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psychologist vol 24 no 12
A healthy contribution A special feature on 25 years of health psychology in the UK
Incorporating Psychologist Appointments ÂŁ5 or free to members of The British Psychological Society
letters 870 news 878 big picture centre careers 930
are you sitting comfortably? 904 interview with Frank Bond 910 new voices: digitalised early years 938 looking back: Charles Spearman 942
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The British Psychological Society Contact The British Psychological Society St Andrews House 48 Princess Road East Leicester LE1 7DR tel 0116 254 9568 fax 0116 227 1314
Welcome to The Psychologist, the monthly publication of The British Psychological
Society. It provides a forum for communication, discussion and controversy among all members of the Society, and aims to fulfil the main object of the Royal Charter, ‘to promote the advancement and diffusion of a knowledge of psychology pure and applied’. It is supported by www.thepsychologist.org.uk, where you can view this month’s issue, search the archive, listen, debate, contribute, subscribe, advertise, and more.
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Associate Editors Articles Vaughan Bell, Kate Cavanagh, Harriet Gross, Marc Jones, Rebecca Knibb, Charlie Lewis, Wendy Morgan, Tom Stafford, Miles Thomas, Monica Whitty, Jill Wilkinson, Barry Winter Conferences Sarah Haywood, Alana James International Nigel Foreman, Asifa Majid Interviews Nigel Hunt, Lance Workman History of Psychology Julie Perks
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vol 24 no 12
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psychologist vol 24 no 12
letters 870 the most important problems in neuroscience; science and art; the NHS; psychology in France; standards of proficiency; hypnosis; psychodynamic therapy in New York; organisational effectiveness; and more news and digest 878 more on the Stapel scientific fraud case; schizophrenia commission; Royal Society archive; Steven Pinker talks; career progression for women; Francesca Happé on autism; nuggets from the Society’s Research Digest; and more media 888 Owen Hughes sees opportunities for psychologists to become more involved in public affairs in Wales
A healthy contribution Marie Johnston, John Weinman and Angel Chater introduce a special feature in which leading figures showcase highlights from 25 years of health psychology in the UK
Are you sitting comfortably? Christina Richards on reader injunctions as an addition to the methodologies of the human and natural sciences Acting with compassion Abi Millar talks to Frank Bond about acceptance and commitment therapy
book reviews 912 trauma; psychology and catholicism; educational psychology; gerontology; and cluttering society 918 President’s column; 200th Research Digest; child sex abuse working party; revised authorship credit guidance; consultation responses; BPS Journals news; and more
THE ISSUE In 1986, when a BPS Special Group in Health Psychology was inaugurated, few people knew that health psychologists existed, let alone what they did. Twenty-five years later, the British Psychological Society’s Division of Health Psychology (DHP) has over 1600 members, working as practitioners and academics in a range of settings. Their work includes helping people to live more healthily and to manage illness, often alongside other healthcare professionals. Increasingly, health psychologists in research are called upon to provide the evidence base for public health initiatives. As part of the DHP’s silver jubilee celebrations, we present a series of short articles from some of the leading lights of the field, showcasing significant contributions. We also meet health psychologists in ‘Careers’ and ‘One on one’. As we sign off at the end of another year of The Psychologist and approach our own silver jubilee volume, may I thank all those who have contributed their time and expertise. Do get in touch if you would like to feature in 2012, on email@example.com. Dr Jon Sutton
careers and psychologist appointments
we talk to a newly qualified health psychologist and a more established one; featured job; how to advertise; and all the latest vacancies new voices
digitalised early years: where next? Natalia Kucirkova with the latest in our series for budding writers looking back
the life and influence of Charles Edward Spearman, with Sandy Lovie and Pat Lovie one on one
…with Roger Ingham
read discuss contribute at www.thepsychologist.org.uk
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Where comedy and brains collide Zarinah Agnew (UCL Institute of Cognitive Neuroscience) performs at London’s Bright Club. E-mail ‘Big picture’ ideas to firstname.lastname@example.org. How does one attempt to make people laugh while talking about functional brain anatomy? That was the challenge facing Zarinah Agnew as she prepared for a spot at London’s Bright Club, a night run by UCL head of public engagement Steve Cross, where scientists come to talk on a theme whilst attempting to make people laugh. ‘Having battled through the initial “I can’t believe I’ve agreed to do this” paralysis, I decided that my priority was to make sure that people went home having learnt at least something about how the brain is organised. Trying to think of something that people could relate to, I focused on body representations and somatotopy in somatosensory cortex. The problem was the jargon, neuroanatomical terms automatically make you sound like a lecturer; try saying dorsolateral post-central gyrus without sending someone to sleep! So I fashioned a brain hat out of an old Trilby and
a brain jelly mould, and built my talk around the idea that the genitals are, somewhat surprisingly, hidden away in the medial surface next to the feet and toes. A pink-faced neuroscientist talking about willies has got to be worth a fiver! So I had the bones of a script, although perhaps not much remaining dignity… ‘The day of the show was honestly one of the most nerve racking I have had. In the evening the event sold out, as it does every month now, and once up on stage I was on a roll. I had a fantastic time, it went down pretty well and a few people came up to me after and said nice things. I learnt a lot about how to talk about science in a more casual way which has been great for other public engagement things that I have done since. I’d highly recommend giving Bright Club a go, both as a speaker and as a punter.’ I For more information, see www.brightclub.org
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Red flag for psychology research? An interim report by Tilburg University into the fraudulent research activities of social psychologist Diederik Stapel has found the extent of his malpractice to be on a ‘shocking scale’, with ‘several dozen’ studies implicated over a period of more than a decade. The investigating committee, chaired by Professor Willem Levelt, a psycholinguist, published their initial findings early in November. A full list of affected studies will be published later with the final report. No other individuals were found to be culpable, but the interim report says the affair has profound ramifications for the reputation and practice of psychology. It has already generated a great deal of mainstream media interest, with ‘Fraud Case Seen as a Red Flag for Psychology Research’ being the chosen headline of the New York Times (tinyurl.com/67kx9j2). According to the Levelt Committee, Stapel’s ‘cunning, simple system’ at Tilburg and earlier at Groningen University was to form intense one-onone relationships with students and other researchers, to discuss hypotheses and methodologies with them at length, to prepare together the necessary materials, but to do all the apparent research collection himself at local
schools. In many instances, the research never took place and the data was entirely fabricated. Other times it was massaged. Only then was it passed to students or colleagues for inspection, analysis and write-up. ‘This conduct is deplorable,’ the report says. The doctoral work of five students at Tilburg and seven at Groningen, some of whom did no data collection of their own, is tainted as a consequence. Another strategy was for Stapel to produce old, unpublished data-sets – also fabricated or doctored – that he claimed were just perfect for answering colleagues’ and students’ new research questions. Concerns had been raised about Stapel’s practices in previous years by three young researchers and by two senior colleagues. But it was only this August when three more young researchers reported their misgivings that a full investigation was launched. ‘The Committee concludes that the six young whistle blowers showed more courage, vigilance and inquisitiveness than incumbent full professors,’ the report says. How did Stapel avoid detection for so long? The Committee finds that much of this has to do with personality and
status – charismatic Stapel enjoyed a ‘virtually unassailable position’ in his department, used his ‘prestige, reputation and influence’, formed close friendships with many of his colleagues and students, and was widely judged to have ‘phenomenal research skills’.
However, that anomalies in his data and unrealistically perfect results were allowed to persist has exposed ‘the flawed performance of academic criticism, which is the cornerstone of science,’ the report says. Stapel’s research, on topics such as how power dehumanises us, and the effect of mirrors on prejudice, was published in some of science’s most
SCHIZOPHRENIA COMMISSION One hundred years after Swiss psychiatrist Eugene Bleuler coined the term schizophrenia, the mental health charity Rethink Mental Illness has launched a ‘Schizophrenia Commission’ chaired by Robin Murray, Professor of Psychiatry at the Institute of Psychiatry in London. The Commission’s aims are to: assess the current care provided for people with schizophrenia in England; review the evidence base for treatment and care; gauge the socio-economic impact of the illness; assess public attitudes; and identify priority actions to improve the lives of people with schizophrenia. The Commission plans to gather evidence between now and April 2012. Their website (www.schizophreniacommission.org.uk) features forms for people to contribute, and public hearings are also due to be held across England, although details for these had not yet been finalised as we went to press. There are 12 commissioners, including Chartered Clinical Psychologist Dr Alison Brabban, who works as a consultant at the Early Intervention in Psychosis service in Tees, Esk and Wear Valleys
NHS Foundation Trust, and as an honorary lecturer at Durham University. Brabban helped develop the schizophrenia guidelines for the National Institute for Health and Clinical Excellence and she’s currently working as National Adviser for Severe Mental Illness for Improving Access to Psychological Therapies. Writing on the Commission website, Brabban said the Rethink initiative ‘provides an ideal opportunity to challenge outdated beliefs about schizophrenia and highlight inadequacies in current UK service provision. I hope that it leads to a significant shift in public and professional understanding of this poorly understood condition and ultimately improves the lives of those affected by symptoms of schizophrenia and by the diagnostic label itself.’ Other commissioners include Terry Bowyer who has a diagnosis of paranoid schizophrenia; Martin Knapp, Professor of Social Policy at LSE and KCL; and Jeremy Laurence, Health Editor at The Independent. The Commission will culminate in a report due for publication in July 2012. CJ
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prestigious journals. Yet clues as to Stapel’s activities went unnoticed: the lack of detail provided in his papers about research participants and about the feasibility of sometimes complex experiments being conducted in schools. ‘Apparently neither the reviewers nor the editorial teams of journals delved into aspects of this kind,’ the report says. Central to the longevity of Stapel’s fraud was that he was able to keep his fabricated raw data from so many people for many years without raising undue alarm. The report suggests this was possible because of ‘a lamentable… culture in social psychology and psychology research for everyone to keep their own data and not make them available to a public archive’. This is an issue that has been raised before: a 2006 paper by Jelte Wicherts and colleagues in American Psychologist found that just 27 per cent of psychology study authors they contacted were willing to share their data for re-analysis (see News, January 2007 tinyurl.com/cg7b972). In another paper published this November, Wicherts and her team found that psychologists were less likely to share their data if the likelihood of errors being found was high or the strength of evidence was weak (PLoS One tinyurl.com/bo49uc6). More worrying still, a study led by Leslie John in press at Psychological Science finds that ‘questionable practices may constitute
the prevailing research norm’ based on an anonymous survey of 2000 psychologists. The Levelt Committee’s interim report (available from tinyurl.com/tilburgstapel) concludes with recommendations to prevent fraud on such a scale from occurring again at Tilburg University and more widely, including: having PhD students complete a short integrity course; establishing a Confidential Counsellor For Academic Integrity; creating rules to protect whistle-blowers; and requiring journals to provide details on where and how data are collected. ‘Far more than is customary in psychology research practice, research replication must be made part of the basic instruments of the discipline. Research data that underlie psychology publications must be held on file for at least five years after publication, and be made available on request to other scientific practitioners.’ In a formal response to the Committee findings, Stapel said he’d read the report with ‘a sense of dismay and shame’. He claimed he’d not been motivated by self-interest and regretted the suffering he’d caused. ‘Unfortunately my present state does not permit me to assess this report completely for any factual accuracies,’ he said. In a separate statement to the press, he said (translated from Dutch) that he’d ‘just wanted to make something more beautiful than it is’. CJ
Opening a window to a fascinating history The Royal Society has made all articles over 70-years-old in its extensive journal archive free to access, permanently. Its archive contains around 60,000 historical scientific papers, with the first edition of Philosophical Transactions of the Royal Society – the world’s first peer-reviewed journal – published in 1665. BPS Fellow Professor Uta Frith, Chair of the Royal Society library committee, said: ‘The release of these papers opens up a fascinating window on the history of scientific progress over the last few centuries and will be of interest to anybody who wants to understand how science has evolved since the days of the Royal Society’s foundation.’
