psychologist august 2019
‘It doesn’t have to be this way’ Creating compassionate NHS organisations www.thepsychologist.org.uk
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psychologist august 2019
contact The British Psychological Society 48 Princess Road East Leicester LE1 7DR 0116 254 9568 firstname.lastname@example.org www.bps.org.uk the psychologist and research digest www.thepsychologist.org.uk www.bps.org.uk/digest www.jobsinpsychology.co.uk email@example.com Twitter: @psychmag Download our iOS/Android apps advertising Reach 50,000+ psychologists at very reasonable rates. CPL, 1 Cambridge Technopark Newmarket Road Cambridge CB5 8PB contact Kai Theriault 01223 378051 firstname.lastname@example.org july 2019 issue 49,412 dispatched cover Eliza Southwood www.elizasouthwood.com environment Printed by Warners Midlands plc on 100 per cent recycled paper. Please re-use and recycle. Mailing bag is potato starch-based and fully compostable. issn 0952-8229 (print) 2398-1598 (online)
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‘It doesn’t have to be this way’ Creating compassionate NHS organisations www.thepsychologist.org.uk
The Psychologist is the magazine 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’
The Psychologist needs you! We rely on your submissions throughout the publication, and in return we help you to get your message across to a large and diverse audience. For details of all the available options, plus our policies and what to do if you feel these have not been followed, see www.thepsychologist.org.uk/contribute The main message, though, is simply to engage with us. Contact the editor Dr Jon Sutton on firstname.lastname@example.org, tweet us on @psychmag or call /write to us at the Society’s Leicester ofﬁce.
Managing Editor Jon Sutton Deputy Editor Annie Brookman-Byrne Production Mike Thompson Journalist Ella Rhodes Editorial Assistant Debbie Gordon Research Digest Emma Young, Matthew Warren
Associate Editors Articles Paul Curran, Harriet Gross, Michelle Hunter, Rebecca Knibb, Adrian Needs, Paul Redford, Sophie Scott, Mark Wetherell, Jill Wilkinson History of Psychology Alison Torn Interviews Gail Kinman Culture Kate Johnstone, Sally Marlow Books Emily Hutchinson Voices in Psychology Madeleine Pownall International panel Vaughan Bell, Uta Frith, Alex Haslam, Elizabeth Loftus, Asifa Majid Psychologist and Digest Editorial Advisory Committee Catherine Loveday (Chair), Emma Beard, Harriet Gross, Kimberley Hill, Rowena Hill, Deborah Husbands, Peter Olusoga, Richard Stephens, Miles Thomas
02 Letters The BAME gap, empathy in care, silence, Sudan and more
10 News Prevention, honours and more 16 Digest Latest research
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22 Shattering the self Ella Rhodes on some mysterious experiences…
30 ‘It doesn’t have to be this way’ Michael West tells Ella Rhodes about work with one of the world’s largest employers – the NHS
34 Creating compassionate NHS organisations We hear from Maria Kordowicz
38 Autism in women Eloise Stark
44 Me and monotropism Fergus Murray on a theory with a family connection…
52 ‘We live in a hugely psychologised society’ Juliet Foster, Chair of the Society’s Education and Training Board
54 ‘This is the moment when everything is changing’ Simon Bignell, a founder of the new Cyberpsychology Section
58 Jobs in psychology
62 Books With Pete Etchells, and a ‘shelfie’ from David Carless
68 Culture Stanley Kubrick exhibition 72 One on One
We are in the midst of a busy summer, attending the European Congress of Psychology, Latitude Festival, and the PsyPAG conference. Jon is so busy on the road that he has left me in charge... Having wished Dr Christian Jarrett a fond farewell after 16 years editing the Research Digest, we are delighted to announce that Dr Matthew Warren has stepped up to fill the role. We look forward to the ongoing evolution of the Digest under Matthew’s watch over the coming years. This month Michael West (p.30) and Maria Kordowicz (p.34) tell us about the importance of compassion in the NHS; Eloise Stark (p.38) and Fergus Murray (p.44) share personal perspectives on theories of autism; and Ella Rhodes (p.22) shatters our sense of self. As ever, we want you to get in touch – please let Jon know that I’m doing a wonderful job if nothing else. Ideally though, let us know if you think you can engage and inform our diverse readership. Send an email or say hi on Twitter! Dr Annie Brookman-Byrne Deputy Editor @psychmag
Every mind matters?
ew teachers will now be trained in identifying early signs of mental health problems in students, as part of a push towards prevention. The government’s prevention plan also includes measures to give social workers, local authorities and healthcare workers more support in promoting the idea of treating good mental health in the same way as good physical health. Prime Minister Theresa May launched the plans in June stating: ‘I believe the next great revolution in mental health should be in prevention’. The government also plans to train more than one million NHS staff in suicide prevention, provide funding to local authorities to deliver suicide prevention plans, and update standards for social workers to increase their knowledge in helping people with mental health problems. An awarenessraising campaign named Every Mind Matters will also be launched in October and from next year parents will be provided with advice on dealing with self-harm, online bullying and stress. Writing for The Guardian Clinical Psychologist Dr Masuma Rahim suggested that, while teachers are in a good position to support young people who may be struggling, Are you a psychologist working the policy in itself was not sustainable in prevention research or for a number of reasons, including practice? We would love to hear the issue of CAMHS under-funding your views on prevention and and problems accessing services psychology’s role in it – from once problems are identified. both physical and mental health Rahim wrote that mental health perspectives. problems are often the result of email@example.com the society a person inhabits and
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suggested taking a public health approach. ‘You can’t separate mental health from the reality of people’s lives. If you live in substandard housing and haven’t enough food to eat you are extremely likely to have difficulties with your mental health. You can’t give people therapy for being poor, vulnerable, or marginalised. You need to tackle the poverty and the vulnerability and the marginalisation.’ She pointed to the irony of this announcement coming just a fortnight following a report on Sure Start centres which found healthcare outcomes had been improved in deprived areas. However, funding for such early years services has been cut by more than 60 per cent in the last 19 years. ‘If you want to improve population-based outcomes you have to invest in your population… But the policies of the last 10 years have shown very clearly that ringfencing funding to improve the health and social outcomes for poor and deprived people is seen as unimportant by the government.’ While Rahim said she agreed more people should learn how to spot mental health issues early she said these ideas sounded like ‘empty words and policies’. ‘If she [May] really believed in championing mental health she would be looking at tackling the root causes and she would be acknowledging the impact of her own party’s policies on the mental health of those who have borne the brunt of them.’ This move by May comes ahead of publication of a government green paper on prevention which is due out over the next few months. In November Matt Hancock, Secretary of State for Health and Social Care, outlined
some of the directions the government is expected to take in its prevention agenda in the Prevention is better than cure document pointing to priority areas such as healthy eating, not smoking, alcohol overuse and mental health. The British Psychological Society has been consulting with members ahead of the publication of the government’s prevention green paper and has plans to release a public briefing document in response. A recent roundtable meeting brought together a group of Society members to discuss their thoughts on the topic. Professor Jim McManus, Director of Public Health (Hertfordshire County Council) and Vice President of the Association of Directors of Public Health was among them. He told me in an interview that from conversations with those working in the Department of Health and Social Care he was glad to hear that the government had recognised the importance of developing strong prevention policy and the good economic and moral case for prevention, but many areas he felt were lacking. McManus said all he had read and heard about the government’s prevention strategy was heavily influenced by biomedical and individualist models of behaviour change. ‘I think what they’ve done is taken a clinical paradigm to prevention that is just not going to deliver and never has. It will be the fifth time that a national government policy has tried that and it hasn’t worked, ever... For example John Reid’s plan in 2004 called Choosing Health was all about drinking alcohol more sensibly, eating sugar more sensibly, not smoking, and it hasn’t worked. ‘Alcohol consumption, in everything other than
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the psychologist august 2019 news the millennial generation, has stayed stubbornly the same. Smoking prevalence, although it’s declining, is not declining primarily because of smoking cessation services, it’s declining because of a whole range of other policy measures. We’re a fatter society than we’ve ever been, weight is going up, type 2 diabetes is going up, the number of obese children in year six is going up.’ McManus also pointed out that while the government’s ideas so far had made a nod towards wider determinants of health, including social determinants, this thinking had not gone far enough. ‘The problem with the social determinants narrative is it can sound a bit woolly and vague. How is improving someone’s housing going to improve someone’s health? Of course, in and of itself, it’s not a magic bullet but it is important. We have to get into very sharp, very focused thinking on explaining why social determinants are important and articulating the role of complexity alongside social, and wider, determinants. The debate at the minute is government saying “we can’t afford to be an ill society so we’re going to tell people to change their behaviour and they’re going to change their behaviour”.’ Three other areas of concern for McManus are the government’s focus on using apps to tackle prevention, the use of genomics, the evidence for which he said had been overstated, and predictive prevention, which he feels is vaguely articulated and unproven in terms of evidence. ‘To my mind one of the single biggest things you could do if you were going to have a really good prevention policy, for the long term or medium term, is ask what does it look like for a child to have reached adulthood successfully – there’s no joined-up policy narrative around that in this country.’ Psychological evidence, and the potential for psychologists in tackling prevention, has so far been entirely absent from prevention plans. Tackling a problem as large as prevention, McManus said, requires complex thinking and looking beyond the individual and at the full life-course of a person. ‘I think the other thing psychologists could do is make a contribution about healthy organisations and how organisations have a role in either making people less well or making people healthier. The next thing psychology could’ve done is brought some models of behaviour change that actually have a grounding in evidence and balance the individual with the social.’ I asked McManus what he would most like to see from any response to the government’s prevention plans from the BPS. ‘My ask of the BPS would be to do several things. One is to say that the individual behaviour change paradigm is dead and ineffective and won’t work by itself, the second thing would be to talk about the importance of social determinants and individual models held in tension, and actually say how that could make a difference. The third thing would be for the BPS to really focus on childhood, we have to get childhood right, and the fact that we aren’t is storing up an awful lot of avoidable and wasted costs. Also I think if the BPS would counter some of the pseudoscience about genomics and predictive prevention that would be a major step forward.’ er
Engaging cross-culturally Tim Lomas digests the research
Find our Research Digest at www.bps. org.uk/ digest Editor: Dr Christian Jarrett Writers: Dr Matthew Warren, Emma Young and Jesse Singal Full reports and much more on the Digest website
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he novelist David Foster Wallace famously told a story of two young fish swimming in the sea, whereby an older fish glides by and asks, ‘How’s the water?’, to which they look at each other in puzzlement and say, ‘What’s water?’ The central point of the parable is that we are constantly immersed in contexts to which we give little thought or consideration, but which nevertheless inﬂuence us profoundly. Among the most powerful of such contexts is language. A century of research on the linguistic relativity hypothesis (LHR; also known as the SapirWhorf hypothesis) has shown that the language we speak profoundly affects our experience and understanding of life, impacting everything from our perception of time and space to the construction of our self-identity. What might the implications of the LHR be for psychology itself? As a science, the field generally aims to be neutral and objective, and to discover universal truths about the human mind. Yet it is surely consequential that the field mostly conducts its business in English, this being the default language in international journals and conferences. For instance, if a phenomenon has not been identified in English – even if it has in other languages – it is unlikely to be a topic of concern, and may not even ‘exist’ for English-speaking scholars at all. One way that the field has sought to address this limitation is by ‘borrowing’ words from other languages and cultures.To ascertain the extent of this cross-cultural borrowing, I analysed a sample of words in psychology and recently published my results in the Journal of Positive Psychology.
