (2008). Working at the edge. Neuropsychiatrie de l'Enfance et de l'Adolescence, 56(6), 403.
Wren, B. (2000). Early physical intervention for young people with atypical gender identity development. Clinical Child Psychology and Psychiatry, 5, 220–231.

A Gender identity development service

We work in the UK service based at the Tavistock Centre in London, offering assessment and intervention for children and adolescents experiencing difficulties with their gender identity development. In addition, we work with children with a transgendered parent. The multidisciplinary team includes clinical psychologists, psychiatrists, social workers and child psychotherapists, working in association with two consultant paediatric and adolescent endocrinologists at UCLH who provide regular adolescent liaison clinics.

Our assessments consider the holistic context of such a presentation, including the history of the gender dysphoria, the family history and young person's developmental and medical history, the attitudes of the family and school, and sources of stress and supports. We particularly focus on areas of gender identity such as the young person's identity statements, cross-dressing, toy and role-play, peer relations, mannerisms and voice, anatomic dysphoria, and rough-and-tumble play (Zucker & Bradley, 1995). We also include risk assessments around any self-harm and possible suicidal ideation and, with the family's permission, liaise with any local services and the school.

The service operates a network model of care, and team members regularly convene and attend local meetings to discuss the needs of the young person in relation to their gender identity development, and agree roles with all involved professionals.

Following our assessment, we might recommend family and/or individual work to monitor the gender dysphoria and address associated difficulties, such as low mood and distress and problems with bullying and stigma in the family, local community or school. We also work closely with schools and local services in order to reduce shame and secrecy, consider the boundaries between what is public and private with regard to information sharing and to manage risk and promote support and coping. Our interventions involve a staged model of care, which include:

Stage 1: Following assessment, further therapeutic exploration of the nature of gender identity. In adolescents, reversible physical interventions are considered if their gender identity disorder (GID) persists and shows a high level of consistency.

Stage 2: Includes wholly reversible intervention to produce a state of biological neutrality – known as hormone-blocking treatment. This occurs alongside continued psychological exploration, support and physical monitoring by a consultant paediatric endocrinologist.I Stage 3: Is considered if the GID persists during Stage 2. Includes partially reversible interventions, e.g. the administration of cross-sex hormone that masculinises or feminises the body.

Stage 4: Includes irreversible interventions, such as surgical procedures. This is not considered before the age of 18, and so the Gender Identity Development Service would facilitate a smooth transition to the adult Gender Identity Service who are able to provide these interventions. Transfer to adult services would usually happen prior to the introduction of cross-sex hormones.

The figures usually quoted suggest that for individuals presenting with GID prior to adolescence about 80 per cent do not persist and find a solution other than gender transition. The most common outcome in this group is homosexuality and bisexuality. Conversely for those who present to the service in adolescence the figures are reversed and about 80 per cent pursue physical sex re-assignment. The recent newspaper articles assume that allowing the young person to live in a role of their perceived identity necessarily leads to gender reassignment. Our experience shows that some young people who lived in role from the age of nine or ten changed during their pubertal development.
There is currently much debate around the timing of physical interventions. In a number of countries in Europe and America the hormone blocker is being offered in earlier stages of puberty. If the young person decides not to pursue physical gender reassignment the blocker is stopped, and their own sex hormones resume. But the debate revolves around the reversibility of this intervention – physical and also psychological, in terms of the possible influence of sex hormones on brain and identity development.

Polly Carmichael and Sarah Davidson

Zucker, K.J. & Bradley, S.J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York: Plenum Press.
 

OUT NOW IN BPS JOURNALS
Collecting data on depression and anxiety from a prospective cohort of nearly 4000 patients referred to the UK Improving Access to Psychological Therapies demonstration site in Doncaster, David A. Richards (University of Exeter) and Rupert Suckling (Doncaster Primary Care Trust) found that the combination of psychological treatment, low-intensity telephony-based delivery, and collaborative care organisational systems delivered results similar to those achieved in clinical trials. The authors used 'smart IT systems' (see www.pc-mis.co.uk) to collect an almost complete set of routine outcome measures 'to assure the effectiveness and quality of our clinical service'. 'Combining stepped care, collaborative care, evidence-based interventions, and a low-intensity workforce, is apparently worthwhile', they conclude, 'but requires organisational persistence and clinical courage.' (BJCP)

Think seven-year-old children should no longer believe in fantastical beings such as the Candy Witch? Elizabeth A. Boerger (University of Mississippi) and colleagues introduced children to the Candy Witch through classroom activities and, in one condition, a staged 'visit'. They in fact found that on each of the five first-year assessments and the one-year follow-up, older children were as likely to describe the Candy Witch as real as were the younger children. The authors conclude that 'it may be a mistake to think of credulity and skepticism towards fantastical entities as opposite ends of developmental trajectory'. (BJDP)

How do you gauge your success at work? There are objective measures, such as income and hierarchical position, other-referent perspectives (for example how successful you feel compared to a friend), and self-referent considerations, such as job satisfaction. In a prospective longitudinal study spanning 10 years, Andrea Abele and Daniel Spurk (University of Erlangen-Nuremberg, Germany) found that objective success influenced both the initial level and the growth of other-referent subjective success,