Let loose on the archive for two minutes, your reporter quickly located such gems as ‘The Localisation of Function in the Brain’ by Scottish psychologist David Ferrier (1874) and ‘Two extracts of the Journal of the Phil. Soc. of Oxford; one containing a paper, Communicated March 31, 1685, by the Reverend Dr Wallis … concerning the Strength of Memory when Applied with due Attention.’ . Wallis concludes ‘that a reasonable good Memory, fixt with good attention, is capable of being charged, with more than a man would at first imagine’. CJ
I The archive is at: http://royalsocietypublishing.org/search
read discuss contribute at www.thepsychologist.org.uk
BETTER CONNECTED The ubiquity of smart phones and internet social networking means that we’re more interconnected than ever before. How can we best exploit this connectivity for the public good – for example, in a search and rescue mission? To find out, the Defense Advanced Research Projects Agency (DARPA) in the United States held a competition at the end of 2009. Forty thousand dollars was on offer for the first team to find 10 large red balloons across the country in undisclosed locations. The winners – a team from the Media Laboratory at MIT – have now published the strategy that led to them recruiting almost 4400 individuals and locating all 10 balloons in just under nine hours (Science; tinyurl.com/cwq8y7a). No other team located all the balloons. Alex ‘Sandy’ Pentland, Director of the Human Dynamics Laboratory in the MIT Media Lab, and his team-mates, used what they call a ‘recursive incentive mechanism’. They promised to award $2000 from the cash prize to individuals who located a balloon and, in ever decreasing amounts, to also reward the person who recruited that finder ($1000), and the person who recruited the person who recruited the recruiter ($500), and so on. This approach led to a sustained level of interest on Twitter and a deep and densely branched network of collaborators, as compared with the other teams. ‘The mechanism’s success can be attributed to its ability to provide incentives for individuals to both report on found balloon locations while simultaneously participating in the dissemination of information about the cause,’ Pentland and his colleagues said. Strategies adopted by other teams included relying on altruism and exploiting existing social networks. For example, the runners-up at the Georgia Institute of Technology offered to donate all proceeds to the American Red Cross. The Geocacher team, meanwhile, drew on the geocaching community, which is a sport that uses navigational techniques to find objects. The MIT researchers said their recursive incentive mechanism could be ‘applied in very different contexts, such as social mobilisation to fight world hunger, in games of cooperation and prediction, and for marketing campaigns’. CJ I Visit http://stories.twitter.com to read about ways that Twitter is being mobilised for social good
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Is ours the age of peace? Endless news of war, riots and terrorism may make it difficult to believe, but human violence has declined for millennia and continues to do so. An Englishman today is dramatically less likely to meet a grisly end by murder, as compared with his medieval ancestors (the chance today is 1/35th the chance back then). Worldwide, there are fewer than ever inter-state wars. Consider the Western European powers, which have enjoyed a ‘Long Peace’ for the last half century. Before 1945, by contrast, they engaged in an average of two wars per year for 600 years! In a ‘rights revolution’, lynching, hate crimes against ethnic minorities and homosexuals, rape, domestic violence, uxoricide and matricide, child abuse, sex abuse, and hunting have all reduced in the USA and many other countries through the last century. These facts were part of an enfilade of evidence delivered by Harvard psychologist Steven Pinker ‘in conversation’ with Matt Ridley at the Royal Geographical Society in London in November; an event organised by Intelligence Squared. Pinker was promoting his latest and longest book The Better Angels of Our Nature: The Decline of Violence in History and Its Causes, in
which he documents and seeks to explain our increasingly pacifistic existence. Pinker organises the fall of violence into six historical phases and processes: the Pacification Process; the Civilising Process; the Humanitarian Revolution; the Long Peace; the New Peace; and the Rights Revolutions. The Pacification Process refers to the fall in risk of violent death that began around 5000 years ago as anarchic, nomadic life was replaced by state rule. Pinker drew on analyses of the injuries sustained by prehistoric skeletons (‘call it CSI Palaeolithic’, he said) and ethnographic statistics compiled from observations of modern-day huntergatherer and hunter-horticulturalist societies. In spite of the two World Wars, these data suggest that violent deaths were dramatically less prevalent (as a proportion of the population) in the 20th century than in prehistoric times. Hobbes may have been speculating, Pinker said, but this new evidence shows he was correct to describe life without government as ‘solitary, poor, nasty, brutish and short’. The Civilising Process is Pinker’s term for the rise and expansion of states, including the ‘Paxes’ (Romana, Islamica,
Hispanica…); the nationalisation of criminal justice; and the growing infrastructure of commerce and trade. Kings and overlords had an interest in their people not killing each other, Pinker said, much like a farmer would rather his livestock lived peaceably. The circumstances evolved in which it was more advantageous to do business with another person than to kill them. Zerosum plunder (someone always loses) gave way to positive sum trade (everyone gains). But as tribal living was replaced by states and autocracies, the risk of violence from one’s peers was replaced by the threat of harm from the authorities. Anarchy gave way to tyranny. Pinker listed some of the barbaric punishments doled out by early authorities, including ‘breaking
PINKER IN THE HOT-SEAT After his talk, Pinker took questions from Matt Ridley (author of The Rational Optimist) and from the audience. Ridley asked a question that was on the minds of many listeners: How is it that if human nature is innate – as Pinker argued with great conviction and scholarship in The Blank Slate – our behaviour and attitudes have changed so profoundly? Pinker retorted that the nature of our combinatorial thought, our rule-based language and cognition, allows a fixed human nature to explore infinite ideas. ‘There is no contradiction in saying that the human mind, operating according to fixed rules, will explore ideas and will eventually wander upon those that have made us all better off,’ he said Questions from the audience touched on issues relating to: abortion rates; the sanctioning of torture by liberal states; the problem of suppressed aggression; the extraction of profit as a form of non-
physical violence; and the effects of violent games and films. Pinker answered that fetuses are not sentient beings and that legal abortion has not drifted towards infanticide. In fact, he said, ‘the valuation of children has reached insane levels’. State-sanctioned torture is deplorable, Pinker acknowledged, but he said in terms of scale, it was insignificant compared to the barbarity of the past. It was perpetrated for a purpose and it was conducted clandestinely precisely because it’s become taboo. Suppressed aggression isn’t a problem, Pinker explained, because there’s no truth to a ‘hydraulic theory’ of aggression. In fact, he said, the research shows that people with more willpower live happier lives. Pinker said that the notion of profit as violence, and similar questions, showed just
how far we’d come in looking for signs of violence, since real violence had become so rare. ‘I came from a family of retailers,’ Pinker said. ‘My grandfather made ties and sold them at a profit. I don’t consider that violence.’ In fact, Pinker pointed out, countries that encourage a profit motive are generally more peaceable. The notion that violent games and films might be making our children violent is a red-herring, Pinker said, since the rise in these media has occurred precisely during the decades that violence has declined so profoundly. In fact, Pinker speculated, since self-control generalises, it’s plausible that playing video games (which often require self-control and discipline) could have reallife benefits. ‘A lot of sacred cows are being slaughtered tonight,’ Matt Ridley quipped – an observation that summed up the evening rather well.
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on the wheel, burning at the stake, sawing in half, and impalement’. He also outlined some of the 222 crimes in 18th-century England that were punishable by death: ‘poaching, counterfeiting, robbing a rabbit warren, being in the company of gypsies, “strong evidence of malice in a child aged 7–14 years of age”.’ Such practices and others, including witch-hunts and slavery, have fortunately declined worldwide in a relatively narrow window of time. What caused this humanitarian revolution? Pinker doesn’t think it has to do with rising affluence – the fall in violence precedes and exceeds rising economic wealth. Instead he pointed to rising literacy and cosmopolitanism during the Enlightenment. As book production and literacy grew, people learned about other cultures, they learned about other people’s perspectives and their empathy grew. The Long Peace describes the time since the end of World War II during which there have been no wars between major powers. Pinker presented data showing how over the last half century the number of wars has reduced, their average length has fallen, and so too, since the 1950s, has their average deadliness. The New Peace is the spread of this pacification process beyond the Western world. For a time, there was an increase in civil wars as inter-state wars declined. But civil wars are now also falling in number and deaths from civil wars haven’t outnumbered the lives saved through there being fewer inter-state wars. Membership of international organisations like the UN and the work of peacekeepers has increased and become more effective during this period. War deaths in the 21st century are at an unprecedentedly low level. ‘The dream of 1960s folk singers is starting to come true,’ Pinker said, ‘the world is almost putting an end to war.’
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FUNDING NEWS The BBSRC is encouraging high-quality research applications to its Welfare of Managed Animals strategic priority area, to develop knowledge of the responses of animals to: their environmental conditions; the consequences of human intervention, genetic selection and management for the normal function of animals; the incidence and alleviation of disease, pain and mental disorders. Measures include welfare, housing, husbandry and environmental impacts, relevant behaviour, cognition and perception and the impact of early life challenges. Deadline 11 January 2012. I tinyurl.com/628eoxy The National Institute for Health Research has the following calls for proposals: 11/93 Quitting smoking in pregnancy and following childbirth 11/111 Interventions for psychosexual dysfunction after treatment for gynaecological malignancy 11/112 Psychological treatment for fatigue in patients with inflammatory arthritis 11/109 An interventional package for parents of excessively crying infants Closing date is 9 February 2012. I tinyurl.com/cvb9t8s The National Research Funding Luxembourg has AFR PhD Grant and AFR Postdoctoral Grants available to support study in Luxembourg or abroad. There are no thematic limitations and are open to all researchers. The interest of the project in the context of Luxembourg R&D is taken into consideration. The closing date for applications for PhD grants is 28 March 2012 and for the Postdoc grants 7 March 2012. I tinyurl.com/8xl3bba The Netherlands Organisation for Scientific Research is offering Veni grants for researchers who are within three years of having completed their doctorates. Funding of up to €250,000 is available. Deadline is 5 January 2011. Researchers from abroad can apply. Vici grants are also available, for senior researchers with their own innovative research and who can act as coaches for young researchers: next deadline is 29 March 2012. Women researchers are particularly encouraged. I tinyurl.com/832zzd2
Violence in perspective – Paolo Uccello’s Niccolò da Tolentino at the Battle of San Romano, c.1438–1440
All this leads to the big question: Why? Why has violence declined so consistently for so long? Unsurprisingly, to anyone who knows Pinker’s other works, he doesn’t think human nature has changed. He cited contemporary evidence on murderous fantasies. Fifteen per cent of women and a third of men frequently think about killing people they don’t like, rising to 60 per cent and three quarters, respectively, admitting to occasional homicidal thoughts. ‘The rest of them are lying,’ Pinker said. The answer, Pinker believes, lies with changing historical circumstances allowing the ‘better angels of our nature’ (a phrase coined by Abraham Lincoln) to triumph over our aggressive instincts. This includes Hobbes’ notion of the Leviathan – a state with a monopoly on justice, which removes the need for moralistic violence (i.e. revenge) and the need to establish a violent reputation as a form of deterrent. The increase in ‘gentle commerce’ driven by technological advances has made other people more valuable alive than dead. And on a wave of travel, journalism, literature, history and fiction, increased cosmopolitanism has created an ‘Expanding Circle’ (a phrase coined by philosopher Peter Singer). That is, our instinct is to care for the well-being of a close-knit circle of our family and friends, but this circle has now widened (in many cases to include other races and species). Finally, Pinker proposed the idea of an ‘escalator of reason’: education has driven up abstract intelligence and allowed us to see violence as a problem to be solved, rather than as a contest to be won. Our moral instincts for tribal loyalty and purity have given way to belief in universal rights and fairness. So, what are the implications of the decline in violence? Pinker said they are profound and he called for an empirical rather than a moralistic mindset towards violence. We should go from asking what we’re doing wrong, to what we’re doing right, he said. Pinker ended with a defence and celebration of modernity. While many people recognise the benefits of better health care and other aspects of contemporary life, he said they often lament the decline of local communities and the rise in muggings and terrorism. But Pinker’s data show that rising individualism and cosmopolitanism have actually coincided with less crime and violence. ‘I believe this calls for a rehabilitation of the ideal of modernity and progress and is cause for gratitude for the institutions of civilisation and enlightenment that have made [the decline in violence] possible,’ he said. CJ
For more, see www.bps.org.uk/funds Funding bodies should e-mail news to Elizabeth Beech on email@example.com for possible inclusion
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Career progression for women in psychology Psychology is becoming an increasingly ‘an absence of career planning and where of chance to make a genuine, if female-dominated discipline at sixth form that can get you’. ‘I’ve largely followed my incremental contribution. and undergraduate level, but the balance heart not my head’, Bruce admitted, ‘and On travelling to Lancaster to give shifts at each step of the career hierarchy. amazing things can follow.’ a seminar in the early 80s, Bruce was Conceived over margaritas in Florida, this Bruce’s story began with a gap year picked up by Andy Young who, it one-day workshop held at the University job at Proctor and Gamble in Newcastle, transpired, had grown up in the next of Nottingham offered a rare and which she got because her dad worked street and had travelled on the same train welcome opportunity to hear the personal there. Programming computers to help in as Bruce as a child. So began a fruitful stories of some top women in collaboration, in the psychology. What obstacles increasingly influential had they encountered in their field of face recognition. career progression, and how Bruce showed a photo had they overcome them? from the first ESRC Dr Nicola Pitchford workshop on face (University of Nottingham), recognition in 1984: who organised the day with a phenomenal line-up, Dr Kate Cain (University of including four women Lancaster), opened who are now professors. proceedings by admitting she Bruce’s talk was full had felt personally vulnerable of sage advice. If you can, in putting the event on. move at least every 10 Would she be judged, or years; if there’s something pigeonholed? However, it was that isn’t working, change clear throughout that this was it; grow your own no militant rally of wronged network; say ‘no’ to ‘more women: a lot of the ‘top tips of the same’; disseminate for success’ would be just as broadly; be a good valuable for men, and ‘academic citizen’ (do Pitchford asserted at the outset book and journal reviews, that she didn’t feel that she serve on committees, etc.) had been discriminated against – you will be asked to do in any way. Instead, it may be more, but ultimately you their own personality traits will be valued. In what which prevent some women was to become a recurring going forward. theme, Bruce spoke Supporting this, Pitchford fondly of several key role pointed to a recent Harvard models and mentors in Business Review article by Jill her life. Flynn and colleagues on ‘four Next up, Professor ways women stunt their Christine Horrocks careers unintentionally’: ‘being (Manchester Metropolitan overly modest’, ‘not asking’, University, and Chair of ‘blending in’ and ‘remaining the British Psychological The one-day workshop on career progression for women in silent’. The report suggested Society’s Psychology of psychology was held at the Trent Building, University of that career progression is not Women Section) described her Nottingham about adding job skills but journey from a demanding job about changing everyday with a marketing agency to thinking and behaviours. The majority the invention of new soap powders may director of a research centre. Horrocks of high-performing women don’t need seem a long way from psychology, but said that along the way she had to make major changes: it’s about the when Bruce found herself doing ‘so badly’ experienced difficult relationships that tweaks. in the first year of chemistry at had been gendered, but not out and out The first speaker supported this view, Cambridge she was drawn to the human discrimination. Dare to stand up, she highlighting the role of serendipity and information processing and computer advised, to negotiate and avoid being personal chemistry in her own career. The metaphors that were beginning to forced down routes that are not right ever-wise and generous Professor Vicki dominate psychology. ‘HIP was hip and for you. Horrocks focused on the job Bruce (Newcastle University) spoke as a IT was it’, Bruce said. Psychology was application and promotion process, ‘planaholic’ who nevertheless confesses to a young discipline, and there was plenty warning the audience against ‘being
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lacklustre’. Use adjectives and action progression if you stay. This echoed a verbs in your application, and take the point made earlier by Professor Horrocks, opportunity offered by a performance who pointed to figures that suggest male review to really give a good account of academics advance more in their careers yourself and make sure everyone knows via these ‘retention payments’. ‘Playing by your good ideas. the rules is not always the best way,’ Horrocks is in the midst of a move Horrocks said; although Professor Bruce from the University of Bradford, and she advised caution in the use of this tactic spoke candidly on how she has always and said that the important point is using thought herself more likely to regret the opportunity to create a conversation. missed opportunities than something she Professor Kumari spoke of the has done. That has applied to her choices importance of finding out the ‘new as a working mother in general: ‘Yes, I’ve and emerging – what’s likely to become suffered the “tyranny of the school gates”, important in the next five to 10 years, I’ve wondered if I’m exchanging my and what skills do you need to get a head daughter’s GCSEs for my own position… start?’ The day’s final speaker, Professor but they’re thriving, independent kids Claire O’Malley (University of now. It’s so easy to concentrate on what Nottingham), advised a similarly longwe might lose and not what we might term view on the funding you need. gain.’ Nurture your team, she advised: plan, As someone who admitted to being and build a track record. For O’Malley, ‘quite forceful’ to get where she is, it was this has led to her involvement in the noteworthy that Horrocks still £13 million Horizon refused to underestimate the Digital Economy importance of good working Research Centre, relations. ‘Those who and a passion for “As Vicki Bruce had demonstrate emotional interdisciplinary commented, ‘What’s competencies – self-awareness, work. ‘Look outside good for women is good social awareness, selfyour own tribes and for men too!’” management, relationship territories’, she management – advance more advised. ‘Spend time in in their careers’, she said. other good institutions, if ‘I used to think winning was everything possible outside the UK. Most advances when I was younger. Now I know when are made when we push at boundaries.’ to retreat and regroup.’ This had a O’Malley said that what you do gendered element: ‘Our identities as senior matters – esteem indicators such as female academics are very vulnerable’, conference keynotes, service for funding Horrocks said. ‘I am not willing to be cast councils and professional societies can as bossy, as problematic.’ count when it comes to promotion. But After lunch, Professor Veena Kumari how you appear to others matters as well, (Institute of Psychiatry) continued the and O’Malley advised the audience to sage advice with an account of her own consider their image, brand, website and efforts to secure an academic foothold overall social network presence. after starting out in India. ‘Hearing of the It was interesting to see the day wisdom and humanity shown by former ending with plenty of advice that was just giants of the field like Jeffrey Gray and as applicable to men as it was to women. Hans Eysenck made me hanker for a As Vicki Bruce had commented, ‘What’s golden age of mentoring in psychology, good for women is good for men too!’ before I quickly realised that our field Other speakers had acknowledged that remains replete with fantastic role models change – for women in psychology, in and mentors, both male and female.’ science and in society – has happened Kumari receiving such support was not fast. Many places are trying hard to luck: as she said, ‘Don’t just take the first recruit more women, ‘balanced values’ postdoc that comes your way. Investigate are the order of the day and supporting potential supervisors and their women into senior positions is becoming supervision history.’ a more prominent agenda in government. It was also fascinating to hear the role Yet we are all so busy doing the day job in Kumari’s career played by a position that it’s rare to have the opportunity to she never took. External job offers can share stories, and to benefit from the offer an opportunity to open a discussion considerable nous of those who have with your employers about your made it to the top. Let’s hope that the organisers of this inspirational day are successful in their own ambition, Share your own views, by submitting a of making this a regular event which letter on firstname.lastname@example.org tours the country and reaches out beyond academia to other sectors. JS
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DEMENTIA AWARENESS The NHS has launched a £2 million campaign to raise awareness of dementia, highlighting the importance of early detection and signs to look out for. The campaign, supported by a leaflet and TV and radio adverts (tinyurl.com/347megq), claims that six out of ten people with dementia go undiagnosed. The NHS has also recently published the results of a survey of primary care trust memory services. The number of people using these services was found to have increased from 605 in 2008/9 to 951 in 2010/11 (tinyurl.com/695albt).