I focused on my own specialism of wellbeing and in particular on a seminal article from positive psychology, published in American Psychologist in 2000 by Martin Seligman and Mihaly Csikszentmihalyi, which inaugurated this emergent field. My approach was to identify the etymology of every word in the main text of the article using the online etymology dictionary www.etymonline.com. My findings reveal the diverse etymological roots of psychology, and of English more broadly. Of the 1333 distinct lexemes (words and their variants) in the article, ‘native’ English words – belonging either to the Germanic languages from which English emerged, or originating as neologisms in English itself – comprise only 39.4 per cent of the sample. Thus, over 60 per cent of the article’s words are loanwords, borrowed from other languages at some point in the development of English. This is higher than analyses of the percentage of borrowed words in English for other categories of phenomena, such as religion and belief (41 per cent), clothing and grooming (39), the body (14), spatial relations (14) and sense perception (11), and in English as a whole (estimated at between 32 and 41 per cent). In the American Psychologist text, the largest contributor of loan words is Latin (44.5 per cent) – which frequently arrived via French following the Norman conquest of 1066 – followed by French itself (7 per cent) and Greek (7 per cent), with the remainder provided by modern German (0.7 per cent), Old Norse (0.5 per cent), Italian (0.4 per cent), and Arabic, Dutch, and Scottish (all
the psychologist august 2019 digest
The most comprehensive review to date has found the average person’s reading speed is slower than previously thought. Of the various estimates of average reading speed bandied around over the years, one of the most commonly cited has been 300 words per minute (wpm). However, a number of findings of slower reading rates challenge that statistic, notes Marc Brysbaert from Ghent University in Belgium in his new paper released as a preprint on PsyArxiv. Brysbaert searched for all studies measuring reading rates in participants aged between 17 and 60 and in languages that use the Latin alphabet. Altogether, he found 190 suitable studies conducted between 1901 and 2019, collectively involving 17,887 participants. The average reading rate across all these studies turned out to be just 238 wpm – much slower than the popular 300 wpm estimate. However, there was quite a lot of variability between studies, particularly those that used very short passages, where the
slowest rate was just over 100 wpm and the fastest nearly 400 wpm. Knowing that reading rates are closer to 240 than 300 wpm might seem fairly inconsequential. But it does have real-world implications. These kinds of thresholds are used by educators to determine whether someone is a slow reader and in need of remedial help – so honing in on a precise number is important. [Matthew Warren]
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This may take longer than you think… Getty Images
0.1 per cent). Moreover, of the words treated as English in origin, 52.1 per cent are neologisms created from other languages (mainly Latin and Greek). If such words were also deemed loanwords (or at least, loan adaptations), the number of borrowed words rises to 70 per cent. One may wonder why psychology has borrowed so many words. Sometimes borrowing reflects the importation of new psychological theories and practices. One example is ‘psychoanalysis’ (coined by Freud as psychische analyse, before being rendered in French as psychoanalyse then Anglicised in 1906). Other borrowed words articulate phenomena of which English speakers may already have known but not yet named or conceptualised, hence the ready adoption of terms to allow such vocalisation. For instance, behaviours we would identify as altruistic presumably occurred throughout the centuries. However, the term ‘altruism’ was not coined until the 1830s – in French as altruisme by the philosopher August Comte, based on autrui, meaning of or to others – and soon after entered English. By borrowing words from other languages, psychology and our understanding of life become more nuanced and enriched. In that respect, psychology would surely do well to go further, and more consciously and actively engage with non-English languages and cultures. Indeed, this is one aim of my own lexicographic project, which involves collecting ‘untranslatable’ words relating to wellbeing (i.e., words without an exact equivalent in English). This is an evolving and collaborative work-in-progress, which currently includes nearly 1200 words, around half of which are crowd-sourced suggestions to my website. A key premise of the project is that the augmentation of English over the centuries has been a haphazard and arbitrary process – shaped especially by conceptual innovation in the ‘classical’ world (particularly Greece around the 5th and 4th centuries BCE, and the Roman empire between the 1st and 5th centuries), and by the vicissitudes of geopolitical power (notably the invasion by Germanic tribes in the 5th century, and the Norman conquest in the 11th century). By contrast, English – and psychology too therefore – has largely overlooked the conceptual and lexical innovations made in more distant cultures. There are exceptions though, such as the fruitful engagement by psychology with mindfulness, derived from a Buddhist concept and practice known in Pāli as sati, which illustrates the great value of this kind of cross-cultural engagement. My project therefore proposes that the field can engage with non-English ideas and practices in a much more inclusive and systematic way (including, of course, through collaboration and co-production with scholars from the cultures in question). Through this and other such endeavours, we can continue to add to the melting pot of ideas, helping the field to continue to develop over the years ahead.
People agree that it takes more effort to cast a spell to make a frog disappear than to make it levitate. The consistency of volunteers’ answers to this and other magic-related questions shows that we apply an intuitive physics to our understanding of imaginary worlds, the researchers said, which helps explain why fantasy is most compelling when it is rooted in reality. (PLOS One)
Dedicated follower of Pokémon If you have healthy vision, there will be a specific region of your brain (in the visual cortex) that responds most strongly whenever you look at faces, and similar regions that are especially responsive to the sight of words or natural scenes. What’s more, in any two people, these face, word and scene regions are located in pretty much the same spot in the brain. However, there is not a specific region for every possible category of visible stimulus – there are no ‘car’ or ‘shoe’ regions, for example (at least, not that have been identified to date). Is that because childhood experience is critical for training the visual cortex – we spend a lot of time looking at faces, say, but not cars? And, if so, in theory, could a lot of childhood time spent looking at a different type of object generate its own dedicated, individual category region? The answer is ‘yes’, at least according to an ingenious study, published in Nature Human Behaviour, of people who played a Pokémon game for years of their childhood. Jesse Gomez led the new study while a graduate student at Stanford University. He was looking for a way to test whether there’s a critical developmental window for the formation of dedicated category regions in the human visual cortex, just as there is in macaque monkeys. He needed a kind of visual stimulus that some adults had been exposed to intensively in childhood but others had not. He thought of how, from about the age of six, he, like many other kids he knew, used to spend countless hours playing a game on his Nintendo Game Boy called Pokémon Red and Blue. It involved identifying hundreds of different Pokémon characters, which look a bit like animals or mythical beasts. Gomez realised that if he could find other people who had also started playing the game intensively at about the same age, using the same device, he could explore whether this had influenced Getty Images
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the organisation of their visual cortex. He managed to recruit 11 such adults (including himself), and scanned their brains while they were shown images of Pokémon characters, as well as other things, such as faces, corridors and cartoons. Gomez and his colleagues found that within the visual cortex (in the ventral temporal region) of the Pokémon experts, there was a discrete area that was most active when looking at the Pokémon characters. There was no such region in a control group of non-players. Other work has found that the brains of people who become experts at recognising a type of object (like cars) as an adult respond differently to those objects than the brains of novices. But these differences are not in the visual cortex; they’re more often in the prefrontal cortex, which is involved in attention and decision-making rather than basic visual processing. Building on the work showing the plasticity of the visual cortex in young macaques, ‘the current finding of a Pokémon-preferring brain region really drives home just how amazing the plasticity of our developing visual system is’, write Daniel Janini and Talia Konkle of Harvard University in a news comment on the paper, published in the same issue. Gomez and his colleagues also found that – as with face-processing or word-processing regions – the ‘Pokemon region’ shared a similar location in all of the experts’ brains. They think that the physical size of an object’s image on the retina is important in determining where, in the brain, the category region forms. The image size of a Pokémon character viewed on an old Game Boy screen by children is consistently smaller than that of someone’s face – and a lot smaller than that of a landscape, for instance – which could have a lasting effect on the way visual representations are handled in the adult brain, the researchers think. As well as being fascinating, the study has potentially important practical implications. ‘Our data raise the possibility that if people do not share common visual experiences of a stimulus during childhood, either from disease, as is the case in cataracts, or cultural differences in viewing patterns, then an atypical or unique representation of that stimulus may result in adulthood, which has important implications for learning disabilities and social disabilities’, the researchers write. Consider autism, for example, which is associated with difficulties recognising faces and an aversion to eye contact. If kids with autism grow up looking at faces differently from how most children do, perhaps this explains the observed deficits in the function of the facesensitive region of their visual cortex, and in turn this could contribute to the social difficulties that autistic children experience. If this account is correct, then finding out how long the window of visual cortical plasticity lasts will be critical for designing effective interventions for autism and other neurodevelopmental conditions. [Emma Young]
the psychologist august 2019 digest
Digitally enhanced Picture in your mind a futuristic, technologically enhanced human. Perhaps you imagined them with a subcutaneous device in their arm for phone calls and browsing the internet. Maybe they are wearing smart glasses for augmented reality. What I’d wager you didn’t think of is the presence of an artificial sixth digit attached to each hand. However, a breakthrough open-access study in Nature Communications – the first to study the physiology and sensorimotor mechanics of polydactyly volunteers (people born with extra fingers) – shows the feasibility and practical advantages that would be gained from such an extra appendage. The results also have implications for the medical treatment of polydactyl people, who often have their extra finger removed at birth on the presumption that it will be of no benefit to them. Carsten Mehring and his colleagues conducted various tests with two polydactyl volunteers, a 17-year-old boy and his mother, both born with an extra fully formed finger between their thumb and index finger (known as preaxial polydactyly). The researchers note that polydactyly is ‘not rare’, with an incidence of around 0.2 per cent in the population. However, fully formed preaxial polydactyly is a rarer subset of that group. Using MRI of the volunteers’ hands, the researchers established that the extra finger has a saddle joint, similar to a typical thumb, and that it is innervated by its own dedicated nerves. Further tests established that the volunteers had independent control of their extra finger and that they were able to use it to perform a pinch grip with each of their other fingers. An MRI of the volunteers’ brains further showed that the extra finger was represented in the brain independently of the other fingers. Another test, that involved concealing the extra finger and asking the volunteers to identify landmarks on it, showed that they had an accurate mental
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representation of their extra digit. Next, the researchers used video motion capture to observe the volunteers manipulating various objects. This showed that the volunteers engaged in a ‘rich ensemble of movement patterns’ and that they frequently used their extra finger in coordination with both their thumb and index finger (it was not simply used as a substitute for these digits). ‘Taken together these results demonstrate that the movements of the six fingers of our two subjects had increased complexity relative to common five-fingered hands’, the researchers said. But do these extra movement capabilities provide any functional advantage? Mehring and his team devised a video game that required coordinating key presses to respond to six boxes oscillating progressively faster up and down onscreen. A different key press was required to respond to each of the six boxes, so people with five-fingered hands would need two hands to succeed at the task, the researchers note. Critically, the polydactyl volunteers were able to achieve the same impressive game performance with one hand as with two. Neuroscience and psychology have studied extensively the profound neural consequences for humans of losing a limb or other
appendage, including documenting the pain caused by the phantom limb effect (usually explained as due to reorganisation of the brain’s representation of the missing part). However, this new study represents the first neuroscientific exploration of having an extra body part, finding ‘… that the human nervous system is able to develop, embody and control multiple extra degrees of freedom and integrate them into coordinated movements with the other limbs, without any apparent deficits or conflicts in the sensorimotor or mental representations.’ This has immediate implications for the medical response to polydactyl, suggesting the need to ‘…thoroughly evaluate the functionality of [the extra digit] in polydactyl infants before deciding whether to remove it.’ Also, from a cyborg perspective, the results ‘… suggest that it may be of value to augment normal five-fingered hands with an artificial supernumerary finger’, the researchers said. In fact this new research paves the wave for an entire new research endeavor. ‘Polydactyl individuals with functional [extra fingers] offer a unique opportunity to investigate the neural control of supernumerary limbs, analyse internal representations of body and the limits of sensorimotor capabilities in humans.’ [Christian Jarrett]
Your breath gently lilts, your vision scans the world in a seemingly smooth, uninterrupted movement, your heart chugs away â€“ sure and steady, and you barely notice. The feeling that you are you, that the body you inhabit is yours, that you can look in a mirror and recognise yourself, rarely changes. Imagine, then, that this sense of self could warp or shiftâ€Ś
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the psychologist august 2019 sense of self
Shattering the self Ella Rhodes on the contradictory nature of the self
magine suddenly seeing your double. You may even see several, and they move just as you do. Not only this but your sense of self may jump between the true ‘you’ and any of those doubles. This is the rare disorder heautoscopy. Conditions like this, schizophrenia, dissociative disorders and depression can dramatically and subtly affect our sense of self. Once believed to be immune to scientific scrutiny, the sense of self is emerging from the philosophical domain and into the light of empirical study. Thanks to research with people with clinical conditions, and the rapid progress of technology such as virtual reality which can allow ‘neurotypical’ people to experience changes in the self, scientists are revealing one of the biggest mysteries of experience. From lofty concept to baseline process? ‘The self is everywhere and nowhere’, says neuroscientist, philosopher and psychiatrist Professor Georg Northoff (University of Ottawa). ‘Originally a philosophical concept, it has always been associated with higher-order cognitive functions and set apart from all other functions like emotions, cognitions, rationality, body, perception.’ This way of thinking was also reflected in early neuroscientific work investigating the self and consciousness in attempts to find specific areas of the brain which corresponded to a feeling of self. ‘You cannot say there are a specific set of regions just involved for the self, like the cortical midline structures which have been candidates for that, or that the self is an isolated function independent from others. No – the self impacts the memory, emotion and cognition. Maybe the self is not a very special higher-order cognitive function… maybe it’s at the very bottom. It’s not the flower in the vase on top of the table but maybe it’s the ground upon which the table stands.’