LOST CHILDHOOD Over 200 experts and campaigners, including many psychologists, signed a letter to The Telegraph in September lamenting the ‘erosion’ of childhood in Britain. ‘It is everyone’s responsibility to challenge policymaking and cultural developments that entice children into growing up too quickly – and to protect their right to be healthy and joyful natural learners,’ the letter says (see tinyurl.com/6lewlds).
OBESITY STRATEGY The Department of Health’s new obesity strategy for England (tinyurl.com/6ja4q3b) claims that adults consume on average around 10 per cent more calories than they need. ‘We all have a role to play, from businesses to local authorities, but as individuals we all need to take responsibility,’ said Professor Dame Sally Davies, Chief Medical Officer.
SUPER RECOGNISERS The idea that a minority of the population may be extremely skilled at face recognition – so-called ‘super recognisers’ - was first proposed in a study of four individuals published in 2009. Now a team of psychologists led by Ashok Jansari at the University of East London are conducting a large-scale ‘live’ experiment at the Science Museum – find out more at www.superrecognizers.com.
KEY QUESTIONS The Brain Mind Forum, a lobbying organisation which lists Professors Colin Blakemore, John Stein and Baroness Professor Susan Greenfield as members of its editorial board, has identified 21 key questions for brain science and society to address in the 21st century. I See www.brainmindforum.org and also p.870
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Will we ever understand autism? ‘When will we understand autism Take development seriously. That’s condition. For example, the idea of ‘mind spectrum disorders?’ asked Professor Happé’s third signpost, which is based blindness’ (a problem understanding and Francesca Happé (Institute of Psychiatry) on research showing, for example, the representing other people’s mental states) in her Rosalind Franklin Award Lecture downstream effects of mindblindness. helps explain the social and at the Royal Society in October. Happé – Children with ASD and low IQ often communications difficulties, but not the a previous winner of the BPS Spearman excel at the Inspection Time task – a repetitive or rigid behaviours. On the medal – didn’t give a date, but she warned speeded-reaction measure, performance other hand, ‘weak coherence’ (Uta Frith’s that we have some distance to go. on which usually correlates with IQ. term) – the ‘eye for detail’ exhibited by We know that the Perhaps this shows, Happé neurodevelopmental condition reasoned, that their IQ is isn’t caused by ‘refrigerator low because they’ve been mothers’, she said, and that unable to ‘cash in’ on their there’s something different in learning potential. After all, the brain and genes. But she much learning is socially admitted we don’t know which mediated, and people with part of the brain (nearly all autism will often struggle areas have been implicated at to learn from others. A one time) and we don’t know developmental perspective how the relevant genes exert also means investigating their effects. There are no autism through adulthood. miracle cures, she said, but It’s shocking, Happé said, ‘expert enlightened education that ‘we know practically with understanding really nothing about autism in works – these are miracles old age.’ Worth reading in happening every day in our that respect, Happé said, special schools and units is a recent interview in around the country’. The Atlantic with Donald To help us solve the Triplett, the first person mystery of autism, Happé diagnosed with autism, offered five ‘signposts’. The first now aged 77 (see is that we should stop seeing tinyurl.com/43gj4w8). the condition as a monolith We need a better and acknowledge its understanding of ASD heterogeneity. Quoting Lorna in women – the fourth Wing (a psychiatrist with a signpost. It’s well known daughter with autism), she that autism is far more said that ‘once you’ve met one prevalent in men than person with autism, you’ve met women (by approximately one person with autism’. The four to one), but Happé triad of behavioural described some manifestations that provide unpublished findings that the basis for a diagnosis – suggest this could be because Professor Francesca Happé gave the Rosalind Franklin Award the social impairments, of our diagnostic practices. communication difficulties and Lecture at the Royal Society in October Using the TEDS sample, repetitive, rigid behaviours and Happé and her collaborators interests – only correlate with have compared 12-year-old each other modestly. Happé and people with autism – is likely to underly boys and girls with and without an her colleagues made that discovery by the repetitive behaviours and autism diagnosis, all of whom scored studying thousands of twin pairs born communication problems, but not the highly in autistic traits. Among girls, from 1994 to 1996 (the Twins Early social deficits. but not boys, the undiagnosed showed Development Study/TEDS). Tests on Happé’s second signpost is for us to dramatically higher IQ and far fewer the same sample also revealed that recognise that autism isn’t just about behavioural problems than the diagnosed. each aspect of the triad is influenced by deficits but represents a different It’s as if, to get a diagnosis, girls need to a distinct set of genes, and that there are cognitive style. People with autism excel have low IQ and more problems. Either individuals who have difficulties with in certain tasks that play to their strength that, or females simply tend to cope one aspect of the autism triad but not the of being focused on details, such as the better with their autistic traits – only others. ‘Autism fractionates,’ Happé said. embedded figure task in which the further research with adults will reveal This variation applies at the cognitive ‘gestalt’ must be ignored. Up to 30 per the answer. level too. Various neurocognitive cent of people with ASD have a special Happé concluded with a plea. explanations for autism have been put talent and their eye for detail may be Tracking down the causes of autism is what ‘gives them a kickstart’ whether that forward, Happé said, but none of them not enough, she said. We need cognitive be in music, art or memory, Happé said. are able to explain all the features of the theories, not least to inform other areas of
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research, such as what tasks to conduct once you have a person with autism in a brain scanner. So you know which family members have relevant traits. So you can design appropriate animal models. And so that we can help shape the world to be less puzzling to people with autism. Consider something as mundane as the design of signs. Happé
described a man with autism who stops dead in the road when the pedestrian signal goes red; a woman with autism who doesn’t wear skirts and therefore won’t enter female toilets that carry the traditional sign of a woman in a skirt. ‘In order to make the world useful, helpful and accessible for people with autism, we have to understand how they
see the world, not merely how their brains are configured or how their DNA looks,’ she said. CJ
I The Rosalind Franklin Award promotes women in science and recognises the work of an individual who has made an outstanding contribution. Watch Francesca Happé’s lecture at royalsociety.org/royalsociety.tv
Stories of psychology Stories of psychology’s past were shared at a celebratory But for younger people, he said he hoped Tajfel would be symposium organised by the BPS History of Psychology Centre a profound and inspiring historical figure. in October. The event at the Wellcome Collection, co-convened Dr Peter Hegarty (University of Surrey) gave a talk on the by Dr Alan Collins (University of Lancaster) and Dr Geoff Bunn sex researcher Alfred Kinsey, demonstrating how his more (Manchester Metropolitan University), marked the transfer of the famous work was informed by his earlier extensive taxonomic Society’s extensive historical archive to its new home at the investigation of gall wasps. Historian Dr Rhodri Hayward (Queen Wellcome Library in London. Mary, University of London) argued that the story of psychology Professor Richard Bentall (University of Liverpool) opened is not easily told through archives, its history having played out with a sombre assessment of the progress made in mental health in other domains. Hayward gave the example of ‘busman’s care relative to the revolution that’s occurred stomach’ in the 1930s, when bus drivers in physical health. As well as documenting complained about gastric symptoms, which the fortunes of behaviourist and Rogerian they said were caused by the stress of having approaches to therapy, Bentall described how to up their speed from 7.5 to 10.5 mph and 20th-century psychiatry was characterised by new-fangled hazards like zebra crossings. an impetuous application of new Their case was bolstered by a study developments into tragically ineffectual comparing their health with that of tram treatments, including the removal of teeth drivers. It’s an important moment in British and internal organs, insulin shock therapy history, Hayward said, as it marks ‘when we and frontal lobotomies. shift from workers’ rights being based in According to Bentall, huge challenges appeal to tradition or a universal set of remain. He claimed today’s psychiatric staff political rights to an appeal to psychological are not interested in patients as people. knowledge’. ‘When I say this to psychiatrists, they get Professor Sally Shuttleworth (Oxford very annoyed,’ he admitted. And he said that University) rounded off the symposium a major reappraisal was under way into the with an overview of the rise of efficacy of pharmacotherapies. ‘Kindness developmental psychology in the 19th and probably remains the most effective early 20th centuries. She argued that serious Dr Rhodri Hayward spoke about therapeutic tool we have available,’ he attention was first paid to the inner workings ‘busman’s stomach’ in the 1930s concluded, ‘but we don’t actually teach that of the child’s mind, not by psychologists like very well.’ Piaget, but in literature. The emergence of An influential figure whose papers are in the Society’s archive books by Dickens and the Brontës, among others, that is social psychologist Henri Tajfel. Next up, Professor Michael represented the child’s mind from the inside, had a huge Billig (Loughborough University), one of Tajfel’s PhD students, influence on child psychology and psychiatry at the time, provided a personal tribute to the man. ‘He bullied me to do a Shuttleworth said. To take one example, the ‘forcing academy’ in PhD,’ Billig said. ‘And I’m so profoundly grateful. He knew more Dickens 1848 book Dombey and Son led straight to a discussion about me and what I wanted to do than I knew about myself.’ in the psychological literature about the effects of education on Billig described how Tajfel, a Polish émigré who lost most the developing nervous system. of his family in the Second World War, wanted to use psychology The actual start of child psychology, Shuttleworth traces to to understand genocide and to change the world for the better. Darwin’s 1877 A Biographical Sketch of An Infant. Others soon Tajfel was dismissive of psychologists who only pursued abstract followed his lead and ‘a flurry’ of similar observational work was work, Billig recalled, and was also highly critical of Stanley published in Mind and other outlets. Fin de siècle Britain saw Milgram – he believed that you only had to read history to the emergence of several child psychology societies including, uncover the findings that Milgram was publishing. in 1893, the British Child Study Association and in 1896 the Billig said that Tajfel saw experiments as having metaphorical Childhood Society – the fascinating records of these societies and rhetorical value. He didn’t aim to uncover universal and others are held in the British Psychological Society archives. processes (and was critical of biological psychology for seeking Wine flowed and speeches were made at a reception after to do so) but wanted to understand how psychological thinking the seminar, hosted jointly with the Wellcome Library, where takes place in historical contexts. ‘He was such a great attendees were given the chance to see another of the archive’s experimentalist,’ Billig said, ‘because he understood the value of treasures: an original print of Wallis Simpson’s hand, made and historical knowledge for psychology.’ Billig said he wouldn’t be interpreted by Charlotte Wolff, taken from her 1936 Studies in visiting Tajfel’s archive, because for him Tajfel is a part of his life. Handreading. CJ
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Epic adventures Journeys into the world’s last wildernesses often prompt poetic reflection about the triumph of the human spirit. Such expeditions also attract the scientific eye of psychologists, who are interested in studying what happens to the human psyche and social relationships under extreme conditions. A new paper by Gloria Leon and her colleagues has gauged the psychological profile and experiences of two polar explorers – given the pseudonyms Bill (age 32) and Andrew (age 35) – who in 2009 became the first team from the USA to reach the North Pole without outside support. Personality profiles of the men prior to the challenge were largely as you might expect – they were both high-scorers in leadership and extraversion and low scorers on harmavoidance. Andrew also scored low in conscientiousness, which may be unexpected given the preparation required for an expedition, and had a tendency to become highly engrossed in his own thoughts and surroundings. The challenge was gruelling, with each man hauling a 300pound sled in temperatures as low as minus 60 degrees Fahrenheit. For the last 66 hours of their trip, the pair had just one hour of sleep for every 16 hours on the move. Throughout the 55 days, the men filled out weekly questionnaires about their coping methods, their relationship, and mood. They were also interviewed a few weeks after their return and again six months later. For the duration of the expedition both men scored high on positive mood and low on negative mood. They survived and succeeded by supporting each other and communicating effectively, and by adopting flexible coping strategies, including positive In the September issue of reinterpretation of challenges Environment and Behaviour and use of relaxation and meditation. Their relationship hit a low point around day 40 when Andrew aired his grievances about planning for the trip, but they worked through this constructively. ‘We were basically one persona when it came to goal orientation,’ Bill said. ‘We had a high degree of self-care for each other and ourselves,’ he explained. Andrew said: ‘Anytime we expressed ourselves it brought us closer... We talked more about recognising differences and embracing our similarities and we celebrated that it was really fun.’ Based on this, the researchers said it was important not to overgeneralise the effects of gender on group processes. ‘By focusing their interactions on supporting each other, competition between them was minimised or essentially eliminated,’ they said. The men were affected somewhat differently on their return, with Andrew ‘Seeing the same patterns emerge of the past which I did not want there anymore’. However, both men experienced a greater sense of unity with nature and a reduction in their need for conventional achievement, in terms of social status and prestige.