How can we experience a seemingly stable self, despite our changing environment? Something which on the surface seems simple – the activity we observe in a brain which is at rest – may hold part of the answer. Northoff tells me the brain is an energy-ravenous
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robust representation of the self in the brain. organ. It’s only around 2 per cent of a body’s total That’s where I was wrong.’ weight, yet the brain uses 20 per cent of our energy; Salomon has been chasing these questions for more and 90 per cent of that is used in ‘resting state’ activity. than a decade, working with typically-functioning ‘Of course, you ask, why does the brain use so people and those with schizophrenia and psychosis. much energy?’, Northoff says. ‘And one of the main ‘Part of the difficulty in finding the neural correlates reasons is there is continuous change and a dynamic of the self is that the brain maintains many different pattern. Compare this to tennis playing; Andy Murray kinds of self-models’, he says. ‘The most fundamental moved a lot when he was waiting for the service of level of the self, the one that we never really think his opponent. Prior to the service he was already about, is what we call “minimal self-consciousness”, moving back and forth. It looks arbitrary, but there’s a or sometimes “bodily self-consciousness”. This is what certain pattern and organisation to it. That’s what your causes you to feel that this body is you, that there is a brain does. In that change there’s probably a certain you in the world, there is an “I”.’ continuity, and that’s your sense of self.’ During the earliest years of our development Northoff has noticed an overlap of active regions in we gradually learn how it feels to inhabit a self – we studies which have investigated the self or the brain’s experience the sensation of moving our own limbs, or resting state network. The variability in the activity proprioception, the steady rhythm of our heartbeat, of the cortical midline structures seems to link to the giving us a stance from which to self, and in bipolar patients there’s see the world through our own a striking pattern. ‘In depression eyes. When these systems break we saw too much change in the “Your self matters for down, as in disorders such as variability in these midline regions. your psychological health: schizophrenia, the world can That goes along with these patients’ it’s your baseline, become a confusing and frightening experience of rumination, these place. thoughts which are all about your default” ‘Some people with themselves: “I’m guilty, I’m a bad schizophrenia feel they are not person, I don’t deserve to live”. It’s actually in control but that an an extreme focus on the self. In the external force is intervening and controlling their manic patients, who are completely distracted by the movements, implanting thoughts or stealing thoughts environment, you see exactly the opposite pattern – from their mind’, Salomon tells me. ‘In these situations, no variability at all in the midline regions.’ On asking especially in psychosis, there is a barrier which defines about experiences of the self, those who were in the me and my subjectivity. Then things which should be manic phase of their bipolar confirmed they do not on the inside, sometimes they ooze out, and things have many self-related thoughts. ‘Basically we infer from the outside sometimes come in. The barrier is from the variability on your neuronal level to the not as strong as it should be, creating this confusing variability in your mental experience.’ and disabling sense of the world. It’s very difficult to I asked Northoff why studying the self really actually act in the world without having some kind of matters, and what the wider implications of findings strong sense of self.’ such as his may be. ‘First, as a psychiatrist, it matters The typically-functioning brain has a way of for me because all psychiatric disorders involve predicting the consequences of our actions, whether changes to the self and everything else – emotion, this is the sound we make when we walk, or the mood, cognition and perception – builds on that. expectation of how it will feel when we scratch an Your self matters for your psychological health: itch. ‘If this connection is not robust, then things it’s your baseline, your default. Because I have this become confusing. Did I do that? Did that come from peculiar combination of philosophy, psychiatry someone else? Was that my action? This leaves you in and neuroscience, for me it really matters… the a vulnerable space. You’re not really sure what you’ve self is a symbol of subjectivity and subjectivity is done, what others have done, how your actions affect consciousness. If you want to understand how the the world. And we think this is the main problem in brain brings forth the mind, you need to understand schizophrenia.’ subjectivity and you need to understand self.’ Salomon tests this idea in his lab using virtual reality. Participants see their own movements in VR, but the movements may be delayed by The minimal self milliseconds. ‘With healthy participants if they make So if the self is our ‘baseline’, our ‘default’, we’d surely a hand movement and you delay it by 200 to 300 expect it to leave a strong signature across the brain? milliseconds, they say “that wasn’t me”. But people ‘The self is an elementary construct, it’s probably the with schizophrenia are very bad at making these most important construct we have in our psychology’, discriminations. They often attribute a movement that’s Dr Roy Salomon, a Cognitive Neuroscientist who runs delayed by 300 to 400 milliseconds to themselves, a lab at Bar-Ilan University in Israel, tells me. ‘The which can be very confusing for them.’ world can be divided into “me” and “everything else”, Salomon has also begun looking at the impact in a way. So I thought there would be a very strong
the psychologist august 2019 sense of self
The internal self Away from the virtual world, some psychologists take a decidely low-tech route to studying the self – whacking a rubber hand with a hammer. In this body illusion, participants place their right hand on a table with a rubber hand in the position of their left. Stroking the real and fake hands in synchrony can create an illusion of ownership, and going on to strike the rubber hand can produce a startled response. Professor of Psychology Manos Tsakiris (Royal Holloway, University of London) has used this paradigm, but with the addition of an important source of information in our bodily sense of self.
‘I can feel my heart from the inside, I can feel my guts from the inside, in a way that doesn’t apply to when it comes to touch, or when it comes to looking at faces for example. So whenever there is this processing of your own body or your own self from the outside, this is also invested and tagged with information coming from your internal body. These resources jointly produce or underpin the awareness of your own self.’
In 2011 Tsakiris used the rubber hand illusion alongside the heartbeat counting task. He found that those people who are particularly accurate at this interoceptive task experienced a weaker response to the rubber hand illusion. ‘When you have a pretty accurate representation of how it feels to be your body from within, you’re less captivated and dominated by exteroceptive information about your body.’ Tsakiris emphasises that one type of focus – environmental or internal – is not necessarily better than the other. Yet low interoceptive accuracy has been associated with some sub-clinical symptoms in terms of emotional regulation, and clinical symptoms in body image disorders such as anorexia nervosa. Tsakiris has even investigated the effects of specific moments within the heart’s rhythm: judgements made as the heart beats (‘systole’) in comparison with
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on higher-level cognitive processes including memory. ‘We know that there are strong associations between memory and sense of self. Surprisingly if you give someone a list of words, and you want them to remember them, what do you think the best instruction would be? We typically think the best instruction would be to tell this person “listen and memorise these words”. Actually, the best instruction would be, “please think of what these words mean to you”. When we relate to something and we actually bring it towards the self, we perceive it better, and we remember it better.’ The implications in an increasingly virtual world are clear. ‘When you’re disembodied, using a military drone from Pennsylvania and dropping bombs in Afghanistan, do you experience the same things? Do you have the same sense of morality? Of responsibility? Are the cognitive processes going on the same? Would you remember them in the same way?’
inbetween beats (‘diastole’). While he admits ‘the jury’s still out’ on what the results in such studies mean, he thinks ‘there’s more and more evidence suggesting that what the heart is doing to the brain is interesting: it’s modulating our brain activity and eventually our cognitive processes’.
The world can be divided into ‘me’ and ‘everything else’
The subjective space of self ‘What if the brain is not just monitoring cardiac parameters, but is actually using just the fact the heart is beating to generate a kind of common space where you can have subjective experience?’ So asks cognitive neuroscientist Dr Catherine Tallon-Baudry (Ecole Normale Supérieure), who is using measurements of the brain’s response to heartbeats (‘heartbeat-evoked responses’) to investigate biology’s role in forming the self. In one study, Tallon-Baudry hypothesised that heartbeat-evoked responses could affect the ability to perceive visual stimuli presented to people at threshold level – just above conscious perception. Participants were simply asked whether they had seen a stimulus or not. Again she found heartbeat-evoked responses to be larger when participants correctly said they had seen something, even when compared with trials where they missed the stimulus or where nothing had been present. ‘What we’ve shown is that the heartbeat-evoked response really behaves as if you had
more information on which to decide, not that you’re changing the way you report your decision, which is still something quite puzzling.’ For Tallon-Baudry, the definition of the self must include the whole of an organism. ‘The line of reasoning in my group is that any organ that continuously generates signals that are present throughout life and that are continuously sent to the brain should contribute.’ Tallon-Baudry has recently moved to study the stomach, which has a slow rhythm of its own (oscillating around every 20 seconds). While she is yet to definitively link this rhythm to the subjective self space her work has uncovered some fascinating insights. ‘The amplitude of the alpha rhythm, which is the dominant rhythm at rest in the brain, depends on the phase of the gastric cycle. Essentially you have slow waxing and waning and it seems to be that it’s the stomach that sets the pace for the modulation and the amplitude of the alpha rhythm.’ More recently, using fMRI, Tallon-Baudry has looked into which regions of the brain covary with this rhythm in the stomach. ‘We found a network of regions which are actually crossing over several resting state networks. It’s more of a sequence of regions, beginning with those which are known to receive visceral input but also regions in the cingulate cortex. Then progressively it reaches regions where it was less expected, for instance in the occipital lobe.’
Tallon-Baudry returns to this idea of a common space for subjective experience – how you might experience a taste, a sound, pleasure, pain, and it all seems to be in the same ‘space’.
‘If I ask you a weird question like “would you rather go to the swimming pool or eat a cake?”, you can answer – even though not all the information converges into one place. Those different frames of reference have to be coordinated. Because it seems that the representation of the visceral organs is actually pretty much distributed in the brain, it might be a way to create this common space so we can have those subjective experiences. Now the difficulty is how to test that experimentally.’