Are we really blind to internet banners? In the September/October issue of Applied Cognitive Psychology It’s a line of research that Google doesn’t want you to know about. Many studies suggest people have a habit of simply ignoring web banners on internet sites – a phenomenon known as banner blindness. The evidence for this ad avoidance is based largely on tests of people’s explicit memory of ads after they’ve browsed a site. Of course that doesn’t mean that the participants hadn’t looked at the ads, nor does it mean that the ads hadn’t lodged their message subconsciously. Now Guillaume Hervet and his team have attempted to address these points in an eyetracking study. Thirty-two participants read eight webpages about choosing a digital camera. On the third, fourth, seventh and eighth pages, a Google-style rectangular text ad (180 x 150 pixels) was embedded in the right-hand side of the editorial content. The second ad was different from the first, and then the same two ads appeared on the seventh and eighth pages, respectively. Also, half the participants were exposed to ads that were congruent with the camera topic of the webpages; the other half to incongruent ads. All advertised brands were fictitious. The results may be of some consolation to Google and their advertisers. Eighty-two per cent of the participants did actually look at one or more of the ads. Or put another way: of the 128 ad exposures, 37 per cent were looked at once or more. Ad congruency made no difference to the looking stats. Had the ad
content made a lasting impression? To test this, after the browsing phase, the participants attempted to read the same ads presented in varying degrees of blurry degradation. Their performance was compared to a new group of control participants who hadn’t done the earlier web browsing. If performance was superior among the participants who'd earlier been exposed to the ads, this would suggest they had a lasting memory of the ad content. In fact, performance was only superior for webbrowsing participants who’d earlier been exposed to ads in a congruent context. So, congruency didn’t affect the likelihood of the participants looking at the ads, but it seems it did affect their memory for the ads. ‘One possibility’, the researchers said, ‘is that the presentation of contextual information – such as the editorial content during a website visit – acts as a prime and activates the participants’ related knowledge in memory.’ Another aspect to the results is how the participants’ behaviour changed over the course of the web browsing. They looked less at the second and fourth ads, which appeared on pages that had been preceded by a page with an ad on it in the same location – the participants seemed to have learned to ignore that area. The lessons for web advertisers are clear: Don’t advertise on every page, vary ad location, and make sure the ad topic is congruent with the website content.
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Steve Jobs' gift to cognitive science
When humans play dead
In PLoS ONE
In the September issue of Biological Psychology
The ubiquity of iPhones, iPads and other miniature computers promises to revolutionise research in cognitive science, helping to overcome the discipline’s over-dependence on testing Western, educated participants in lab settings. That’s according to a team of psychologists who say the devices allow experimentation on an unprecedented scale. ‘The use of smartphones allows us to dramatically increase the amount of data collected without sacrificing precision,’ say Stephane Dufau and his colleagues, ‘and thus has the potential to uncover laws of mind that have previously been hidden in the noise of smallscale experiments.’ In contrast, they argue that conducting cognitive psychology experiments over the internet has not been a great success because of problems obtaining the necessary precision of timing. To illustrate their point, the researchers developed an iPhone/iPad App that replicates the classic ‘lexical decision task’ used by psychologists to study the sub-second mental processes involved in reading. Participants are presented with a series of letter strings and simply have to indicate as quickly as possible whether each one is a real word or not. The App was launched as a seven-language international effort in December 2010, and after just four months data had been collected from over 4000 participants. By way of comparison, it took more than three years to collect a similar
amount of data via conventional means. It will be easy to add further languages to the App, including non-Roman alphabet languages like Chinese. The free Science XL App presents the task to users as a test of word power and offers a choice of task lengths from two to six minutes. Once enrolled, participants use Yes/No buttons on the touch-screen display to indicate whether the letter strings that appear are real words or not. Each participant’s performance stats are presented at the end and they are given the option of forwarding their results to the researchers via e-mail. Extreme negative outliers were excluded from further analysis. There is the obvious issue of participants choosing to only send in favourable performance data. However, this doesn’t spoil the ability to examine the effect of different factors on performance. For example, the data collected via the App matched many known features of lexical decision time data: reaction times were quicker for more common words and mean times correlated with data collected in psychology labs. Using smartphones ‘has wide multidisciplinary applications in areas as diverse as economics, social and affective neuroscience, linguistics, and experimental philosophy,’ say Dufau and his collaborators. ‘Finally it becomes possible to reliably collect culturally diverse data on a vast scale, permitting direct tests of the universality of cognitive theories.’
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When a rabbit or other animal is trapped by a predator, the ‘fight or flight response’ will kick in. If that fails, a last-ditch defence mechanism is to go completely immobile, to play dead. Researchers in Brazil now say that in times of grave danger, this same automatic last resort is also exhibited by humans and is experienced as a terrifying feeling of being ‘locked-in’. Volchan and her colleagues recruited 33 trauma survivors (15 women), including 18 with a diagnosis of post-traumatic stress disorder (PTSD). They were asked to describe their ordeals in minute detail, and these accounts were transformed into a 60-second audio narrative presented by a male voice in the secondperson, present tense (e.g. ‘You are walking home and a man appears...’). Each participant's account was played back to them over headphones while they stood on a platform that records body sway. Their heart
rate was also monitored and afterwards they were asked questions about how they felt as they listened to the recording. Participants who reported a strong sense of being paralysed, frozen, unable to move or scream, tended to show less body sway, higher heart rate and less heart rate variability. This was true across both PTSD and non-PTSD patients, but it was the PTSD patients who were more likely to report feelings of paralysis whilst listening to the recording of their ordeal. ‘We succeeded in experimentally inducing tonic immobility in humans and recording its biological correlates,’ the researchers said. ‘Tonic immobility still remains largely unrecognized in humans… essential steps to alleviate entrapment symptoms, guilt and prejudice in the aftermath of tonic immobility are the recognition of tonic immobility and dissemination of this knowledge to the public.’
The material in this section is taken from the Society’s Research Digest blog at www.researchdigest.org.uk/blog, and is written by its editor Dr Christian Jarrett. Visit the blog for full coverage including references and links, additional current reports, an archive, comment and more. Subscribe by RSS or e-mail at www.researchdigest.org.uk/blog Become a fan at www.facebook.com/researchdigest Follow the Digest editor at www.twitter.com/researchdigest
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A healthy contribution
Marie Johnston, John Weinman and Angel Chater introduce a special feature to mark the founding of the Society’s Health Psychology Section 25 years ago
The Health Psychology Section of the British Psychological Society was inaugurated in December 1986. This special feature celebrates progress during those 25 years. An introduction by the founding chair, a founding committee member, and a current committee member is followed by a series of selections from some of the top figures in the field, as they choose a significant contribution to the discipline and the health of the nation.
What progress has been made in health psychology research, application and training? How has health psychology developed in the UK?
BPS Division of Health Psychology http://dhp.bps.org.uk Weinman, J., Johnston, M. & Molloy, G. (Eds.) (2007). Health psychology [Fourvolume set]. London: Sage. French, D., Vedhara, K, Kapteim, A.A. & Weinman, J. (Eds.) (2010). Health psychology (2nd edn). Oxford: BPS Blackwell.
What were the main reasons for its emergence as a distinct discipline in the 1980s?
Abraham, C.S. & Michie, S (2008). A taxonomy of behaviour change techniques used in interventions. Health Psychology , 27(3), 379–387. Ader, R. & Cohen, N. (1975). Behaviorally conditioned immunosuppression Psychosomatic Medicine, 37, 333–340. Doll, R., Peto, R., Boreham, J. & Sutherland, I. (2004). Mortality in relation to smoking. British Medical Journal, 328, 1519.
he emergence of health psychology (HP) as a distinct disciplinary area can be traced back to an American Psychological Association (APA) task force that met in 1973 (your first author was a corresponding member) to examine ways in which psychologists could contribute to the maintenance of physical health, the management of people with physical health problems and healthcare delivery. This led to the development of the APA Division of Health Psychology and Joseph Matarazzo’s 1980 presidential address on a ‘new health psychology’. The term ‘health psychology’ was first used in print by Stone et al. (1979), and the first journal (Health Psychology) appeared in 1982, followed by Psychology & Health in 1987 and the British Journal of Health Psychology in 1996. Looking back, there are many possible reasons for the emergence of HP: I Epidemiological evidence of the importance of behavioural factors health: such as the link between reduced smoking behaviour and rates of lung cancer (Doll et al., 2004), as well as the early results from the Alameda County Study (Housman & Dorman, 2005) underlining the potential for behaviour change as a method of enhancing health. I Evidence for health service effectiveness and efficiency: which became necessary and led to the measurement of a wide range of outcomes, with many being in a psychological domain. I Medical schools: that added behavioural sciences to the curriculum,
Fishbein, M. & Ajzen, I. (1975). Belief, attitude, intention, and behavior. Reading, MA: Addison-Wesley. Housman, J. & Dorman, S. (2005). The Alameda County Study. American Journal of Health Education, 36(5), 302–308. Hrisos, S., Eccles, M.P., Francis, J.J. et al. (2009). Are there valid proxy measures of clinical behaviour? Implementation Science, 4, 37.
often taught by psychologists. The publication of projects from medical students created a body of health psychology research. Communication skills training: began to develop for health professionals, originally with the aim of improving patient satisfaction and adherence. Primary care: became a focus for clinical psychology where the line between physical and mental health was more blurred and interventions based on psychological theory were applied. Behaviour modification and therapy: had demonstrated that theoretically based methods could change behaviours and be clinically effective (D.W. Johnston, 1991). Psychophysiology and psychoneuroimmunology (PNI) emerged: coming from an understanding of how psychological and physiological factors interact, particularly in the cardiovascular (Steptoe, 2007) and immune (Ader & Cohen, 1975) systems. Social psychologists: frequently used the health domain for testing theoretical propositions, such as the relations between beliefs, attitudes and behaviour (e.g. Fishbein & Azjen, 1975), resulting in a body of evidence and theory development in factors that can predict health behaviour. AIDS/HIV: was diagnosed in the early 1980s, leading to increasing interest in behaviour change and to the funding of behavioural research.
However, the immediate prompt to action in the UK was the British Psychological Society’s reconsideration of the role of the Medical Section. In a letter to the BPS Bulletin (the precursor of The Psychologist) in August 1985, Marie Johnston and John Weinman argued there was a need for a Health Psychology Section. Following consultation with the BPS, the Section was inaugurated at the BPS London Conference in December 1986 with Marie Johnston as chair.
Johnston, D.W. (1991). Behavioural medicine: The application of behaviour therapy to physical health. Behavioural Psychotherapy, 19, 100–108. Johnston, M. (1994). Health psychology: Current trends. The Psychologist, 7, 114–118. Johnston, M. & Vogele, C. (1993). What benefits can psychological preparation for surgery achieve?
Annals of Behavioral Medicine, 15, 245–256. Johnston, M., Wright, S. & Weinman, J. (1995). Measures in health psychology: A user’s portfolio. Windsor: NFERNelson. Marteau, T.M. & Johnston, M. (1987). Health psychology: The danger of neglecting psychological models. Bulletin of the British Psychological Society, 40, 81–84
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The first Section conference was in a discipline would require more focus Sussex in 1987 and there has been an on psychological principles in framing annual conference ever since. In 1993 the research questions, using theory and BPS Annual Conference invited a review designing methods of investigation. of ‘Current Trends in Health Psychology’. In the early 1990s, symposia at HP This paper (M. Johnston, 1994) proposed and European Health Psychology Society a definition of HP as ‘the study of (EHPS) conferences focused on social psychological and behavioural processes cognition. There is now much agreement in health, illness and healthcare’, to offer about core models, with theories such as a simple definition and reemphasise the scientific nature of HP. The paper reviewed six developments representing health (PNI; social cognition models), illness (disease vs. behaviour outcomes; effective interventions) and health care (preparation for surgery; screening for disease). In 1993 the Health Psychology Section became a Special Group and in 1997 health psychology in the UK was given Divisional status, recognising the distinct training needs and professional practice AIDS/HIV was diagnosed in the early 1980s, leading of health psychologists in the to increasing interest in behaviour change and to the areas of research, consultancy, funding of behavioural research teaching and training. This allowed members to obtain chartered status within the BPS, the theory of planned behaviour (TPB) and which regulated training and practice in the health action process approach (HAPA) HP until 2010 when the regulation of explaining behaviour, the commonsense professional standards and qualifications self-regulation model (CS-SRM) explaining was taken over by statutory registration the response to illness or health with the Health Professions Council. conditions, and the social cognitive theory (SCT), implementation intentions and Research control theory often used to assist So what progress have we seen in the last behaviour change. 25 years? In terms of research, this can be gathered under various headings. Methods There have been substantial Theory and models developments in research methods, In 1987, the year after the start of the HP specifically in measurement, design and section, a paper for the BPS Bulletin by statistics. Methods have become more Marie Johnston and Theresa Marteau on transparent and replicable, for example ‘the danger of neglecting psychological in developing theory-based measures, and models’ argued that health psychologists there is more reporting of early qualitative tended to frame questions and offer work and theories such as the TPB and theory and methods within a medical SCT, which have clearly published framework. It argued that progress as methods of measuring key variables.
Matarazzo, J.D. (1980). Behavioral health and behavioral medicine: Frontiers for a new health psychology. American Psychologist, 35, 807–818. Michie, S., Abraham, C., Whittington, C. et al. (2009). Effective techniques in healthy eating and physical activity interventions: A meta-regression. Health Psychology, 28, 690–701. Michie, S., Rumsey, N., Fussell, A. et al. (2007). Improving health: Changing
behaviour. NHS Health Trainer Handbook. London: Department of Health. Morrison, V. & Bennett, P. (2006). An introduction to health psychology. Edinburgh: Pearson. Ogden, J. (2007). Health psychology (4th edn). Maidenhead: Open University Press. Steptoe, A. (2007). Psychophysiological contributions to behavioral medicine
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There is also much agreement that useful evidence can be obtained by both quantitative and qualitative methods. Measurement Since the 1980s there has been less emphasis on measuring deficit or negative states such as anxiety, and increasing emphasis on measuring behaviour and theoretical constructs postulated to influence behaviour. The emergence of new psychometrically sound measures (M. Johnston et al., 1995) led to a greater consensus. However, there has been disappointing progress in establishing the validity of many measures. Behavioural and psychological measures are increasingly important as health outcomes. There is a growing emphasis on finding objective measures of behaviour, including routinely collected data, such as: the use of electronic monitoring to assess medication adherence; prescribing data to reflect the behaviour of clinicians: the use of exercise facilities to reflect exercising behaviours; and the use of accelerometers to assess activity levels. However, these methods have additional problems, including the difficulty in gaining a true match to the behaviour and measuring the full and appropriate range of behaviours (Hrisos et al., 2009). Physiological and psychophysiological measures continue to be important but tend to be restricted in use to groups specialising in their use. Research designs and statistical methods There has been a shift from the much criticised, cross-sectional study of the relationship between two self-report measures to more prospective studies with objective assessments and the development and evaluation of theorybased interventions. Prospective designs offer some progress in assessing causal questions as the hypothesised cause precedes the outcome, but clearly experimental designs are necessary to
and psychosomatics. In J.T. Cacioppo, L.G. Tassinary & G. Bernston (Eds.). The handbook of psychophysiology (3rd edn). New York: Cambridge University Press. Stone, G.C., Adler, N.E. & Cohen, F. (1979). Health psychology: A handbook: Theories, applications, and challenges of a psychological approach to the health care system. San Francisco: Jossey-Bass.
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test causality, and these continue to be rare. Process evaluations are increasingly used to assess whether an intervention has changed the targeted theoretical construct with resulting effects on the outcome variable.
and to date there have been 10 ‘Health Psychologists in Training’ on this programme. However, it is not yet clear how the training and professional roles for health psychologists will be funded in future. The numbers of postgraduates undertaking PhDs in HP has risen very impressively over the past 25 years, Intervention and many of these also completed Health psychologists are Stage 1 and 2 HP training, thus increasingly involved in developing qualifying as BPS-accredited health In 1985 Marie Johnston and John Weinman argued interventions to change behaviour psychologists. for the establishment of a Health Psychology Section with a view to improving health On the basis of teaching and outcomes, and this competency has research, a number of university been added to the professional departments have developed strong HP training in HP. Interventions derive from contracted to focus on the competencies research groups that have been influential two main traditions: persuasive messages needed by staff to deliver behaviour in establishing the international based on social psychology, and cognitive change programmes, and the work recognition of UK HP research. behavioural methods more related to resulted in the Health Behaviour Change clinical psychology. While many Competency Framework (2010; see Conclusions tinyurl.com/628slol). Health psychologists successful interventions have been We have been mightily impressed by are also often asked to respond to NICE published in HP and medical journals, what has been achieved in HP from small and government consultations both evidence synthesis has made it clearer beginnings. HP research has developed directly and through the DHP Specialist than ever that we need shared transparent a large body of evidence with increasing Knowledge List as part of DHP Publicity methods for describing interventions in sophistication of theory and methods and Liaison. Health psychologists also order to have a cumulative body of used. Intervention development and serve on research and health committees evidence that can be applied in practice evaluation is now on a more secure including MRC, NIHR, NICE, Scottish (e.g. M. Johnston & Vogele, 1993; Michie footing and looks promising for the Government Chief Scientist Committee. et al., 2009). The work done by Abraham future. We are increasingly called on and Michie (2008) and colleagues in as consultants or collaborators on developing reliable methods of describing Teaching and training programmes and projects where behaviour change techniques using a Health psychology is taught in behaviour may influence health, illness or taxonomy approach is a significant undergraduate psychology courses, health care. Thus there continues to be a advance, but indicates the amount of in postgraduate master’s and doctoral need for well-trained health psychologists work to be done. The future evidence courses and in training other health and for other health professionals to have base for interventions will depend on the professions. To become a full member of health psychology inputs. publication of studies that have both clear the Division of Health Psychology and The challenges lie in ensuring that trial methods and descriptions that allow apply for chartered status a student needs professional commitments do not reliable replication. a BPS-approved psychology degree, MSc undermine our contributions to highin health psychology (Stage 1) and two quality research, in enabling professional Consultancy and committees years supervised practice thereafter (Stage health psychologists to gain the posts that In offering consultancy, health allow HP to make optimal inputs to health 2). To practise health psychology, they psychologists bring their theory and and health care and in continuing to also need to be registered with the HPC. methods to address identified problems, integrate our work with that of other Most university psychology and this has been clearest in consultancy psychological as well as biomedical departments were slow to recognise HP disciplines. We are confident that the to government. Work for the Public as a distinct area, and even now it is still current strength of health psychology can Health Directorate of the Westminster relatively uncommon for it to be taught meet these challenges. This issue illustrates government by Susan Michie, Charles as a mandatory part of the undergraduate this, by asking top figures in the field to Abraham and Nicky Rumsey focused on psychology degree. Nevertheless, there are choose a significant contribution to the behaviour change to reduce behavioural now good textbooks, including several UK field and the health of the nation. risk factors for disease, such as smoking, texts in more than one edition (e.g. low physical activity, alcohol use and Morrison & Bennett, 2006; Ogden, 2007). I Marie Johnston ‘unhealthy’ diet. Amongst other things, In contrast to the patchy role of HP in is Professor of Health Psychology at the they completed major reviews (Abraham the undergraduate curriculum, the UK has University of Aberdeen & Michie, 2008; Michie et al, 2009) that seen the strong development of email@example.com contributed to the Wanless Report (2004; postgraduate training, particularly in the see tinyurl.com/6l2kzfs), and the form of master’s (Stage 1) programmes. I John Weinman From the first master’s courses in HP in Choosing Health public health White is Head of Health Psychology Section at 1988 (London, City and Surrey) rapid Paper (2004). Michie and Rumsey led the Institute of Psychiatry expansion has resulted in well over 20 the writing of the NHS Health Trainer accredited courses, plus a few doctoralManual (2007) and the development I Angel Chater level professional HP courses. In 2007 the and evaluation of the England-wide is at the University of Bedfordshire Scottish Government (NES) supported the NHS Health Trainer Service. In Scotland, firstname.lastname@example.org first funded Stage 2 trainee places in HP, Diane Dixon and Marie Johnston were
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Socio-economic status and obesity: epidemiology and explanations
hroughout much of human history, wealth has divided those who cannot afford to eat and those able to indulge themselves with a life of gluttony and sloth. The 20th century marked a change in the implications of poverty in developed countries: intensive agriculture, effective food distribution and supply networks, low food prices and welfare provision have democratised access to energy-dense foods. The traditional association between low socioeconomic status (SES) and leanness has disappeared, or even reversed. A review in 1989 confirmed the historical links between poverty and leanness in developing countries but showed that in developed countries, lower SES was associated with higher levels of obesity in women. Patterns in men and children were more inconsistent (Sobal & Stunkard, 1989). More recent reviews have showed that the inverse association between SES and weight now extends to children (Shrewsbury & Wardle, 2008). One challenge for health research is to explain why women’s and children’s weights are socio-economically graded but men are less affected. A possible mechanism behind the SES gradient is that obesity confers social disadvantage, leading to lowered SES. There is evidence that overweight young people, particularly women, have worse employment, income and marriage prospects, and are more likely to experience downward social mobility, than those who are thinner in early adult life (Gortmaker et al., 1993). A second possibility is that in contemporary industrialised countries, low SES confers a risk of becoming obese. Lower SES is linked to environmental risks, such as poorer access to healthy nutrition and active recreation, lower health literacy and higher levels of social stress. These factors should affect both sexes, but women may be more likely to conform to social norms for behaviours related to weight. Voluntary health behaviours that can affect weight, such as healthy eating and activity, are also socially patterned, and higher SES women express more concern about weight and diet than either men or women of lower SES (Wardle & Griffith, 2001). High SES women could be said to inhabit a microculture that places a high value on appearance and stigmatises overweight,
motivating lifestyles that are less likely to lead to weight gain. They are also the group that have experienced the lowest gains in weight over the two to three decades of the ‘obesity epidemic’. A third possible explanation is that genetic risk for obesity has become socioeconomically distributed due to weightrelated social mobility over generations; although there is no evidence to date that any obesity-related gene variants are linked to SES. However, it is clear that genes and environments must interact: genetic susceptibility to weight gain will be more strongly expressed in environments that facilitate overeating and inactivity. A study of genetic and environmental influences on weight has shown that thin parents in all SES groups are likely to have thin children, but obese parents in lower SES environments are more likely to transmit obesity to their children than obese parents in higher SES environment (Semmler, et al., 2009). Environmental conditions linked with lower SES may therefore be more permissive of the expression of genetic vulnerabilities for weight gain. This leaves the question of why the SES gradient in weight in children resembles that of their mothers rather than their fathers. Maternal transmission of obesity risk is stronger than paternal transmission; that is, children’s weights correlate more strongly with their mother’s than their father’s weight (Whitaker et al., 2010). This may reflect the fact that child feeding is a role predominantly taken on by mothers, and higher SES women’s concerns for dietary health, and the value they place on thinness, could influence their children’s weight through the home food environment that they create.
Explanations for links between SES and weight based on social mobility, lifestyle and expression of genetic susceptibilities are not mutually exclusive and are all likely to contribute to the socioeconomic and gender inequalities in obesity. References Gortmaker, S.L., Must, A., Perrin, et al. (1993). Social and economic consequences of overweight in adolescence and young adulthood. New England Journal of Medicine, 329, 1008–1012. Semmler, C., Ashcroft, J., van Jaarsveld, C.H.M. et al. (2009). Development of overweight in children in relation to parental weight and socioeconomic status. Obesity, 17, 814–820. Shrewsbury, V. & Wardle, J. (2008). Socioeconomic status and adiposity in childhood: A systematic review of cross-sectional studies 1990–2005. Obesity, 16(2), 275–284. Sobal, J. & Stunkard, A.J. (1989). Socioeconomic status and obesity – A review of the literature. Psychological Bulletin, 105, 260-275. Wardle, J. & Griffith, J. (2001). Socioeconomic status and weight control practices in British adults. Journal of Epidemiology and Community Health, 55, 185–190. Whitaker, K.L., Jarvis, M.J., Beeken, R.J. et al. (2010). Comparing maternal and paternal intergenerational transmission of obesity risk in a large population-based sample. American Journal of Clinical Nutrition, 91, 1560–1567.
Fiona Johnson is at the Department of Epidemiology and Public Health, University College London email@example.com Jane Wardle
is at the Department of Epidemiology and Public Health, University College London
Designing more effective behaviour change interventions
ehaviour change is important to health psychology practice and research. NICE have provided guidance on health behaviour change intervention (see Abraham et al., 2009, for an introduction to the guidance), and the House of Lords Science and Technology Committee has recently completed an
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inquiry into the use of behaviour change interventions by the government, to which the present UK government has responded positively. The content of behaviour change interventions is crucial to their effectiveness. Understanding what content is associated with effectiveness for which
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behaviours is fundamental to intervention maintain self-efficacy (Abraham et al., design. Unfortunately, the absence of 2012). This work shows how a standardised definitions of behaviour mechanism-based framework of BCTs change techniques (BCTs) included in could be developed ranging across the interventions can make it difficult to diverse set of BCTs that behavioural specify exactly what was in an intervention scientists use to promote behaviour and so impede accurate replication. change. This work is ongoing (Michie et To help resolve this problem we al., 2011). developed a theory-linked taxonomy of 26 Work on BCTs has also highlighted generally applicable BCTs. We found that the importance of routine care content. these could be reliably identified across Imagine two randomised control trials 195 published intervention descriptions. comparing different novel interventions to This work demonstrated the routine care. The two feasibility of developing studies report effect standardised definitions of BCTs sizes of 0.5 and 0.2. included in behavioural We would usually “Our work highlighted interventions so that intervention conclude that the problematic variability content can be directly compared former intervention in reporting” and accurately represented. Our is more effective and work also highlighted recommend its adoption problematic variability in current over the latter. However, reporting of behaviour change intervention this interpretation assumes that the routine content (Abraham & Michie, 2008). care content relevant to the behaviour was We also found that when we compared identical. If, instead, the apparently less descriptions in 13 journal articles with effective intervention was compared to fuller descriptions of the same very high-quality routine care while the interventions in manuals, the latter other was compared to poor routine care, included more BCTs. This was a worrying then the apparently less effective finding because it suggested that scientific intervention may be the most effective! reports may not fully convey the content So the content of active control groups as of complex interventions. This warrants well as interventions themselves is critical further investigation with larger samples. to understanding the results of trial data In a subsequent study we used this (de Bruin et al., 2010). taxonomy of BCTs to examine the link These findings emphasise the need to between content and effectiveness in used standard terms to describe the interventions using behavioural and/or content of behaviour change interventions cognitive techniques to increase physical and active control groups. Doing so will activity and healthy eating among adults. A meta regression of experimental and quasi-experimental evaluations of 122 interventions showed that the BCT ‘selfmonitoring’, explained the greatest amount of heterogeneity of effectiveness. Selfmonitoring involves the intervention ffective communication can result participant becoming more aware of how in improved engagement with they are currently behaving. This can services/treatments, better prognosis facilitate evaluation of performance and and health outcomes, and increased new goal setting. Interventions that patient satisfaction; poor communication included self-monitoring or combined leads to misdiagnosis and self-monitoring a group of self-regulatory mismanagement, and is the cause of most techniques derived from control theory patient complaints. How clinicians and (Carver & Scheier, 1982) were found to patients interact influences their ability to be more effective. This study showed that understand each other, reach a diagnosis, decomposing interventions into choose and implement treatment. theoretically derived BCTs and conducting Stewart’s (1995) review showed that meta-regression enables identification of quality of clinical communication has an effective components of interventions effect on patient outcomes including (Michie et al., 2009). emotional health, pain control, symptom Our initial BCT taxonomy has been resolution and physiological measures developed and improved. In one such as blood pressure. development, we created a 40 BCT generic The past 25 years has seen a shift from taxonomy in which BCTs are grouped into a paternalistic doctor-centred model of 11 sets according to the psychological care (the expert doctor uses their changes they target. For example, different knowledge to make decisions for the BCTs are used to change normative beliefs passive patient) towards a patient-centred to those that are used to enhance and
enhance data synthesis, accelerate scientific understanding of behaviour change processes and help to ensure adoption of best practice. References Abraham, C. (2012). Mapping change mechanisms and behaviour change techniques. In C. Abraham & M. Kools (Eds.) Writing Health Communication. London, SAGE Publications Ltd. Abraham C., Kelly, M.P., West, R. & Michie, S. (2009). The UK National Institute for Health and Clinical Excellence (NICE) Public Health Guidance on Behaviour Change: A brief introduction. Psychology Health and Medicine, 14, 1–8. Abraham, C. & Michie, S. (2008). A taxonomy of behavior change techniques used in interventions. Health Psychology, 27, 379–387. Carver, C.S. & Scheier, M.F. (1982). Control theory. Psychological Bulletin, 92, 111–135. de Bruin, M., Viechtbauer, W., Schaalma, H.P. et al. (2010). Standard care impact on effects of highly active antiretroviral therapy adherence interventions. Annals of Internal Medicine, 170, 240–250. Michie, S., Abraham, C., Eccles, M.P. et al. (2011). Methods for strengthening evaluation and implementation. Implementation Science, 6, 10. doi:10.1186/1748-5908-6-10 Michie, S., Abraham, C., Whittington, C. et al. (2009). Identifying effective techniques in interventions. Health Psychology, 28, 690–701.