The virtual self Virtual reality gives researchers the ability to manipulate the sense of self using these internal signals. Cognitive neuroscientist Dr Jane Aspell (Anglia Ruskin University) can often be found in her lab confusing the selves of her participants using fullbody illusions. She’s creating an approximation of out-of-body experiences, heautoscopy, and autoscopy – all of which interfere with our sense of self. In these experiments, participants are filmed from behind and through VR headsets can see their own body in front of them. Aspell’s work builds on the work of Olaf Blanke’s lab which has found if participants
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the psychologist august 2019 sense of self
are stroked on the back while being shown their own back through VR, and if the stroking on their own back and that of their virtual body is in synchrony, they Another self will feel their sense of self moving toward their virtual There’s a hint of ‘parlour trick’ about some of these self. Aspell found, in a similar set-up, when subjects body illusions. But Dr Domna Banakou, a Postdoctoral are shown their virtual body standing in front of them and surrounded by a light which pulses in time to their Fellow at the University of Barcelona EVENT lab (Experimental Virtual Environments for Neuroscience own heartbeat, people feel as if the spatial location and Technology), has been exploring how changing of their self becomes unstable and they identify more the self impacts our real-world behaviour. with their virtual self. This ties in with Tallon-Baudry’s In one VR experiment participants, particularly findings linking brain representations of the heart to those with lower self-esteem, performed better on a the self. cognitive task while inhabiting the body of virtual Aspell’s work broadly explores the role of bodily Einstein – regardless of their baseline IQ. Banakou signals in constructing the self, but the question of also observed that participants’ implicit bias against how the brain combines all this information to create older people was reduced after their experience as a stable feeling of ‘I’ remains a mystery. ‘We know a bit Einstein. Similarly, her work has shown a reduction in about which areas of the brain are involved. There’s racial bias, measured by the Implicit Association Task, an area the temporoparietal junction which we know after White participants virtually is one key area for multisensory inhabited a Black body. integration… Olaf Blanke found “Banakou’s team, led by Banakou’s team, led by that’s the area which is functioning Research Professor Mel Slater, are abnormally when someone has Research Professor Mel also embarking on a fascinating an out-of-body experience. Slater, are also embarking project which will recreate famous This area receives signals from on a fascinating project concerts in VR so people can multiple modalities and then, by integrating them, somehow gives which will recreate famous experience being in the crowd – or even part of the band. Projects like rise to that coherent sense we have concerts in VR so people this will become more common of being a single person, being can experience being in as the technology improves, and located in our body.’ Aspell says it’s ‘quite a weird the crowd – or even part of many of the ways we will be able to investigate the sense of thing’ that the brain localises touch the band” self in future may not have been according to the body part, but also invented yet. While the potential is maps where the body part is within massive, Banakou warns of ethical space. ‘We were shifting that part considerations. ‘There is no ethical code regarding of the tactile localisation so it still feels like it’s on your the use of VR, that’s an entire field of its own… back but it feels like your back is over there. Using a Big companies care about entertainment, and that’s reaction time task called the crossmodal congruency effect, we measured that in an objective way by looking alright, but this is where we come in with our research to show that the changes we can achieve in VR or at interactions between light flashes and reaction augmented reality are so powerful. You can change time to touches. We could show the touch really was yourself so easily, we don’t know how long it lasts, but experienced in a different location in space to the it’s very important that we take on board the questions actual location of the body… which is bizarre.’ in this field and take them seriously.’ Intriguingly, in a study published earlier this year Aspell found that people with autism spectrum disorders (ASD) were less susceptible to full body Reintegration illusions. They did not feel any self-identification with The self, as we know it, provides a world of their virtual self, nor did they experience a shift in contradictions; it is stable but moveable, individual location of their self from real to virtual body. Aspell and social, complex but potentially basic. For now, and her colleagues suggested these results may be answers to the mysteries of the how, what and why of due to differences in the integration of the senses this feeling of self remain incomplete. But the potential among people with ASD, leading to a less flexible and possibility offered by the technologies of tomorrow self representation. She’s continuing to work on how give hope that we will understand what gives you the sense of personal identity is linked to multisensory ‘me’ of experience. Psychologists who have been at the representations of our bodies. ‘We think that identitiy forefront of disintegrating the self are likely to become somehow has its foundation in the multisensory increasingly involved in putting it back together again. representation of the body but we don’t know much about the links between these two aspects of self at all. It’s a challenge coming up with experimental designs Ella Rhodes is The Psychologist’s Journalist. which can test these kinds of questions.’ Ella.Rhodes@bps.org.uk.
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Michael West ‘It doesn’t have to be this way’ Michael West, Professor of Organisational Psychology (Lancaster University Management School) and Visiting Fellow with the King’s Fund, spoke with Ella Rhodes to outline three major projects he is involved with for one of the largest employers in the world – the NHS.
Currently in the NHS there are 103,000 vacancies. That’s one in 11 of all staff, including close to 40,000 nursing vacancies. There are very high levels of sickness absence compared with the rest of industry, and the level of turnover is similarly high. Lots of people are leaving the NHS for various reasons at every level. Added to that we know that 50 per cent more staff in the NHS suffer from debilitating levels of work stress compared with the general working population as a whole. Every year in the staff NHS survey, 38 to 40 per cent of staff report being unwell as a result of work stress in the previous year. The level of work stress in the NHS is of real concern. We know chronic work stress – and it is chronic in the NHS – is associated with cardiovascular disease, hypertension, heart attacks, addictions, cancer, diabetes, and more severe mental health problems including depression. It is a paradox that the NHS is a service focused on promoting health and wellbeing but in the process it’s damaging the health and wellbeing of a large proportion of its workers. It’s worth noting that the NHS employs one in 20 of the workforce in the NHS in England, and if we take social care into account it’s probably around one in 10. We know it impacts on the quality of care. We know that higher levels of stress are associated with errors that can harm patient care, and in the acute sector it’s associated with higher levels of patient mortality. It doesn’t have to be this way.
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From coal face to coal face I was drawn into occupational psychology and working with the NHS for a few reasons. When I finished my PhD on the psychology of meditation back in the 1970s, I worked in a coal mine in South Wales for a year as a labourer. What I observed underground was just how important teamworking was to safety and wellbeing at work. When I started to work in the NHS it became clear that the quality of teamworking in the NHS is often quite poor. I worked with colleagues to design the NHS National Staff Survey and we ran it for nine years. In
the 15 years since the survey has been implemented we’ve collected data from around a quarter of a million people per year. We estimate from that data that about 40 per cent of staff in the NHS work in what we’d call real teams – those with clear objectives that meet regularly to review their performance. But around 96 per cent of people say they work in teams in the NHS. We also know that the more people who work in what we’d call ‘pseudo-teams’ – the 55 or 60 per cent not working in real teams – the higher the levels of stress, injuries and patient mortality. We estimate that if we could increase the percentage of staff in real teams in the acute sector in hospitals from 40 per cent to just 65 per cent that would be associated, at a minimum, with the prevention of 5,000 avoidable patient deaths annually. We must extend and build the quality of teamworking within the NHS. Creating compassionate cultures I’ve come to believe that the core value of our health services, and the core work value of the vast majority of those who work within healthcare, is compassion. All of those who work within the NHS have a vocational commitment to helping others. The challenge for us is to create compassionate cultures in the NHS where they can effectively provide the high-quality compassionate care they want to deliver. We have to ensure that leaders lead with compassion rather than being directive, punitive and blaming which is a particular problem within the NHS at times. I’m currently involved in three projects in the NHS that are seeking to implement these principles, including working with the regulator NHS Improvement and the King’s Fund in developing a culture and leadership programme for trusts. I’m also co-chairing a General Medical Council (GMC) inquiry, with Dame Denise Coia, into the mental health of doctors. The third project is part of the NHS Long Term Plan, Workforce Implementation Initiative called Best Place to Work. The culture and leadership programme stemmed from a research programme that I, and colleagues in a
the psychologist august 2019 the NHS workforce
number of universities, worked on following the Mid Staffs inquiry into poor quality care and avoidable patient deaths in that hospital. It was a four-year (ÂŁ1 million) study funded by the Department of Health looking at the extent to which there were cultures of high-quality care across the NHS in England. We identified five key cultural factors which were present in high-quality care organisations. One was a strong shared vision or narrative around delivering high-quality care, which was embodied by all or
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most of the leaders. These were organisations that had simplified what the strategic priorities were, and ensured there were a limited number of clear objectives at every level in every team and for every individual within their organisations. People were not overwhelmed by initiatives or priorities. Leaders also created a feedback-rich environment by providing data for teams, so they could be clear about how well they were doing. These were organisations that had an enlightened
Deci and Ryan’s selfdetermination theory describes the three core needs people have at work
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approach to people management. They had developed how to improve it. Overall, we found that, by far, the their leadership internally (not just sending them away best predictor of NHS Trust performance was staff on training courses) to create more collective and experience as measured in the National Staff Survey. compassionate leadership. And leaders were generally authentic, open, optimistic and appreciative. These organisations had also given staff the The importance of leadership training, freedom and resources to make improvements Having identified those key cultural characteristics in in their areas of work. They were striving to become the best performing trusts, I had conversations with flatter, less hierarchical organisations. There was a colleagues in the King’s Fund and NHS Improvement very high level of trust in these organisations, along focused on how we could help organisations nurture with lower levels of discrimination these cultures. The most important against minority groups. This factor influencing culture is “Overall, we found that, by the leadership at every level of created a sense of justice, fairness and autonomy or control. We also the organisation. Yet there were far, the best predictor of found that these were organisations problems with NHS leadership: NHS Trust performance that generally had high levels of many people in interim leadership was staff experience as engagement, which proved to be positions, many leadership the best predictor of NHS hospital/ measured in the National vacancies, and no pipelines of trust performance. There was a people being prepared for future Staff Survey” strong commitment to quality leadership roles. The very senior improvement, learning, and leaders of organisations, such as innovation also. They empowered Chief Executives, were in post, staff at every level to make improvements rather than on average, for less than two years. In some cases, creating cultures of blame and fear, or climates that clinicians were being pressured to take on senior were underpinned by very strong hierarchies and leadership roles such as medical director. excessive bureaucracy. We worked with the Centre for Creative These organisations also were more likely to have Leadership, a US not-for-profit international well-developed team and inter-teamworking across organisation, along with the King’s Fund and NHS the organisation, so that teams were functioning Improvement to develop a culture and leadership effectively. At a minimum, teams had clear objectives programme focused on those five areas. The and met regularly to review their performance and programme involves firstly helping organisations in
the psychologist august 2019 the NHS workforce
and not establishing any continuity regarding work the NHS assess their existing culture and leadership relationships and supervision. The major problem through a variety of methods. The second step is almost all NHS staff face is excessive workload. That designing a leadership strategy in relation to the five is having a huge impact on staff turnover, sickness areas of culture, but also developing everybody in absence and major recruitment problems. We will also organisations to ensure widely held compassionate look at the experience of the sub-groups of doctors leadership skills (attending, understanding, and the particular challenges they face, for example empathising and helping). The third stage is doctors in emergency medicine who are working in implementing the strategy. very pressured environments, There are now 80 NHS trusts on and both UK and international the culture and leadership journey. “The most important BME doctors who face high levels Some of those are high performing, but some are more challenged in factor influencing culture of discrimination, disciplinary and differential their performance, because we is the leadership at every processes promotion. want to ensure that the programme level of the organisation” There’s a fortuitous alignment is applicable across the range. with the NHS Long Term Plan and The intent was that all the tools the Workforce implementation we developed would be evidenceGroup – they’re urgently addressing similar kinds based and open-source. We have drawn primarily on evidence from psychology and work and organisational of issues for all groups of NHS staff. As part of the implementation of the NHS Long Term Plan, psychology to develop the 60+ tools and these are the NHS has also set up a programme to look at free to download from https://improvement.nhs.uk/ resources/culture-and-leadership/. Each individual tool what changes needed to be made to address the workforce issues I have described. The aim is that the (such as compassion-based recruitment) includes a Workforce Implementation Plan will form part of the description of what it is, why it is important, what the implementation of the 10-year NHS Long Term Plan. research evidence is, how it is done. We provide case There are workstreams on leadership development and studies from NHS organisations wherever possible. talent management, technical skills and enablement, and the workstream on making the NHS a ‘Best Place to Work’ which I am contributing to. Towards the best place to work The Best Place to Work stream is chaired by Dr We’re just over a year into the GMC inquiry into Navina Evans, who is the Chief Executive of East doctors’ mental health. We’ve heard lots of evidence London Foundation Trust. At the start of the process from doctors, had roundtables with the Royal we adopted a model from psychology that describes Colleges, we’ve been interrogating various data sets the needs underpinning the wellbeing and motivation and reviewing all the literature both nationally and of staff – called self-determination theory (developed internationally, to get a sense of the prevalence and by Deci and Ryan). It describes the three core needs incidence of mental health difficulties for doctors. Our people have at work: work is looking also at the consequences for doctors • the need for belonging, conferred by being a valued and for health care quality. We are aiming to have an member of the team and organisation; initial draft of our report produced by the summer, • the need for competence or effectiveness (this is to probably to be published in September. do with people growing and developing their skills The intent is that we will identify the factors in in response to the challenges they face at work); doctors’ workplaces that need to be changed in order • the need for autonomy and control in the to deal with the problems that they are facing. We’ll workplace, where people can control their working design or provide examples of interventions that are environment and ensure the work they are doing most likely to make a difference to the work lives of is consistent with their values and professional doctors and trainees. Those interventions will not be integrity. focused on health and wellbeing programmes such as mindfulness and exercise, good though those things What the evidence suggests is that if any of those three are; they’ll be focused on changing the workplace workplace needs is not met, it will have a damaging factors that damage doctors’ health and wellbeing. impact on health, wellbeing and motivation at work. In Some of those will be familiar such as quality of other words, it’s no good just having two that are really teamworking, supervision, bullying and harassment, good and one that isn’t… you have to make sure all discrimination, justice and fairness, autonomy and three needs are being met in the workplace. control. It feels a real privilege to be involved in these There are also hygiene factors to do with rotas, initiatives in the NHS. The plan is that there will be long hours, not having places to sleep at night when significant interventions at a national level to change you’re on call, not having anywhere to get a hot the workplaces people are experiencing. And that in drink or something to eat. For junior doctors there turn will have an impact on the health and wellbeing of is also the problem that they are being bounced from the communities the NHS serves. organisation to organisation during their training
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Creating compassionate NHS organisations Maria Kordowicz In advance of her November workshop, we asked Maria to tell us about compassion in the workplace. What is a ‘compassionate organisation’? An organisation espousing the value of compassion. Buddhist teaching on compassion presents a way of being which cherishes living beings and demonstrates concern for alleviating the suffering of others. A compassionate organisation is one which holds this at the core of its functioning and its purpose, both in how it interacts with its external environment and at the micro level. This can sound like a lofty aim – there are some practical solutions stemming from research in this area that can help foster a compassionate organisational culture. However, research in this area, or an evidence-base, arguably needs development. We can usually feel a sense of compassion in our workplaces, as well as the lack of it; defining the aspects of a compassionate organisation, as well as capturing their impact, can be difficult. This likely relates to the notion of compassion stemming from the spiritual realm, debatably making it an ill-fit with more Dr Maria Kordowicz is a Chartered Psychologist, Quality Improvement Research Fellow and Programme Lead for the MSc in Public Health at the School of Population Health and Environmental Sciences, King’s College London. Maria will be facilitating the workshop ‘Creating compassionate NHS organisations’, reflecting on the meanings and benefits of compassionate NHS organisations, to help develop strategies for embedding compassionate practices within the NHS on 6 November 2019 in Liverpool. Find out more and register at tinyurl.com/y3qphqpf. 34
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positivist research approaches in the area of organisational development and workplace wellbeing. If an organisation is not compassionate, what are the consequences? Papers in this area tend to look at related concepts such as stress and burnout, mindfulness, and the quality and nature of relationships within the workplace. We have a growing evidence-base that compassionate actions within an organisation may reduce employee burnout, increase staff retention, foster innovative collaborations and a sense of belonging. The Mid-Staffordshire case is often cited as an example of the absence of compassion both on the individual employee level and organisationally which, as we know, led to serious failing in standards of care with harrowing consequences. Are there specific challenges for creating compassion within NHS organisations? Indeed, the Francis Inquiry called for a greater focus on delivering compassionate care, and identified recruitment, training and leadership as some of the domains of NHS organisational functioning where compassion should be embedded. Compassion is fundamental to patient care and is a value at the core of how the NHS aims to interact with its users and the public. Yet, compassion is difficult to define and thus to operationalise, especially in response to a top-down mandate. Since 2010, the NHS has undergone an uneasy period of unprecedented change, against an austerity backdrop. Some commentators have argued that organisational compassion in a market-led NHS is a fallacy. The challenges of recruitment, retention, absenteeism, presenteeism, reports of bullying and staff burnout at all levels are ever-present. There is talk of resilience building in staff, but my feeling is
the psychologist august 2019 interview
that this can pathologise and shift the blame onto the individual, without taking responsibility at the organisational level for creating an appropriately resourced infrastructure. Thus, systemic problems require our attention. I think there is great opportunity for compassion to be nurtured not only in how the NHS interacts with its external environment but in how it treats its staff and how its staff treat one another. What is the number one thing that organisations can do to be more compassionate? I am not sure there is a number one thing! There isn’t a quick fix. Compassion takes time to embed and sustain. At the risk of giving an anecdotal answer, during 15 years of my organisational development work with NHS organisations, I have witnessed that a safe protected space to reflect goes a long way in helping to foster a mutually supportive empathetic environment. This may sound simple, but we are so busy, so focussed on productivity, often over people.