Charles Abraham has an NIHR-funded post at Peninsula College of Medicine & Dentistry, University of Exeter – views expressed are his own firstname.lastname@example.org
model, where patients’ opinions are valued and they are involved in treatment planning. Clinical communication is a growing field to which health psychologists contribute across the full spectrum.
Clinicians are cautious about addressing patients’ emotional concerns
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Illness cognitions influence how we interpret health threat information and predict health status, functioning and coping (Hagger & Orbell, 2003). By understanding these factors, consultations can be individually tailored and become more effective. An important application of this is adherence; approximately 50 per cent of medications are not taken as intended, with serious health and economic implications. Research (e.g. Horne et al., 1999) demonstrates that patients weigh up the necessities and concerns of treatments to reach decisions over their regime compliance and that deciding not to follow ‘doctor’s orders’ is a form of coping behaviour. Clinicians are cautious about addressing patients’ emotional concerns; cues and concerns voiced in consultations are often missed or avoided by health professionals. They report lacking either the time or skill to deal with them. Conversely, evidence reveals that time spent responding to patients’ concerns can shorten consultations whilst increasing patient satisfaction. Health care often involves complex information that needs to be communicated in a way that patients can understand and recall. Psychology informs us of the value of chunking information and making use of primacy/recency effects to ensure key points are remembered. Risk information is particularly challenging. To make informed decisions, people need to know what factors predict disease, their personal risk, and the risks associated with having (or refusing) treatment. Human interpretation of such information is often poor, and health professionals can also struggle to interpret and communicate risk data. Studying how patients process information means that health professionals can learn to explain risk in a patient-centred way. Helping patients then change their behaviour (e.g. attend screening, exercise), is a complex communication task. WHO estimate that 60 per cent of mortality is associated with avoidable lifestyle behaviours (e.g. smoking, poor diet). Many health professionals feel inadequate in facilitating behaviour change: they want to protect the patient relationship and fear that raising challenging topics damages rapport. As behaviour change becomes a global health priority, improving clinicians’ skills becomes increasingly important. Recently, a taxonomy of effective health behaviour change techniques (Abraham & Michie 2008) has helped to progress training in
behaviour change talk, as it provides an accessible framework for conveying complex health psychology theory and evidence to non-psychology practitioners. All of this means that health psychologists play an important role in developing and delivering communication training. Doctors conduct around 100,000 consultations during their career. Clinicians can learn how to be flexible to a patient’s model, communicate information understandably, deal with emotions/concerns, and facilitate sustained behaviour change. This is not without challenges, as health professional curricula are still largely developed and delivered by clinicians/scientists unfamiliar with psychology who don’t always recognise its contribution. Nevertheless there is increased involvement of health psychologists in curriculum development for medicine (Bundy et al., 2010) and similar developments are afoot for other health professionals’ training. In conclusion, effective communication heals and clumsy communication can harm. Whilst the mechanisms by which clinician–patient communication predicts health outcome are only partly understood, health psychologists have informed the development of theory, intervention and training to equip clinicians to communicate more effectively with patients.
References Abraham, C. & Michie, S. (2008). A taxonomy of behaviour change techniques used in interventions. Health Psychology, 27(3), 379–387. Bundy, C., Cordingley, L., Peters, S. et al. (2010) A core curriculum for psychology in undergraduate medical education. Available at tinyurl.com/6zlo7ke Hagger, M.S. & Orbell, S. (2003). A meta-analytic review of the common-sense model of illness representations. Psychology and Health, 18, 141–184. Horne, R. & Weinman, J. (1999). Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. Journal of Psychosomatic Research, 47(6), 555–567. Stewart, M.A. (1995). Effective physician–patient communication and health outcomes: A review. Canadian Medical Association Journal, 152, 1423–1433.
Jo Hart is at the School of Medicine, University of Manchester email@example.com
Sarah Peters is at the School of Psychological Sciences, University of Manchester
Appearance and body image
wenty-five years ago, there was a paucity of research into the psychology of appearance and body image. However, interest in this area has since increased rapidly, as demonstrated by the growing number of appearancerelated papers published in psychology journals and, since 2004, the production of the international journal Body Image. Much of this work has been conducted by health psychologists interested in issues such as the role of appearance as a motivator for behaviours associated with health risks (including smoking, dietary restriction and sun tanning) and the psychosocial impact of disease and biomedical interventions that alter appearance. Research in this area has typically been segregated into that which focuses on visible difference (disfigurement) and that which deals with dissatisfaction with ‘normal’ appearance. However, two recent UK studies (both of which are the largest in these areas to
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date) have demonstrated that the issues facing these two groups are surprisingly similar. Firstly, health psychologists recently developed the Body Confidence Test to accompany a Channel 4 TV series aired in February 2011. With over 74,000 responses to date, this has become the largest body image study in the world. The final results will highlight the nature and extent of appearance-related issues amongst men and women of different ages and backgrounds. Preliminary results from the first 23,886 respondents (21,387 women; 2,499 men) provide a snapshot of how British adults feel about their appearance and body image, and the impact of sociocultural influences. For example, 54 per cent of women rarely feel proud of their appearance and 56.6 per cent of men are often upset by their looks; 70.2 per cent of women and 41.5 per cent of men feel pressure from magazines and television to have a perfect body; 29.7 per
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cent of women and 27.7 per cent of men reported pressure from friends to look attractive; and 23.8 per cent of women and 15.7 per cent of men often feel pressure from family to change their appearance (Diedrichs et al., 2011). Both men and women thought that increasing diversity in the body shapes and physical appearance displayed in the media would Nichola Rumsey, Nicole Paraskeva and Diana Harcourt be the best way to promote a healthy body image. Regarding the 1.1 million body image issues. Furthermore, they have people in the UK living with a visible demonstrated the value of appearancedifference such as cleft lip and palate, related outcome measures suitable for use burns scarring, skin conditions and altered with people with or without a visible appearance due to cancer treatment, the difference (e.g. the Derriford Appearance Appearance Research Collaboration (ARC) Scale). Finally, the overwhelming response (a group including both health and clinical to these studies demonstrates how psychologists) recently conducted the important body image and appearance are largest multicentred study to date for the public, and how interested they are exploring the factors and processes in taking part in research in this field. facilitating adjustment to disfigurement (Rumsey et al., 2010). Many participants demonstrated positive adjustment, but more than 65 per cent had significant levels of appearance-related anxiety and social avoidance. However, as highlighted in previous research (Moss & Carr, 2004), adjustment was not predicted by demographic or condition-related factors. Instead, psychosocial factors (optimism, colleague (Stafford, 2007) has fear of negative evaluation, satisfaction written about the dangers in with social support and feeling socially considering the findings of accepted) were key predictors, as was the psychological research ‘obvious’. To adapt importance (salience) that the individual the argument slightly, I think that many places on appearance. All of these are attempts to change health behaviour (only amenable to interventions that focus on a fraction of which involve psychologists) appearance-specific rather than generic are based on the ‘obvious’. cognitions, behaviours and outcomes. Large-scale approaches to changing These two studies demonstrate the health behaviour have tended to centre extent of psychosocial distress associated around educating people about the health with appearance but highlight that whilst risks associated with the way they are many people report concerns, many others acting. The rationale is ‘obvious’: people do not. They also highlight psychosocial want to live longer healthier lives and the factors that influence the variability in way to achieve this is to tell them that their adjustment, provide a wealth of current behaviour is not going to lead to information from which new interventions a longer healthier life. can be developed to help people living The problem, though, is that a with appearance-related concerns, and majority of people are actually pinpoint where best to target these reasonably well-informed about health interventions to promote adjustment and risks and are already generally motivated positive body image. Members of the to engage in health behaviours. Based on Centre for Appearance Research my own research, I would estimate that (http://hls.uwe.ac.uk/research/car.aspx) 60–70 per cent of participants report have therefore developed a stepped model being motivated to make – and feel including face-to-face, online and group capable of making – positive health interventions designed to ameliorate behaviour changes. From the perspective distress in individuals and promote a of broad-brush public health campaigns, change in attitudes concerning appearance the implication is that there should be at societal level. additional emphasis placed on These studies also emphasise the need translating this motivation into action. for campaigning and education around
References Diedrichs, P., Paraskeva, N. & Rumsey, N. (2011). Channel 4 online Body Confidence Test: Preliminary report. Bristol: Centre for Appearance Research. Moss, T. & Carr, T. (2004). Understanding adjustment in disfigurement: The role of the self-concept. Psychology & Health, 19, 737–748. Rumsey, N., Byron-Daniel, J., Charlton, R. et al. (The Appearance Research Collaboration) (2010). Identifying the psychosocial factors and processes contributing to successful adjustment to disfiguring conditions: Final report. The Healing Foundation.
I Diana Harcourt,
is at the Centre for Appearance Research, Department of Psychology, University of the West of England Diana2.Harcourt@uwe.ac.uk I Nichola Rumsey
is at the Centre for Appearance Research, Department of Psychology, University of the West of England I Nicole Paraskeva
is at the Centre for Appearance Research, Department of Psychology, University of the West of England
Is ‘planning’ an ‘obvious’ way to change health behaviour?
In terms of Gollwitzer’s (1999) model, we should be targeting the volitional phase, as opposed to targeting only the motivational phase as seems to happen at present. ‘Planning’ is one possible approach to tackling this issue: if a majority of people are motivated to act in ways that are beneficial to their health, then the gap between motivation and action might be explained by a lack of planning. However, research shows that the precise nature of the plan can exert a large influence on health behaviour change. For example, Armitage (2009) randomised participants who were
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drinking more alcohol than recommended by the UK government either to ‘plan’ to drink within government-recommended levels or to form plans by linking in memory critical situations with appropriate behavioural responses (i.e. form ‘implementation intentions’, Gollwitzer, 1999). The alcohol intake of participants who were asked to ‘plan’ decreased by 0.73 units of alcohol per day, but decreased by significantly more (by 1.37 units of alcohol per day) in the group who formed implementation intentions. In this study, then, implementation intentions – a very specific, well-researched kind of plan – exerted roughly double the effect of generic plans. The question arises, though, as to how implementation intentions could be made into slogans or advertising materials that work on a larger scale. From this perspective, asking people to form their own implementation intentions is problematic for several reasons: (a) people generate many idiosyncratic critical situations and appropriate behavioural responses that will not generalise; (b) the administrator has little control over the quality of the implementation intention; and (c) the participant has to generate an implementation intention from memory. This led me (Armitage, 2008) to
develop a ‘volitional help sheet’, a tool that draws on Prochaska and DiClemente’s (1983) transtheoretical model to help people form implementation intentions (Gollwitzer, 1999). The volitional help sheet works by encouraging people to link situations in which health-risk behaviours might be triggered (i.e. ‘temptations’ from the transtheoretical model) with 10 core strategies by which health-risk behaviour is changed or health-protecting behaviour is sustained (i.e. ‘processes of change’ from the transtheoretical model). One advantage of this approach is that ‘successful’ implementation intentions could be extracted for use in future campaigns. Armitage (2008) asked smokers to plan to quit using the volitional help sheet and randomised them to: (a) identify critical situations/appropriate behavioural responses (control group); or (b) draw a line between critical situations and appropriate behavioural responses (experimental group). The results showed that significantly more people quit in the experimental group (19 per cent) compared with the control group (2 per cent). Thus, simply planning to quit and identifying critical situations/appropriate behavioural responses was not sufficient to change behaviour – linking the two elements was crucial (Gollwitzer, 1999).
In conclusion, there is a danger in assuming that changing behaviour is ‘obvious’ – even seemingly simple plans need careful formulation before they can exert strong effects. References Armitage, C.J. (2008). A volitional help sheet to encourage smoking cessation. Health Psychology, 27, 557–566. Armitage, C.J. (2009). Effectiveness of experimenterprovided and self-generated implementation intentions to reduce alcohol consumption in a sample of the general population. Health Psychology, 28, 545–553. Gollwitzer, P.M. (1999). Implementation intentions: Strong effects of simple plans. American Psychologist, 54, 493–503. Prochaska, J.O. & DiClemente, C.C. (1983). Stages and processes of self-change in smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390–395. Stafford, T. (2007). Isn’t it all just obvious? The Psychologist, 20, 94–95.
Chris Armitage is at the Department of Psychology, University of Sheffield firstname.lastname@example.org
Health Behaviour Research Limited – making psychology available for public benefit
nly a fraction of health behaviour interventions in use in health services are based on psychological research, and only a fraction of interventions developed and evaluated by health psychologists are in use in health services. Academic psychology puts a premium on high academic impact publications from research, read by a narrow academic readership. There is little incentive and resource for translating research into practice. The Applied Research Centre in Health and Lifestyle Interventions has pioneered the systematic development of interventions that meet known health service priorities, and where from the outset the requirements of the end user, including the funder of services for the end user, are factored into the design. A step further in translating research into common practice is taken by making the product directly purchasable by end users. We are mindful that the most influential health psychology theory
known to non-psychologists is the breastfeed, but feel unsupported by health transtheoretical change model (TTM). This services to do so. Clinicians complain their is because three decades ago the leading colleagues give conflicting advice and are researchers, James Prochaska and Wayne poorly trained to support breastfeeding. Velicer, established a spin-out company Those who volunteer for training are the from the University of Rhode Island least likely to need it, as they assess (www.prochange.com). Products are themselves as more competent than their derived from research funded via academic more reluctant colleagues (Wallace & and commercial Kosmala Anderson, 2007). sources. From our Whether they are or are not experience of more skilled is unknown, as “We decided to… collaborating on a this is never tested nor is commercialise the stages of change their knowledge tested after interventions developed” intervention (Wallace they attend training. et al., 2007) we We developed a system decided to adapt this that would enable mass training, business model to commercialise so creating a rapidly upskilled staff who the interventions developed using can give consistent care to all mothers. We a number of theoretical models. designed the assessment and training using Health Behaviour Research Limited principles from self-determination theory (www.healthbehaviourresearch.co.uk) (Ryan & Deci, 2000) to support began trading in 2007. motivation to learn and practise new skills. Using research from our own Several hundred staff have now used our systematic reviews and primary research, online unique breastfeeding knowledge we know that many women want to test (CUBA – Coventry University
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Breastfeeding Assessment) and the training programme. Recent results show that improvements in knowledge after training negated any pre-training differences in knowledge and qualifications, so that children’s centre staff support workers scored as well as midwives and doctors. Our research on the psychological determinants of teenage sexual health and risk has been employed by the NHS to develop several psychological theory-based interventions now in use by hundreds of people. An example is a group programme for parents to improve communication with their children about sex and relationships. Because this was not accessed by fathers and other hard-to-reach groups, we have developed a ‘Serious Game’ version. This uses virtual role play, building on social learning theory of Albert Bandura to improve confidence to use styles of communication that research has shown to be more effective. Other aspects of the intervention use theories of risk perception to address common
misperceptions of sexual risk behaviour. The game is in use across Coventry and Warwickshire in partnership with public health and council services (see www.besavvy.org.uk and www.healthinterventions.co.uk). The next stage version will be launched commercially. Many people value research-based self-management resources they can trust. Research shows the needs of those with complex conditions are often unmet by traditional services. Our research led us to develop a self-accessed web portal providing information and support for self-management for women with multiple sclerosis (MS) who have concerns about pregnancy and childbirth (www.mumsandms.org.uk). Once evaluated, the next stage version will be directly accessible and maintained by user subscription. In our experience, making psychology saleable enables widespread access to the tangible products of psychological research.
Unexpected targets in treatment for chronic pain
hronic pain is an important problem within health psychology. It is also a very large problem for those affected by it, and one that can lead to a great deal of suffering and disability. The role of health psychologists in relation to chronic pain is perhaps obvious, to find ways to reduce suffering and promote healthy functioning. One way to do this is to seek to reduce the pain, as pain and healthy functioning appear to be in an inverse relationship. This is an extremely natural way to frame the relationship between pain and functioning, and consistent with the perspective of most patients. At the same time this view appears to be at odds with the latest evidence from psychological studies of treatment outcome. So, what processes ought to be the focus in treatment for chronic pain? A somewhat counterintuitive approach to chronic pain is demonstrated within acceptance and commitment therapy (ACT, Hayes et al., 1999). ACT is an empirically based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behaviour-change strategies, to increase psychological flexibility. In a small randomised trial of ACT for people with chronic pain from whiplash-associated disorders (Wicksell et al., 2008) participants
in the ACT condition demonstrated significant improvements in disability, life satisfaction, fear of movement and depression, and, notably, no improvement in pain intensity. Follow-up analyses showed that it was not changes in pain, anxiety, depression or self-efficacy that mediated treatment results. These results were mediated by the theoretically specified process from ACT, psychological flexibility (Wicksell et al., 2010). A larger study done in the UK looking at a group-based form of ACT actually showed a medium-sized effect on pain (d = .50), although this was among the smallest effects apparent at post-treatment. Additional analyses examined variance in the degree of participants’ improvements at follow-up. These revealed that changes in pain during treatment played only a minor role in improvements achieved in depression, anxiety, physical disability and psychosocial disability, while changes in aspects of psychological flexibility appeared significantly more important (McCracken & GutiérrezMartínez, 2011). Psychological flexibility is, loosely, the capacity to accept or to be open to psychological experiences, to be aware and present focused, to choose one’s directions according to one’s values, and to take action
References Prochaska, J.O. & Velicer, W.F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12, 38–48. Ryan, R.M. & Deci, E.L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development and well being. American Psychologist, 55(1), 68–78. Wallace, L.M., Evers, K.E., Wareing, H. et al. (2007). Sexual behaviour and attitudes towards sexual activity and condom use of children aged 13–16 years in England. Journal of Health Psychology, 12, 179–183. Wallace, L.M. & Kosmala Anderson, J. (2007). Training needs survey of midwives, health visitors and voluntary sector breastfeeding support staff in England. Maternal and Child Nutrition, 3, 25–39.
Louise Wallace is Professor at the Applied Research Centre in Health and Lifestyle Interventions, Coventry University L.email@example.com
depending on what the situation affords. This is a process in the interaction of direct experience with cognitive processes in which the constraining effects of the cognitive influences on behaviour are minimised. This process derives from the therapeutic model of ACT. There are now numerous studies showing that chronic pain does not need to change for the lives of the people who suffer with it to change for the better. Other intriguing findings show that changes during treatment in physical strength appear less important than psychological processes related to avoidance, and adherence to trained ‘self-management methods’ during treatment appear to show little relationship with treatment outcome, a puzzling if not provocative finding. The more one looks at processes in treatment the more one is surprised that the expected processes do not appear to be at the core of how people shift from patterns of suffering and disability to patterns of healthy engagement and activity. The key processes appear to focus less directly on symptoms and less on control, and more on acceptance and the psychological contexts around symptoms and suffering. Processes like these are emerging across a wide range of health conditions that fit squarely within the scope of health psychology, conditions such as chronic pain, epilepsy, obesity, diabetes, smoking, insomnia, cancer, and end of life (McCracken, 2011). They seem to mark a significant shift in approaches to chronic conditions in particular, including
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Are illness representations key?
n the 1980s Howard Leventhal and his colleagues published a series of papers on the common-sense model of the self-regulation of illness behaviour (see Cameron & Moss-Morris, 2010, for review). This model specifies that individuals hold cognitive representations of their illnesses that include beliefs about the identity, cause, timeline, consequences, cure/controllability and cause of their conditions. They also have emotional responses or emotional representations of their illnesses which influence, for example, whether they seek medical help or adhere to treatment recommendations. A substantial literature has emerged over the past two decades showing that illness representations are associated with a variety of patient outcomes including psychological adjustment and illness severity.
some of the most prevalent, costly and challenging conditions in health care today. References Hayes, S.C., Strasahl, K.D. & Wilson, K.G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. McCracken, L.M. (Ed.) (2011). Mindfulness and acceptance in behavioral medicine: Current theory and practice. Oakland, CA: New Harbinger Press. McCracken, L.M. & Gutiérrez-Martínez, O. (2011). Processes of change in psychological flexibility in an interdisciplinary group-based treatment for chronic pain based on acceptance and commitment therapy. Behaviour Research and Therapy, 49, 267–274. Wicksell, R.K., Ahlqvist, J., Bring, A. et al. (2008). Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplash-associated disorders (WAD)? A randomized controlled trial. Cognitive Behaviour Therapy, 37, 169–182. Wicksell, R.K., Olsson, G.L. & Hayes, S.C. (2010). Psychological flexibility as a mediator of improvement in acceptance and commitment therapy for patients with chronic pain following whiplash. European Journal of Pain, 14, 1059.e1–1059.e11.
Lance M. McCracken is at the Institute of Psychiatry, King’s College London, and INPUT Pain Management Centre at St Thomas’ Hospital Lance.McCracken@kcl.ac.uk
We wanted to see whether illness representations could actually predict who develops a chronic illness in the first place. Functional somatic syndromes such as irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS) provide a unique opportunity to investigate this possibility. Biopsychosocial models of these syndromes suggest that biological factors such as acute infections and injuries precipitate these conditions, whilst patients’ negative interpretations of the acute illness serve to maintain or perpetuate the symptoms. In turn these negative beliefs direct ways of coping, such as avoiding activity, or engaging in bursts of activity followed by periods of prolonged rest. These behaviours ultimately maintain symptoms, confirm beliefs that the illness is chronic, uncontrollable and serious, and lead to ongoing disability (Moss-Morris, 2005). To test this model, we recruited 620 people from primary care with a positive test for Campylobacter gastroenteritis, a nasty form of food poisoning, and no previous history of any bowel conditions (Spence & Moss-Morris, 2006). Participants completed a series of questionnaires at the time of infection, including the Revised Illness Perception Questionnaire (IPQ-R). IPQ-R subscales measuring beliefs about how long they thought the illness would last, how serious they believed the consequences of the illness to be, and how emotionally distressed and puzzled they were by their illness were combined to form a negative illness representation score for each individual. Patients who had more negative beliefs about their food poisoning episode at the time of the acute infection were significantly more likely to go on to develop IBS three months later and to still have IBS symptoms six months later. In a similar study we showed that people who developed CFS after an episode of infectious mononucleosis (glandular fever), perceived their acute illness as a serious, distressing condition that will last a long time and is uncontrollable (Moss-Morris et al., 2011). People who developed CFS also held a stronger illness identity; that is, they ascribed a number of daily physiological complaints to their glandular fever. More recently, we investigated perceptions of injury in a cohort of patients who had just experienced a mild traumatic brain injury (Hou et al., in press). All patients had the same level of mild concussion but 22 per cent went on to develop postconcussional
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syndrome (PCS), a diagnosed symptom cluster including headache, dizziness, fatigue, irritability, concentration difficulty, memory impairment and insomnia. The strongest predictor of the development of PCS six months post-injury was patients’ negative perceptions of their acute mild head injury. These results have important clinical implications. Negative illness representations were a consistent predictor of all three syndromes, together with anxiety and the tendency to engage in bursts of activity followed by periods of prolonged rest (all-or-nothing behaviour). Early interventions targeting negative illness representations and associated behaviours may prevent the onset of chronicity in patients with known precipitants of functional syndromes. We already have evidence that altering illness perceptions is an effective treatment mechanism for reducing symptom severity. In a randomised controlled trial of cognitive behavioural therapy for multiple sclerosis fatigue, we showed that patients in the CBT arm developed more positive representations of their fatigue, which in turn mediated the reduction in the severity of fatigue (Knoop et al., 2011). For people with more acute symptoms, we may be able to use more straightforward brief interventions to prevent the onset of these debilitating symptoms. References Cameron, L.D. & Moss-Morris, R. (2010). Illnessrelated cognition and behaviour. In D. French et al. (Eds.) Health psychology (2nd edn) (pp.149–161). Oxford: BPS Blackwell. Hou, R., Moss-Morris, R., Peveler, R. et al. (in press). How does a minor head injury result in enduring symptoms? Journal of Neurology, Neurosurgery and Psychiatry. Knoop, H., van Kessel, K. & Moss-Morris, R. (2011). Which cognitions and behaviours mediate the positive effect of cognitive behaviour therapy on fatigue in patients with multiple sclerosis? Psychological Medicine. tinyurl.com/5wnlyar Moss-Morris, R. (2005). The role of illness beliefs and behaviours in the development and perpetuation of chronic fatigue syndrome. Journal of Mental Health, 14, 223–235. Moss-Morris, R., Spence, M. & Hou, R. (2011). The pathway between glandular fever and chronic fatigue syndrome. Psychological Medicine, 41, 1099–1108. doi:10.1017/S003329171000139X Spence, M. & Moss-Morris, R. (2007). The cognitive behavioural model of irritable bowel syndrome. Gut, 56, 1066–1071.
Rona Moss-Morris is Professor of Psychology as Applied to Medicine at the Institute of Psychiatry, King’s College London firstname.lastname@example.org
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What’s stress got to do with it?