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There is the ‘slow food’ movement – I would argue that conscious ‘slow work’ can go a long way towards creating organisational compassion. Is there anything that individuals can do to improve compassion in the workplace? Yes, plenty. The practice of compassion encompasses a commitment to alleviate the suffering of others. Literature suggests that role-modelling is a powerful tool in teaching, so demonstrating compassion towards colleagues likely encourages others to do the same. Being willing to discuss good practice, as well as errors, openly in a non-judgmental manner can foster a sense of trust and a willingness to work together to solve problems. Paul Gilbert speaks of developing a compassionate self-identity through identifying and picturing the qualities one wishes their compassionate self to have. To end with a quote from the Dalai Lama ‘if you want others to be happy, practice compassion. If you want to be happy, practice compassion.’
what to seek out on the
website this month
Looking back Find all our ‘Looking back’ articles – on the history of psychology and the psychology of history – via https://thepsychologist.bps.org.uk/lookback Including a recent online extra, with Rabbi David Ariel Sher on the life of Professor Reuven Feuerstein https://thepsychologist.bps.org.uk/we-cannot-afford-lose-even-one-child
Find all this and so much more via
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2019 CPD workshops Professional development opportunities from your learned Society We are pleased to launch our popular core programme and some of our workshops for 2019. Supervision skills: Workshop 2 – Enhancing supervision skills
Expert witness: Workshop 1 – Roles, responsibilities and business
Expert witness: Workshop 2 – Writing the expert witness report for court
Supervision skills: Workshop 3 – Models of supervision
Working successfully in private practice
Writing for publication
Expert witness: Workshop 3 – Court room evidence
Expert witness: Workshop 4 – Choosing, using and presenting psychometrics in court
The application of rational emotive behavour (REBT) in sport
Creating compassionate NHS organisations
How to help your clients lose weight permanently: The principles and practices of appetite training
Supervision skills: Workshop 4 – Ongoing development: Supervision of supervision
Creating compassionate NHS organisations (Liverpool)
Introduction to advanced psychotherapy skills: Intensive short-term dynamic psychotherapy (ISTD)
Working successfully in private practice
For more information on Supervision skills and Expert witness training and dates visit: www.bps.org.uk/find-cpd You can book on all workshops here: www.bps.org.uk/events
www.bps.org.uk/cpd @BPSLearning #BPScpd 36
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Autism in women Eloise Stark asks, why do we go under the radar?
More than 1 in 100 people in the UK are estimated to have an autism spectrum condition (ASC) – a ‘triad’ of impairments related to social interaction, social communication and social imagination. Individuals also tend to have a repetitive and stereotyped pattern of activities. Around five times as many males as females are diagnosed with autism – yet the true prevalence of autism in women is believed to be a lot higher.
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was diagnosed with autism aged 27, and all of a sudden my life made a lot more sense. But why did I go under the radar for so long? And are there many more women out there who don’t know that they are autistic? What distinguishes girls and women with autism from boys and men with autism? And what should we do about it?
History The ignorance surrounding autism in women goes back to the founding fathers of autism research. The term autism was first used by Eugen Bleuler in 1908. It stems from the Greek word autós, meaning self, and Bleuler used it to describe a patient with schizophrenia who had withdrawn into his own world. The study of autism was resurrected independently in the 1940s by two doctors, Leo Kanner in the US and Hans Asperger in Austria. While Kanner focused on children with the most obvious needs, Asperger focused upon children who appeared to be very able, and would later get the diagnosis of Asperger’s syndrome. Both doctors came into contact with girls displaying similar difficulties, and Kanner even stated in 1971 that autism seems to present differently in girls and boys. Yet neither pursued those differences between the two sexes, setting the legacy of inequality for years to come. Subsequent research focused upon boys, and considered autism to be a predominantly male condition. The diagnostic criteria were thereby based upon the presentation of autism in boys and
the psychologist august 2019 autism in women
men. Girls and women with autism went largely under social life, friends, partners and frequent meet-ups. Given this, I began to explore whether one possible the radar. difference between males and females with autism More recently, the ‘extreme male brain’ theory could be their social motivation. Girls with autism developed by Simon Baron-Cohen has proposed often crave friendships, and have a strong need to that men are better at systematising and women at belong to a social group. Boys with autism are often empathising. From this, he suggests that the male content playing alone, with no overt efforts to join in brain is more ‘autistic’ and that females with autism social games. Research from 2016 showed that autistic have ‘male’ brains. However, the theory that autistic girls showed similar social motivation and friendship individuals are not good at empathising has recently quality to non-autistic girls, whereas boys with autism been challenged (Bird & Viding, 2014). reported less motivation for social contact relative to For many girls and women, comparing themselves boys without autism and girls both with and without with autistic males and the archetypal ‘Rain Man’ autism (Sedgewick et al., 2016). savant, it can be difficult to see yourself as autistic Following on from this theory, the apparently too. If you’re not a boy who excels at mathematics increased social motivation in girls would presumably but doesn’t understand people, you can’t possibly be impact upon the development of social skills and autistic, right? Sarah Hendrickx, a wonderful speaker on autism in women, was herself diagnosed only in her social cognition. This could account for the fact that girls and women appear so much early forties. She comments, ‘by this better at ‘camouflaging’ their social time, I had written six books on “…autistic girls showed motivation – learning to fit in autism, completed a Masters degree similar social motivation enables them to mimic what their in autism, delivered nearly 1,000 peers do intuitively. The more autism training/conference sessions and friendship quality to social experience you get, the better and worked with several hundred non-autistic girls, whereas a social creature you become. In autistic people in a professional boys with autism reported contrast, if a male with autism capacity’. Thankfully, handfuls of less motivation for social doesn’t have high social motivation and a need to socialise, he won’t researchers across the world have contact relative to boys develop the skills as successfully started exploring the potential for without autism…” because he simply won’t have as a different presentation in women, many social experiences or be as to answer the question of whether interested in them when he does. the male bias in diagnosis is a true Others have picked up on these differences. bias. I attended a National Autistic Society conference Dr Judith Gould talks about the differences in in November 2016 on Women and Girls with Autism, diagnosing autism in females compared to males. and the conference venue was packed with interested She references Hans Asperger’s use of the term ‘little autistic women and professionals. It seems like the professors’ to describe males with autism who amassed times are a-changing, but what do we already know, huge knowledge about obscure obsessions and could and where do we go from here? lecture on their chosen topics with immense aptitude. In contrast, Dr Gould references girls with autism as ‘little psychologists’, who would often show fascination Social motivation – is this the difference? in the minds and behaviours of those around them. During my ‘autism journey’ through the diagnostic She has said that girls with autism often grow up to process and to this day, I have reflected a lot on how study psychology at university, and often progress to autism differs between girls and boys, women and doctoral research into social factors. Here I may guiltily men. I have an autistic cousin, a man, and I always raise my hand, as the holder of an undergraduate thought that I couldn’t possibly be autistic because degree in experimental psychology from Oxford, I wasn’t like him. I came to the conclusion that as a and as a current DPhil student researching the child, even though I didn’t understand social rules or neuroscience of face perception… things like fashion trends, I always had a hunger for friends and social opportunities. I remember being five years old, and my previous ‘best friend’ Hannah from Camouflaging school had found a new best friend called Michelle. Let’s dig deeper into ‘camouflaging’ – using learnt I followed the two of them around for months, not strategies to conceal social difficulties. I developed lots understanding how to fit in and become part of their of tricks to appear socially competent. I mirror the double act. I was desperate for a ‘best friend’ and other person’s body language – if they cross their arms, eventually my mum directed me to a wonderful little so do I. I regulate my eye contact consciously – looking girl called Claire who I could be a best friend to. at my social partner and periodically looking away So despite my social difficulties, I had high precisely three seconds after they do. I have modelled social motivation. And I don’t believe that this is an a lot of my social behaviour and conversational habits isolated case – many of the adult women with autism on my mum or other people close to me. For 27 that I have spoken to also tell me of their need for a
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difficulties. Of course, some years I thought that these rules individuals may have both autism and strategies for interacting were and EUPD, but it seems from normal and that everyone did this, experiences I have read about that until a clinician pointed out to me this misdiagnosis is a common that for most people, these things one. This perhaps suggests that are intuitive and they don’t even a lack of knowledge about how need to think about them in social autism presents in girls and women situations. prevents the correct diagnosis. To understand camouflaging Timely identification of the we maybe need to do a sort of Eloise Stark is a DPhil condition can mitigate problems cost–benefit analysis. For women, Candidate in Psychiatry at the and improve wellbeing, not it allows us to ‘fit in’, pass job University of Oxford to mention avoiding years of interviews, mingle at work, make firstname.lastname@example.org inappropriate psychological and and keep friends and even find medical treatment. For instance, a partner. But the costs are often knowing that you are autistic is a big shift in one’s debilitating anxiety, tales of repeated social failures identity. When I first found out, I felt like I was seeing that bring a blush to the cheeks, the obsessive desire life through different lenses. Parts of myself that I was to ‘fit in’ clouding judgement. People have often said, ‘How can you be so academically clever, but so socially very critical of, such as my inability to attend social events for long periods of time, became understandable naive?’ and therefore forgivable. In addition, the constant need It must be noted that although women often to camouflage is exhausting, often leaving me feeling ‘camouflage’ their autism, men can too. It therefore low and emotionally drained. Now that I know that cannot be a female phenotype: perhaps it’s explained the issue of social capacity can be explained by autism, by social motivation rather than being a lone I give myself credit for lasting as long as I do in social distinguishing feature between genders. situations, and also have the confidence to say when I need time out (which I call ‘shutdown’ and usually involves a dark room and an audiobook). I therefore Mental health believe that diagnosis is key for wellbeing. One common way for women with autism to arrive upon a diagnosis is through the mental health system. Research Diagnosis and beyond shows that late-diagnosed Key sources Another route for diagnosis for women is following individuals often experience concurrent mental health difficulties the diagnosis of one of their children. Exploring the Baron-Cohen, S. (2002). The extreme idiosyncrasies of autism and how it might be apparent related to the stress of constantly male brain theory of autism. Trends in in their offspring, they sit there and think, ‘that sounds having to adapt to daily life in Cognitive Science, 6(6), 248–254. a lot like me’. But given the great disparity in the a society that demands social Bird, G. & Viding, E. (2014). The self proportions of males and females diagnosed with an competency, is full of bewildering to other model of empathy: Providing a new framework for understanding ASC, and the evidence suggesting that this is a false sensory experiences, and requires empathy impairments in psychopathy, dichotomy, it seems we might still be missing many people to ‘fit in’ (Lai & Baronautism, and alexithymia. Neuroscience more women who fit the criteria. Cohen, 2015). Whereas high social and Biobehavioral Review, 47, 520–532. How does it feel to be diagnosed as autistic later on motivation in women leads to lots Eaton, J. (2018). A guide to mental health in life? The best explanation I have heard came from of social contact, this can actually issues in girls and young women on be very stress-inducing and anxiety- Neurotribes author Steve Silberman, who said that it is the autism spectrum. London: Jessica Kingsley. like finding the Rosetta Stone to oneself. Many people provoking. Hendrickx, S. (2016, 1 April). What say that they always knew that they weren’t ‘normal’, A common misdiagnosis for you see is not what you get: Life whatever ‘normal’ is, and finding out that they have autistic women is ‘emotionally as a femaile autistic [Blog post]. autism is a light bulb moment. unstable personality disorder’ or Standard Issue. Available at http:// What happens next? Unfortunately, many women EUPD. One prominent symptom of standardissuemagazine.com/voices/ say that they fall through the cracks following EUPD is interpersonal difficulties, see-not-get-life-female-autistic Lai, M.C. & Baron-Cohen, S. (2015). diagnosis, as their geographic location doesn’t provide which evidently has a big overlap Identifying the lost generation of adults appropriate services or support systems for adults with with autism as women struggle with autism spectrum conditions. Lancet autism. The majority of services are aimed at children, to follow social norms. Women Psychiatry, 2(11), 1013–1027. or at autistic people with the most obvious needs, with autism may become angry Sedgewick, F., Hill, V., Yates, R. et al. such as hygiene or feeding. More needs to be done to due to unexplained changes to (2016). Gender differences in the social support adults with autism, particularly those adults their routine or when plans have motivation and friendship experiences of autistic and non-autistic adolescents. who appear to be swimming along serenely as a swan, to change. Dr Judy Eaton (2018) Journal of Autism and Developmental but might be kicking madly underwater to stay afloat. writes how anger in EUPD is often Disorders, 46(4), 1297–1306. Many newly diagnosed women want to fit in, but due to perceived abandonment have to learn to anticipate their difficulties, prepare resulting from early attachment
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the psychologist august 2019 autism in women
accordingly and perhaps even shift expectations. For instance, my noise-cancelling headphones are a lifesaver on my daily bus rides where I struggle with auditory overload. I am still trying to overcome my instinct to get off the bus every time someone sits next to me, but getting the later bus, which is far less busy, often solves that problem. I believe that the therapeutic goal for individuals diagnosed with autism, both men and women, boys and girls, should be to educate us to bear the difficulties we experience through several means. First, understanding our strengths, such as obsessive attention to detail, can help us find careers and pastimes where we excel. Understanding our challenges can help us to mitigate them, such as by only wearing soft cotton clothes so we don’t experience unbearable tactile sensitivity to awful inventions such as nylon. It is important to empower people to be their own hero – find our own special strategies for our own special challenges. Personally, I have also found skills such as distress tolerance, mindfulness, and cognitive behavioural therapy (CBT) to be helpful. Should we be found? If there are more women with autism who have gone under the radar and don’t know they have the condition, there are ethical questions. If they haven’t
come to medical or psychological attention, are they functioning well enough and therefore don’t need a diagnosis? Diagnosis may signify that something is wrong, whereas for many women living with autism, they may have found their right niche and be living happily. It’s certainly an interesting question to consider. For me, the challenge shifts to understanding how we can best support both children and adults with autism who have different drives and goals. My dream is to become a clinical psychologist. Several people have told me that I could never do so due to being autistic… their perception is that I must have poor social skills. However, my social motivation has given me the practice to become just as socially competent as many adults without autism, and I no longer see this as a barrier to my chosen career. My advice for women or girls diagnosed with autism is simple. In Margaret Atwood’s The Penelopiad she writes: ‘…water always goes where it wants to go, and nothing in the end can stand against it. Water is patient. Dripping water wears away a stone. Remember that, my child. Remember you are half water. If you can’t go through an obstacle, go around it. Water does.’ This applies to the autistic female too – if you can’t go the neurotypical route, find your own.
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Me and monotropism Fergus Murray – science teacher, writer and ‘autist’ – on a theory with a family connection… Autism is still widely seen as mysterious – the most widely recognised symbol of it (unpopular in the autistic community) is a puzzle piece. Has one theory which comes close to explaining autistic experience been largely overlooked by psychologists?
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he most established psychological theories of autism leave vast swathes of autistic experience completely untouched, and tend to leave people with harmful misconceptions. The one theory I think comes anywhere close to explaining the whole shebang – monotropism – has been largely overlooked by psychologists. This rankles with me as an autistic adult, as a science teacher and (full disclosure) as the offspring of the theory’s originator, Dinah Murray. As someone on the spectrum myself, I dislike the pathologising, deficit-based framing of the best-known theories of autism, and I hate the mistakes they lead to in practice: assuming we lack empathy and have no idea what’s going on in anyone else’s head; painting autistic cognition as inherently more ‘male’; expecting skills we’re slow to pick up as kids to be lacking throughout our lives. It bothers me as a science teacher, almost as much as it troubles me as an autist, that psychologists settled for theories of autism which simply fail to provide any explanation for so much of autistic thinking. Granted, my background is in physics and philosophy rather than psychology, but I’ve always understood that when your theory only partially explains the phenomena being examined, you should keep looking for a better theory. When there are persistent threads left unexplained – such as the sensory differences so common among autistic people – you really need a more complete framework. Partial theories can be useful, but it’s all too easy to stretch them beyond their domain of applicability, and it can cause real problems, like assuming autistic adults have no theory of mind. Maybe it’s my autistic perfectionism, but I don’t like theories to leave too many loose ends. Monotropism provides a far more comprehensive explanation for autistic cognition than any of its competitors, so it has been good to see it finally starting to get more recognition among psychologists (as in Sue Fletcher-Watson’s keynote talk at the 2018 Autistica conference). In a nutshell, monotropism
the psychologist august 2019 autism
is the tendency for our interests to pull us in more strongly than most people. It rests on a model of the mind as an ‘interest system’: we are all interested in many things, and our interests help direct our attention. Different interests are salient at different times. In a monotropic mind, fewer interests tend to be aroused at any time, and they attract more of our processing resources, making it harder to deal with things outside of our current attention tunnel. The classic paper on this, ‘Attention, Monotropism and the Diagnostic Criteria for Autism’ largely focuses on how the theory provides convincing accounts of all the features of autism listed in diagnostic manuals, and ties them together in a way other theories fail to. The authors do a persuasive job of this, but I find the diagnostic criteria so lacking when it comes to accounting for the experience of autism that I’m not going to use that framing. Instead I will focus on some key features of autism as seen from the inside:
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autistic inertia; sensory differences; social differences; and focused interests. I close with some thoughts on implications for practice, the role of developmental perspectives, and potential research directions. Autistic inertia The bulk of what’s usually referred to as ‘executive dysfunction’ in autism – difficulties getting going with things, executing plans, and tearing ourselves away from things once we’ve started – are more informatively talked about as ‘autistic inertia’. That is, resistance to a change in state: difficulty starting, stopping or changing direction. This is central to many of the difficulties autistic people face in life, but it is also part of what makes autistic thinking distinctive and valuable. I’m a little uncomfortable with ‘executive dysfunction’ as a label for this, because it makes it
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most of the time makes the combination of spoken seem like it’s a problem with steering; it’s more helpful words, body language and eye contact tremendously to think about momentum of thought carrying us challenging. Add autistic inertia to the mix, and we forward, often to conclusions that others might have can also see why autistic people often need more missed. Thinking in terms of inertia also gives some processing time and can find the back-and-forth of insight into the discomfort of being interrupted, or neurotypical conversation difficult plans changing. It’s as if we’ve to keep up with. loaded a cart to the brim with Monotropic processing also thoughts and feelings, and then we “The monotropic mind explains the literal-mindedness suddenly have to steer it round a tends to expect one thing that autistic people are notorious sharp corner. to follow from another for. Polytropic minds have multiple This tendency follows naturally interests aroused at any time, from monotropism. Whatever more directly than that” pulling in multiple strands of interest is most aroused in a information, both external and monotropic mind tends to pull in a internal. They are primed to be on whole load of processing resources. the look-out for things like social implications, and That naturally makes it harder to change track, effortlessly decode metaphors and indirect language. especially when you understand that the paths of our The monotropic mind tends to expect one thing to thoughts always leave an imprint in our minds, and follow from another more directly than that. Most autistic ones leave deeper grooves than they might in autistic people get the hang of metaphors eventually, the average mind. but many still report the literal meaning of a saying tends to come to mind first, and it takes a moment’s processing to substitute the metaphorical intent. Sensory differences Autistic focus tends to mean we miss a lot of things It is easier for autistic people to process one channel that other people register, but other people probably at a time. Distributing our attention between multiple miss just as many things – just different things. streams takes effort, and sometimes just doesn’t work at all. Again, monotropism is characterised by intensity Psychologists like Peter Vermeulen talk about ‘contextblindness’: a useful concept, but we all construct our wherever our focus is, at the cost of processing own contexts all the time, and a better way of thinking resources that might otherwise let us deal with other about this is probably as ‘a mismatch of salience’, to input, interests or filters. This is often a problem in borrow the title of Damian Milton’s essay collection. social situations. Autism is occasionally mistaken for deafness, especially in small children: if we aren’t tuned I might miss your context, but don’t assume you in to it, auditory input might register as an unwelcome understand mine without checking. A lot of processing power goes into modelling interruption we would much rather ignore, or it might other minds, something that can seem effortless but not register at all. is never trivial. It becomes much harder when the Conversely, if we can’t tune an input out, it is often minds in question are very different from your own. experienced as horribly intrusive. There is discomfort When autistic people fail to do this, it’s not so much at our attention being constantly pulled away from that we’re unable – the idea of ‘mind-blindness’ is where we want it to be; we tend to feel things strongly deeply misleading – but that we don’t always have the if they’re present in our awareness at all; and filtering processing power left over to do it effectively, when our takes energy. Our brains throw a lot of resources at attention is being pulled strongly in another direction. whatever our focus is on, which accounts for both the intensity of conscious awareness and the pain of distracting stimuli we can’t filter out. There is likely Focused interests a developmental aspect to this: neural pathways that Interests are at the heart of the monotropism account, receive a lot of stimulation grow stronger, so perhaps autistic people are prone to long-term hyper-sensitivity and have been present in characterisations of autism right from the start. Their near-absence from the more in senses receiving intense attention, and underestablished theories of autism, and indeed the entire sensitivity in channels we regularly tune out. psychological literature on autism, is glaring. The Often, if we get overloaded, it helps to have diagnostic criteria talk about ‘restricted’ and ‘repetitive’ controlled or predictable input. Stimming, flapping, interests, but the main characteristic feature of autistic rocking and humming provide something we can do ‘special interests’ is really how much we focus on them and feel without having to think about it, and can (or they focus us), not how restricted or repetitive they make it much easier to filter, to focus on something are. else, or to deal with feelings of overwhelm. Everyone’s passions are repetitive; that’s just in the nature of strong interests. When people talk about ‘restricted interests’ what they mostly seem to mean Social differences is that they can’t fathom our failure to be interested Many social differences are sensory differences at root. in things that seem important to them. It is true that Being unable to process multiple channels of input
the psychologist august 2019 autism