cclesiastes tells us that ‘there is nothing new under the sun’, and it is certainly true that the idea that the mind and body may be connected has been around for a long time. But a chance discovery in the 1970s revolutionised our understanding in this area. Ader and Cohen were seeking to produce a taste aversion response in animals trained to associate saccharine (conditioned stimulus) with an immunosuppressant substance known to produce nausea and vomiting: cyclophosphamide (unconditioned stimulus). However, in their early trials they noticed a significantly higher mortality rate in the animals exposed to the unpaired saccharine. This observation led them to wonder whether they had inadvertently conditioned their animals to suppress their immune systems. They tested this seemingly outrageous proposal by conducting a further conditioning experiment in which they also assessed the immune system. Ader and Cohen reported that, even after a single exposure to the conditioned stimulus (i.e. saccharine), these animals displayed evidence of significant immune suppression. Suddenly, behaviourally conditioned immune suppression was a reality, and tangible proof that the mind and body are connected was presented to the scientific world. In the years that followed, investigators widened their focus to the psychological parameters that appeared to affect our biology. This research demonstrated, time and again, that psychological stress modulated the immune system. Much of this early research was, however, conducted in vitro: the clinical relevance was unknown. This all changed with the ground-breaking study of Cohen et al. (1991). They exposed healthy volunteers to respiratory viruses; quarantined them and monitored them for the development of respiratory symptoms and clinical colds. Cohen reported that the greater the level of stress at baseline, the greater the incidence of both respiratory symptoms and clinical colds. Psychological stress, it would appear, could significantly increase vulnerability to infectious disease. So, stress might increase disease risk in young healthy people. But the young and healthy can, and do, recover quickly from minor illnesses such as the common cold. What happens in populations more vulnerable to ill health and for whom even minor illnesses can be fatal? This was examined by Jan Kiecolt-Glaser and
colleagues (1996). She recruited a small group of chronically stressed older adults (spousal carers of patients with dementia) and a non-caregiving control group. All participants were given an influenza vaccine and were followed up to examine the proportion of people able to generate an antibody response denoting protection against flu. The rate of vaccine failure was significantly higher in the chronically stressed group: with only 38 per cent of carers being protected against flu, compared with 68 per cent of the control group. Perhaps the most striking feature of these results, which have been replicated many times, is that they reveal that the effects of chronic stress on the immune system are so insidious, that even after vaccination, the chronically stressed remain at increased risk of disease. The effects of stress on health appear not, however, to be restricted to disease vulnerability. Considerable effort has been devoted to exploring the effects of psychological stress on disease progression and disease activity. A multitude of chronic diseases have been investigated (HIV, cancers, autoimmune conditions, etc.). Here the evidence is less clear cut, confounded, perhaps inevitably, by the complexity of the diseases and their treatments. But we are observing the development of psychological interventions aimed at, not only enhancing emotional well-being and quality of life, but potentially also prolonging life and/or reducing symptom burden. The results from these early intervention studies offer considerable hope and promise. For example, stress management in women positive for viruses associated with an increased risk of cervical cancer, has been shown to reduce the risk of developing the
disease (Antoni et al., 2008). Similarly, stress management has been shown to boost the effectiveness of influenza vaccinations in chronically stressed older individuals (Vedhara et al., 2003). So the mind and body are indeed connected, and these connections may be of clinical relevance. In decades to come, health psychology will advance our understanding of these relationships; the mechanisms that underlie them and will develop interventions which harness these powerful effects of the mind on the body. We are facing an unrivalled opportunity to make health psychology central to our understanding of health and disease. References Ader, R. & Cohen, N. (1975). Behaviorally conditioned immunosuppression. Psychosomatic Medicine, 37, 333–340. Antoni, M.H., Pereira, D.B., Marion, I. et al. (2008). Stress management effects on perceived stress and cervical neoplasia in low-income HIV-infected women. Journal of Psychosomatic Research, 65, 389–401. Cohen, S., Tyrrell, D.A.J. & Smith, A.P. (1991). Psychological stress and susceptibility to the common cold. New England Journal of Medicine, 325, 606–612. Kiecolt-Glaser, J.K., Glaser, R., Gravenstein, S. et al. (1996). Chronic stress alters the immune response to influenza virus vaccine in older adults. Proceedings of the National Academy of Sciences, USA, 93, 3043–3047. Vedhara, K., Bennett, P.D., Clark, S. et al. (2003). Enhancement of antibody responses to influenza vaccination in the elderly following a cognitivebehavioural stress management intervention. Psychotherapy and Psychosomatics, 72, 245–252.
Kavita Vedhara is at the Institute of Work Health and Organisations, School of Community Health Sciences, University of Nottingham email@example.com
What can the internet do for future health psychology?
indings that open up fascinating possibilities for the future point to the potential role of the internet in supporting healthy behaviour and illness management (Heron & Smyth, 2010). The internet could potentially give lay people convenient, private access to expert advice and support for managing all aspects of health – and it presents healthcare providers with an inexpensive means of offering this to much of the
population. Encouragingly, a recent review (Webb et al., 2010) confirmed that, on the whole, web-based health behaviour change interventions are effective. However, their effectiveness varies widely, indicating that much more research is needed into when, why and how these interventions can work. Until now, a barrier to research into web-based interventions has been the need for the software infrastructure for each
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intervention to be programmed individually by software developers – a laborious and costly process that results in an intervention that then cannot easily be modified. However, over the past three years the LifeGuide team, led by University of Southampton, has overcome this problem by creating free, open source software that can be used by people without a programming background to build and modify their own web-based interventions and easily adapt them for use in different contexts. The LifeGuide Community (which anyone can join, simply by logging onto www.lifeguideonline.org) already has over 500 members worldwide who are interested in creating their own interventions, ranging from postgraduate students to leading international researchers. LifeGuide interventions now being developed and trialled include interventions to help people to lose weight, increase their physical activity, stop smoking, and prevent or self-manage colds and flu (Yardley et al., 2010), bowel symptoms, high blood pressure, eczema and stroke. LifeGuide is particularly useful for international collaboration, as interventions can be copied and then modified for different countries. For example, hundreds of GPs from the UK, Spain, Belgium, the Netherlands and Poland are currently recruiting thousands of patients in an EC-funded LifeGuide intervention to reduce antibiotic prescribing rates across Europe; this has involved translating the webpages into five different European languages and altering text to suit local customs and preferences. As this example illustrates, a scientific advantage of web-based interventions is that they can facilitate cost-effective automated collection of very large datasets, providing sufficient statistical power to permit sophisticated analyses of the mediators and moderators of interventions – allowing us to find out what works for whom. A particularly interesting finding from the review of web-based interventions cited above (Webb et al., 2010) is that digital interventions appear to be more effective if they use more ways of interacting with the user, by e-mail and text messages (e.g. to motivate and cue behaviour). Increasingly, internet users are turning to mobile phones to provide the information and support they need where and when they need it. Previously, digital
behaviour change interventions have mainly been delivered by PCs and provide advice for users to implement at some point in the future, based on users’ answers to questions about their past or future activities and feelings. Over the next few years the LifeGuide team will be developing software to allow all LifeGuide users to fully exploit the potential of mobile phones to provide more timely support for behaviour change. Mobile phones can detect what the user is currently doing, without the need for users to answer questions, by sensing their location, activity level, who they are with or talking to and even their mood (Klasnja et al., 2009). Detecting this information will allow us to deliver exactly the right kind of support to users at the right time. We will also link to online social networks, which can provide information about users’ attitudes and social contacts, so that our interventions can draw on encouragement from a virtual community of online peers. It may sound like science
fiction, but technology is making strides towards allowing us to provide affordable, personalised health interventions, accessible anywhere, any time. References Heron, K.E. & Smyth, J.M. (2010). Ecological momentary interventions. British Journal of Health Psychology, 15, 1–39. Klasnja, P., Consolvo, S., McDonald, D.W. et al. (2009). Using mobile and personal sensing technologies to support health behavior change in everyday life. Annual Symposium Proceedings of the American Medical Informatics Association, pp.338–342. Webb, T.L., Joseph, J., Yardley, L. & Michie, S. (2010). Using the internet to promote health behavior change: A meta-analytic review. Journal of Medical Internet Research, 12, e4. Yardley, L., Joseph, J., Michie, S. et al. (2010). Evaluation of a web-based intervention providing tailored advice for self-management of minor respiratory symptoms: exploratory randomized controlled trial. Journal of Medical Internet Research, 12(4), e66.
Lucy Yardley is in the Academic Unit of Psychology, University of Southampton L.Yardley@soton.ac.uk
Helping people to walk more
uidelines for good health encourage regular physical activity of moderate intensity (i.e. sufficient to get a person slightly out of breath). Brisk walking is a form of moderate physical activity that is especially acceptable to populations who are the most physically inactive. It does not have to be scheduled, nor does it require any special clothes or equipment, so it is very low cost. Although there have been many studies demonstrating that interventions can successfully increase walking, they have largely been devoid of theory. Consequently there is a limit to how much evaluations of these interventions can inform the development of future interventions: they provide little information on why these interventions work or do not work. We have developed and evaluated an intervention to help adults increase their walking, based on the theory of planned behaviour, a generic model of human behaviour that has been used in literally hundreds
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of studies. This theory was extended to include consideration of volitional processes, specifically how to help people translate their ‘good’ intentions into action. Extended developmental work using this theory identified that the strongest predictor of intentions to walk more was self-efficacy – the degree of confidence a person has that they can successfully carry out a behaviour (in this case walking). Thus, the people who most intended to increase their walking were those who felt most confident that they could walk more, not those who thought they would enjoy it, or who thought that it would be good for their health. Further, the most common reasons why the general public gave for why it would be easy or difficult to walk more concerned (lack of) time (Darker et al., 2007). Our intervention therefore had the overall strategy of changing this belief about not having enough time to walk more, thereby
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increasing self-efficacy for walking and, in line with theory. These large effects in turn, increasing walking. To bring this on walking have since been replicated about, we used techniques that aimed to when the intervention was delivered by elicit from participants their own reasons a different person to volunteers in London why they could walk more, (e.g. by asking (French et al., in press). them to think of times when they found it The approach we have taken to helping easy to walk, and what are the factors that people increase their walking has been make it easier for them to increase their successful, at least in the short term. We walking). The final intervention consisted are now examining whether this of a structured set of six intervention works in the techniques, with each long term when delivered participant providing their in primary care. To optimise “this intervention own reasons why it would be our chances of success, the had large effects on easy for them to walk more, intervention has since been walking behaviour” including prompts to refined, informed by a translate participants’ systematic review of what is intentions to walk more into the best way of increasing selfconcrete plans about how exactly they efficacy for physical activity (Williams & would do this additional walking, and how French, 2011), and extended they would bring about factors that they developmental work with practice nurses had identified as making it easier for them and patients in primary care, to increase to walk more. acceptability to both recipients and An evaluation of this intervention providers (French et al., 2011). We are found that it had large effects on the continuing to adapt this intervention for walking behaviour of 130 volunteers in other specific groups, such as people who Birmingham, as assessed by pedometer recently experienced a stroke. (Darker et al., 2010). These increases were We believe this work demonstrates maintained for the follow-up period of six the importance of a systematic approach weeks. Further, the effects of this to developing interventions to change intervention on objectively assessed health-related behaviours, underpinned behaviour were mediated by self-efficacy, by explicit psychological theory.
Darker, C.D., French, D.P., Longdon, S., Morris, K. & Eves, F.F. (2007). Are beliefs elicited biased by question order? A theory of planned behavior belief elicitation study about walking behaviour in the general population. British Journal of Health Psychology, 12, 93-110. Darker, C.D., French, D.P., Eves, F.F. & Sniehotta, F.F. (2010). An intervention to promote walking amongst the general population based on an ‘extended’ Theory of Planned Behaviour. Psychology and Health, 25, 71-88. French, D.P., Stevenson, A. & Michie, S. (in press). An intervention to increase walking requires both motivational and volitional components: A replication and extension. Psychology Health and Medicine. French, D.P., Williams, S.L., Michie, S. et al. (2011). A cluster randomised controlled trial of the efficacy of a brief walking intervention delivered in primary care: Study protocol. BMC Family Practice, 12, 56. Williams, S.L. & French, D.P. (2011). What are the most effective intervention techniques for changing physical activity self-efficacy and physical activity behaviour – and are they the same? Health Education Research, 26, 308–322.
David French is in the Applied Research Centre in Health and Lifestyle Interventions, University of Coventry firstname.lastname@example.org
Practitioner Doctorate (PsychD) in Psychotherapeutic & Counselling Psychology The ﬁrst of its kind to be accredited by the British Psychological Society, this doctoral course offers training over three years for full-time trainees. Successful completion of the Doctorate also confers eligibility for Chartered Psychologist status with the BPS and for registration as a Counselling Psychologist with the Health Professions Council.
Trainees are exposed to a range of theoretical traditions, including psychodynamic and cognitive-behavioural theory. They are given the opportunity to apply these perspectives under supervision in three, year-long practice placements. These can be within NHS, student counselling, occupational, voluntary and other settings which are identiﬁed, supported and monitored by the course team.
Entry requirements: Graduate Basis for Conditional Membership from the British Psychological Society; normally at least an upper second class degree in psychology; sufﬁcient personal maturity, stability and robustness to cope with the demands of the course. Closing date for September entry: 3 February 2012 For further information and application forms:
The course has a strong research tradition and an outstanding trainee University of Surrey, Guildford, Surrey GU2 7XH publication record, especially in qualitative and critical psychology. Only 14-15 trainees are accepted each year to ensure a high staff-trainee ratio.
T: 0800 980 3200 or +44 (0)1483 681681 E: email@example.com www.surrey.ac.uk/psychologist
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ONE ON ONE
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The Moral Maze that sex was not illegal (yet).
…with Roger Ingham Professor of Health and Community Psychology at the University of Southampton, and Director of the Centre for Sexual Health Research
of moral, cultural, religious, personal, legal, economic and other frameworks. The behaviour has to be understood within these contexts, which makes it a lot more complex than any number of seven-point scales and multiple regressions can hope to address. Many groups have vested interests in policy formulation.
Ingham, R. & Aggleton, P. (Eds.) (2006). Promoting Young People’s Sexual Health; International Perspectives. Abingdon: Routledge. ‘A collection of chapters that highlight the complexities of the area and suggest some positive ways forward.’
One hero Difficult, since there have been many, but (philosopher of science) Rom Harré stands out for the way he challenged the pseudo-scientific aspirations of much of social psychology in the 1970s (and still present in some places). Much of the shift towards qualitative approaches and the importance of language and discursive frameworks can be traced back to his influence. I was fortunate enough to be in the same college as him at Oxford, so we had regular lunches together – I like to think I understood some of what he used to say.
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One high spot of your career Having the opportunity to point out to Daily Mail columnist Melanie Phillips on
One moment that changed pregnancy, travel to faraway the course of your career places, etc. Getting a phone call out of the One factor that makes blue in 1986 asking me to give sexual health so interesting a lecture on safe sex. When It’s so much more than the HIV first became an issue, nobody quite knew how to react. Because I had previously worked on ‘reallife’ applied issues (like footballrelated violence), someone felt that I would also know about sex. Curious but true. After a couple of weeks of declining, but realising the sheer complexity of the area, I capitulated. The talk led to an Roger Ingham offer of research email@example.com funding, this led to more grants, work with the specific activities themselves; World Health Organization, it’s the way that the whole area 10 years advising the previous is surrounded by a wide range UK government on teenage
One low spot Observing the failure to get sex and relationships education as a statutory part of the school curriculum when it was so close, and despite the overwhelming evidence in its favour (as well as overwhelming public support). It was scuppered during the final days of the previous government by a mix of mis-truths and panic creation by the right wing moralists, and some fearful conservative Lords. One of my cultural crutches Whenever I feel too pessimistic about the state of the world, I turn to Leonard Cohen to cheer me up. Words that inspire and help to make sense of it all. One challenge facing health psychology It’s been brilliant seeing the fledgling area grow in strength and numbers, and long may this continue. But I sometimes feel that there needs to be greater engagement in, and awareness of, the policy process, and the ways that different political approaches lead in fundamentally different directions in some domains. Achieving a suitable balance between doing excellent research on the one hand, and pointing out the impact of inequalities, the power of vested commercial interests, the negative impact that sheer prejudice can exert, and so on, on the other hand, will be immensely challenging. In some cases, we may need to be more aware of whose behaviour we actually need to be changing.
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vol 24 no 12
Published on Nov 23, 2011
This is a preview of the December issue of The Psychologist, published by the British Psychological Society. The whole issue will be availab...