we’re often powerfully interested in a few things for a relatively long time, but they do change over the years, and sometimes over much shorter time periods. For my part, I have many interests, some of them fascinations since childhood, most of them all-consuming when I get into them. Chatting with autistic adults about the things that interest them often makes the idea that their interests are ‘restricted’ seem preposterous. What is true is that our interests pull us in very strongly and persistently, compared with most people. It can be hard to think about anything else when we’re particularly invested in a topic, and hard to imagine how little other people might care about it. That can be a huge asset in many fields – intense focus is indispensible in science, maths, technology, music, art and philosophy, among others. Obviously autistic people are not the only ones capable of hyperfocus and persistent interests, but it is a common feature of the autistic psyche, and one that is too often squandered when workplaces and schools are not set up to allow it. Implications for practice The biggest practical thing to take away from this is the importance of meeting the child, or adult, where they are. This is not an insight unique to the monotropism perspective, but nothing else I’ve seen demonstrates with such clarity why it’s so crucial. Treat interests as something to work with. Recognise what someone’s passionate about and learn how to become part of the attention tunnels which come with monotropic focus, rather than trying to just reach in and pull the person out of the flow states that are so important to us. Never pathologise ‘special interests’, and don’t assume that autistic interests are ‘restricted’ – there are plenty of ways to get us interested in new things, it’s just that they mostly involve taking existing interests and building on them. Stability is a basic human need, and life as a monotropic person in a polytropic world is often unstable. It is deeply destabilising to be pulled out of an attention tunnel, to be regularly surprised by people’s actions, or to feel you are not being understood. Much of autistic behaviour can be seen as attempts to restore some kind of equilibrium. ‘Restricted, repetitive behaviours’ are a natural response to feelings of instability. They allow you to assert control over what is happening, and feel safer. This is probably a useful general rule, not something that’s only true in autism – we see restricted, repetitive behaviours in all sorts of contexts, it’s mostly just that autistic people’s ones stand out as particularly odd, to most people. Helping autistic people to maintain a sense of stability should be a priority for those around them. It’s widely understood that routines can often help autistic people, but I’m not sure it’s widely understood why. A lot of it is about minimising mental load: taking out things that we have to think about, so that we can
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‘My mum Dinah started thinking about the mind as an interest system when I was a kid, with her PhD on Language and Interests submitted when I was eight. A few years later she read about autism in Uta Frith’s book Explaining the Enigma, and I remember her excitement as she started to realise her model could easily be modified to explain rather more of this enigma than Frith or anybody seemed to have managed up to then. So I grew up knowing about monotropism, and we have discussed it extensively since. I always knew that my way of thinking tended that way, but it took years for either of us to fully identify with it. In many ways, our autism is atypical – we are not introverted, nor socially unskilled, and our interests are wide-ranging (if sometimes all-consuming). We fit the profile sometimes misleadingly labelled ‘female autism’ rather well, but this was even less understood then that it is now. It took spending a lot of time around autistic people to recognise that our easy understanding of their way of thinking came not just thanks to the valuable lens of monotropism, but also because it often resembled our own.’ Fergus Murray (aka Oolong) is a science teacher and writer based in Edinburgh; formally assessed as autistic in 2010, at the age of 32. The photos on the previous spread are his own, ‘illustrating the idea of degrees of branching’.
maintain focus. Another big part of it is that changing plans involves such a mental shift that it’s exhausting. The ability to feel in control is central to all of this, and externally imposed routines sometimes backfire for that reason. Frustrations and anxiety about control can manifest in demand avoidance, meltdowns and shutdowns at times. The dynamically developing mind No theory about minds is complete unless it’s dynamic and developmental: we are all changing all the time, and big parts of what make autistic people different have to do with heading down different development paths. Whatever the cause, a failure to connect with the people around you, especially parents, is going to have long-term implications for a person and how they relate to those around them. Perhaps even bigger than that is the disorientation faced regularly by so many autistic children, coupled with wrenching dislocations as they are forced to change tracks again and again to suit other people’s schedules. High levels of stress and anxiety have far-reaching effects on a person’s long term mental and physical health, and it can be difficult to disentangle some of these from the traits that follow directly from autistic ways of thinking.
The developmental perspective is particularly crucial because we go on learning throughout our lives, and some of the things that are impossibly difficult when we are young get much easier over time once we start focusing on them and practising. This does not mean we stop being autistic – all signs are that a monotropic brain is for life – but it does mean that many of the traits which are considered telltale signs of autism in children are only sometimes seen in autistic adults. Different experiences in youth and throughout life, and particularly the different choices we make about where to focus our attention, are likely to account for a good chunk of the diversity of ways that autism can present. Growing up in a household where eccentricity was embraced and hyperfocus understood probably helped me to grow into a relatively confident adult, and not an especially anxious one. Neither myself nor my mother grew up thinking of ourselves as autistic, but we were allowed to be weird, and that makes a big difference. Part of the variation in autism is also likely to be due to different degrees of monotropism: it has been suggested that the trait might follow a normal distribution, with some people being very monotropic, while others (perhaps the world’s natural multitaskers and peoplewranglers) are unusually polytropic. Key sources However the trait is distributed, the implication is that some people Beardon, L. (2017). Autism and Asperger are closer to having autistic minds Syndrome in Adults. than others without qualifying Chown, N. (2016). Understanding as autistic themselves, and some and evaluating autism theory. Jessica autistic people have more atypical Kingsley Publishers. Chown N., & Beardon L. (2017) Autism minds than others in terms of Theory. In: Volkmar F. (eds) Encyclopedia monotropism. This doesn’t make of Autism Spectrum Disorders. Springer, the spectrum linear: there are so New York, NY many different ways for autism to Fletcher-Watson, S., Adams, J., Brook, manifest, and so many co-occurring K. et al. (2018). Making the future conditions, that no one variable can together: Shaping autism research through meaningful participation. come close to capturing them all. Autism, 1362361318786721. Lawson, W. (2011). The passionate mind: How individuals with autism learn. Jessica Kingsley Publishers. McDonnell, A. & Milton, D. (2014). Going with the flow: reconsidering ‘repetitive behaviour’ through the concept of ‘flow states’. Milton, D.E. (2012). On the ontological status of autism: the ‘double empathy problem’. Disability & Society, 27(6), 883–887. Murray, D., Lesser, M. & Lawson, W. (2005). Attention, monotropism and the diagnostic criteria for autism. Autism, 9(2), 139–156. Murray D. (2018) Monotropism – An Interest Based Account of Autism. In: Volkmar F. (eds) Encyclopedia of Autism Spectrum Disorders. Springer, New York, NY.
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Implications for research If, as I’ve argued, monotropism provides a common underlying explanation for all the main features of autistic psychology, then autism is not nearly as mysterious as people tend to think. We do not need to rely on theories which explain only a few aspects of autistic cognition, with no convincing explanation for sensory hyper- and hypo-sensitivity, or the intensity of autistic interests. Why then is monotropism not already better known, despite a flourishing of attention in recent years? I believe the reasons are more sociological than
psychological. When ‘Attention, Monotropism…’ was published in 2005, none of the three authors were professional psychologists, although one has a PhD in psycholinguistics, and had worked extensively with people on the autistic spectrum; another, Wenn Lawson, received a PhD later for further work on this theory, with their thesis on ‘Single Attention and Cognition in Autism’ since turned into the book A Passionate Mind. Lawson had an official diagnosis of autism, which should be an asset for anyone working in autism, but is still seen by some to undermine credibility instead. The other two were undiagnosed. None were enmeshed in the world of professional psychology, and despite Lawson’s book pointing to several possible tests, they do not seem to have known which strings to pull to make sure psychologists conducted the empirical work needed to rigorously test monotropism. Autism deserves good, well-evidenced theories, and while it is easy to point out major flaws in autism theories that psychologists have largely accepted, it makes sense that they would be reluctant to accept a newer theory from relative outsiders, however much it explains. Sue Fletcher-Watson, a psychologist in the field, points out that ‘often in psychology a new theory is built on top of an empirical finding — this is what happened certainly with Theory of Mind which was rooted in a 1985 experimental study by Simon Baron-Cohen, Alan Leslie and Uta Frith. For non-autistic psychologists, there is no lived experience of autism out of which to build a theoretical model and so experimental data have to come first. This could be another reason why autistic-led theories, drawn at least in part from internal observations, struggle to make a big impact in mainstream research.’ This could be about to change. More researchers in recent years have started listening seriously to autistic perspectives on our own experiences and the theories used to describe us, and this is undoubtedly part of the reason monotropism has been gaining more attention. As psychologists dig deeper into aspects of autistic experience they have tended to overlook, including perceptual processing and the nature of autistic interests, there is great appeal in a framework that ties together these seemingly disparate strands (while deepening explanations of things like executive function and social problems). Perhaps it can also provide some helpful hints for neuroscientists. Meanwhile, insight into the monotropic mind is already helpful for anyone living and working with autistic people; I would love to see more practice-based research, looking at the impact of being able to make better sense of autistic behaviour and perspectives. My hope is that in a few years psychologists will look back at the fragmentary accounts they have been working with, and wonder why it all seemed such a puzzle for so long. But I’m not a psychologist, I’m just an autistic schoolteacher; perhaps you should take what I say with a grain of salt.
the psychologist august 2019 autism
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‘We live in a hugely psychologised society’ Juliet Foster talked to Ian Florance about her new role as Chair of the Society’s Education and Training Board.
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The Society’s new Education and Training Board continues with the educational focus of the Education and Public Engagement Board, which had its final meeting last year. It will be one of four boards, the others being Practice, Public Policy and Research. Its Chair, Juliet Foster, tells me it’s being formed for a number of reasons. ‘We have seen an exponential increase in the number of school and university students studying psychology – not only full-time but also as a component of a separate qualification. Similarly, in addition to traditional routes, many people who have no initial psychological training are now doing in-service or professional training courses to develop as managers, leaders, coaches, teachers, health professionals. We need to be able to respond to this shift. Some of my friends have switched to psychological careers later in life: it’s a subject that can suit that approach, which in turn fits with UK career structure trends and demographics.’ Juliet also raises the NHS Long Term Plan. ‘That communicates a hugely expanded, very exciting role for psychology in the future: more people treated for mental health issues; more professionals involved in delivering psychological solutions. As a Society we have a responsibility to ensure best practice for education and training in psychology within this framework. In many ways we live in a hugely psychologised society and people come into contact with psychology more and more… but there is still often little understanding of the diversity and range of approaches within psychology.’ When I read the plan at www.longtermplan.nhs. uk after my conversation with Juliet, I realised how ambitious it is for psychological intervention. To take one example, some of the milestones for 2023/24, just for adult mental health services, include access to IAPT services for an additional 380,000 people a year; a single, universal point of access and alternative forms of provision for people experiencing mental health crisis; introduction of mental health transport vehicles and mental health nurses in ambulance control rooms; and mental health liaison services in all acute hospital A&E departments.
Juliet continued: ‘We recognise that the NHS Long Term Plan, and other developments, could shift the notion of the psychological workforce dramatically. More people and more different professions will offer psychologically-based treatment; more people will receive such treatment. Put all this together and we have to rethink how psychology is taught and to whom. The traditional routes into these careers will not be the only things we have to consider – although maintaining a focus on them will also be crucial. The Board aims to outline a cradle-to-grave approach to learning, and teaching, psychology.’ Diversity within the profession is also important to Juliet and the Board. ‘It needs to be reflected in our approach to education and training. There’s evidence that students from lower socio-economic backgrounds are over-represented at A-level in Psychology compared with some other subjects, but diversity and inclusion tend to decrease in various ways the further they go in the training route. It’s interesting that, unlike other STEM subjects, female students are hugely overrepresented at undergraduate level. We need to understand the choices students are making at all stages of their careers and why. It’s important not just to ask highly targeted questions: you need to understand the whole culture around this and all the factors that are involved, otherwise you’ll come up with misleading answers.’ I asked Juliet if this approach stemmed, at least in part, from her training in social psychology and her 20 years of teaching social psychology at Cambridge University and now King’s College London. ‘Yes. I’m particularly interested in the way we’re socially situated and the influence that has: areas like the public understanding of health and illness and the way that knowledge is socially maintained and challenged. My relatively new role as Deputy Dean of Education at Institute of Psychiatry, Psychology and Neuroscience, King’s College London will also influence my approach. I’m looking at best practice and teaching in HE. For too long it was felt that if you could research you could teach. I love the fact that that has changed and is still changing – that we think about how students learn, and how we teach.’
the psychologist august 2019 careers
Given these influences it’s no wonder the Board has such a wide remit, promoting excellence in psychology training across the lifespan in a range of ways. ‘Our work is not just about reacting to the influences I’ve outlined: it’s as much to do with predicting what’s going to happen and what are the desired outcomes. To do this we’ll need to engage with every interest group to help the Society understand their needs: this will mean talking to, among many others, people in education, businesses, organisations which use psychological services, the NHS. The Board itself will need a very wide range of expertise to achieve this. I suppose one of the things I’m looking forward to is talking to such a wide range of people – I’ve always enjoyed that. My first priority is exactly that – fact-finding. Learning about how the Society works, talking to teachers and students at all levels of education and to training providers.’ Have you got sufficient resources to deliver this huge programme? ‘That’s one question I can’t answer directly. I’ll be finding out – and I hope so. What I do know is that we’re going to depend hugely on our members – their inputs, their efforts and, of course, their connections with involved people outside the Society.’ Will the growth of psychology in the way you’ve described risk lowering standards? ‘That’s always a risk, and it is bound to be a concern for some members of the Society. But it will be our job to look at exactly this issue, and to ensure we can be part of the debate about what constitutes excellent education and training in psychology. We need to consider, and value, the status quo whilst also being aware and not being afraid of, change. And our recommendations must be evidence-based. We should aim to have resources to undertake real research into the area.’ Presumably your work could impact the Society dramatically. ‘Take the Divisions as an example. Divisions give support to people with similar jobs and concerns. We shouldn’t underplay that role. But equally, the Divisions can be quite separate in some ways: we can end up learning less from one another than we should, and this can narrow the idea of psychology. Engaging fully with the range of psychologists within the Society as part of an
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educational project will be essential. We’ll also want to invite non-psychologists into the Board’s work: the NHS plan highlights their role in psychological delivery. So, psychologists won’t be doing this on our own. Outside voices, as well as inside, will be critical.’ What would you see as success, in say three years’ time, Juliet? ‘Having a really coherent strategy about educating and influencing. I’d like us to make the Society better known, and to be seen as really driving best practice across education and training.’ I asked Juliet to sum up the new Board’s job. ‘Psychology is relevant to every aspect of life: it has such a vital role to play in addressing the issues we face within today’s society. This is our chance to decide how we’re going to educate future practitioners to be more effective in meeting challenges and to help other professionals, and users of psychology, to understand the discipline and use it effectively.’
‘Games have helped me a lot throughout my life’ Dr Pete Etchells is Reader in Psychology and Science Communication at Bath Spa University. Annie Brookman-Byrne asked Pete to tell us about his first book, Lost in a Good Game: Why We Play Video Games and What They Can Do For Us.
Dr Pete Etchells
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You’ve spent many years blogging about science. What made you take the jump and write a book, particularly on a topic that is very personal for you? Writing a book is something that I’ve always wanted to do, right from when I was a kid – although I think, back then, I had designs on writing some sort of epic sci-fi space opera. Over the past few years though, I really felt as though there was a need to lay out a more detailed thesis about why the public discussion around video games has become polarised. It’s not really a topic you can drill down to in much detail over the space of a blogpost, so a book seemed more appropriate. That, and it gave me the chance to talk about one of the most important people in
my world – my Dad – in such a way that I could share his life with others. Throughout the book you describe the many issues with the research base around the impact of gaming. If you could design and run the perfect study investigating the effect of video games, what would it look like? Hah, good question! To be completely honest, I don’t know – it’s something that I’ve been grappling with, unsuccessfully, for a number of years now. But I think it’s a problem that goes to the heart of the video game debate. Although they’re seen as mere playthings, or too simple to be worthy of academic attention, it’s actually
the psychologist august 2019 books remarkably difficult to construct a well-designed and robust study about gaming effects. We’re talking about something that people do in their leisure time, which can last for minutes or hours. To try and capture that experience in the lab, in the space of about half an hour, is a near-impossible task. And the effects that we worry about are ones that can last for long periods of time – changes in personality or behaviour, aggression or impulsivity. Capturing a snapshot of those effects within a limited timeframe doesn’t really do the topic justice. If I had the resources though, I guess it would be really useful to set up a huge longitudinal study, something akin to the Children of the 90s study. If we want to figure out what the long-term effects of games are, it would be great if we could get thousands of people into the lab, at multiple time points, over the course of many months or years, and track their gaming habits in between. That’s no easy undertaking. You took many trips to museums and to meet people in the making of the book. What was your favourite excursion? Every trip that I took for the book was fascinating for different reasons. If I had to pick one though, I think it would be my visit to the Musee Mecanique – an old-world arcade on the edge of San Francisco’s tourist district. It really gave me a sense of how video games are embedded in the history of arcade machines; ‘modern’ games like Tekken and Battlezone sat alongside older mechanical games and pinball machines from the 1950s and earlier. I guess it was more about the location though. I took a trip to San Francisco with my Dad in 1995, and the arcade isn’t that far from another tourist trap that brings back very happy memories of that holiday. Just outside Ripley’s Believe It Or Not museum is a visual illusion – a giant flowing tap that appears to be floating in mid-air, apparently unaided. I remember at the time that I was completely perplexed about how such a thing could exist. My Dad was always keen to encourage a sense of scientific curiosity and investigation in me, and rather than simply explain the illusion, he instead urged me to figure it out for myself. After a moment’s hesitation, I jabbed my hand into the water pouring from the tap – only for it to hit a clear Perspex tube. It was the literal backbone of the illusion, providing both the support structure and constant flow of water. A simple but effective idea – certainly for an 11-year-old kid – but one that’s stuck with me my entire life. I don’t get the chance to go to San Francisco often, but when I do, it always makes me think of my Dad. In the book you describe how some games researchers compare scientists who suggest the effects of games are negligible, like you, to Holocaust deniers. What do you think it is about games that evokes such strong reactions? I think people on both sides of the debate really care about the effects that games are having on us. So it’s partly because of that, but partly also because games are such a ubiquitous form of entertainment nowadays. If there’s a chance that they might be doing something detrimental to us (or kids in particular), and if you’re on
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the side of the debate urging caution about them, it’s understandable that you might view people who are more dismissive of their effects with disdain or scepticism. That’s just human nature. It’s really unfortunate that the disagreements often become so vitriolic though – I don’t think that’s helpful for encouraging good, open science to be done, nor do I think it particularly helps in the more public-facing debates about games. It would be great if we could take a more dispassionate look at them, and start to think more closely about the grey area inbetween those two extremes – that games are all-good or all-bad – to try and figure out where their true effects lie. You say in the book that games give us the chance to find out something about ourselves. What have you found out about yourself through gaming, and would you say that writing a book also gave you the chance to find out something about yourself? Games have helped me a lot throughout my life. Whenever I’ve been faced with big, life-changing events, I’ve often been able to find solace in playing something for a little while. I find that it gives me time to process whatever it is that’s happened, so that hopefully I can deal with it more positively later on. Especially when I was younger, I didn’t have the opportunity to make many friends in my local area, so games also became a conduit through which I could develop social relationships and friendships, and I think that possibility is something that’s often missed in the wider concerns about whether games are bad for us. Of course, it depends on the game as well, and through the course of writing the book, I got the chance to play a few games that, at their heart, allow you to test and interrogate your own moral compass in a relatively safe space. It was always a relief that when I was faced with a difficult decision, what I thought I might do in that sort of situation, versus what I actually did do, were the same thing! As for writing a book, well, I found out that I have a chronic tendency to leave things until the last minute, for better or worse. It was a huge learning experience, and while I hope that the end result was something that is worth a few hours of everyone’s leisure time, I’ve definitely learned some tips and tricks to make writing the next one a little less stressful.
Lost in a Good Game: Why We Play Video Games and What They Can Do For Us by Pete Etchells is out now (Icon, £14.99). Keep an eye on @psychmag on Twitter for your chance to win a copy.
Struggles, hope and opportunity Girls and Autism: Educational, Family and Personal Perspectives Barry Carpenter, Francesca Happé and Jo Egerton (eds) Routledge; pb £29.99
This collection of voices is not simply a review of the current knowledge and perspectives on girls and women with autism, but a manifesto. Whether you’re a teacher, clinician, parent, or autistic female yourself, you can play a part in effecting meaningful change. What does it mean to be a girl with autism in 2019? The book cleverly views this question from a multitude of angles, all of which chime with my own experience. During diagnosis, you might be left waiting, misunderstood, or judged against predominantly male criteria. In society you might be marginalised, stereotyped, or suffer from mental illness due to the strains of trying to fit into a neurotypical lifestyle. Within the education system, you might be frustrated, unsupported, and even excluded. Having struggled myself at mainstream school to fit in and behave according to the everconfusing and multidimensional
social rules, the book captures these struggles with painful accuracy. But this book also talks of hope and opportunity. With flexibility, realistic expectations and understanding, these ‘lost’ girls can ‘find’ an identity and a way of living successfully in a neurotypical world. The example of Limpsfield Grange School for girls with communication and interaction needs shines out through insightful and eloquent comments from current students. Empathic and dedicated parents can mitigate many adversities, as demonstrated by the voice of parent Carrie Grant. I would urge you to read this important discourse yourself, but if you’re pushed for time, here are three key messages that run through the whole book. First, ‘female does not equal not-male’. It is clear from the voices and profiles of autistic girls within
the book that the autistic female is developing an identity of its own. We need to value an individual’s strengths and individuality above their challenges. Second, community is important. Autistic girls and women need support, but they can also support each other, such as in the ‘Girls Group’ discussed by Sharonne Horlocke in Chapter 7. ‘Alone we can do so little. Together we can do so much’, quotes Sarah Wild. Lastly, I would like to reiterate the message of Katie’s dad (Chapter 3), whose anecdote about difference not being an impediment to progress has really stuck with me: ‘Some cars are petrol and others are diesel, but they all get to where they need to be.’ Reviewed by Eloise Stark, DPhil Candidate in Psychiatry at the University of Oxford. See also p.38
Privileging the voices of young adults Applied Educational Psychology with 16-25 year olds Brian Apter, Christopher Arnold, and Julia Hardy (eds) UCL IOE Press; pb £25.99
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The Children and Families Act 2014 and associated special educational needs and disability (SEND) legislation saw a radical extension of educational psychologists’ client group, with statutory responsibilities to young people with SEN up to the age of 25 (when adult services are required to take over). This has come during a period of rapid professional change within a context defined, at least in part, by austerity and limited resources. This ‘perfect storm’ has meant that the response of our profession has not been as comprehensive as we might have wished and this book, commissioned and compiled by the BPS Division of Educational and Child Psychology, is a valuable contribution that brings together key issues and ideas. The first section, ‘Settings, opportunities and ethical issues’, highlights considerations around capacity and consent – particularly salient with this age group. Our profession needs to ask questions about how our practice promotes autonomy and independence. There are also some useful pointers for developing personcentred approaches within this ‘emerging market’ but more evidence of criticality around equal opportunity and participation issues would have been welcome. The second, ‘Casework and psychological intervention’, is more successful in terms of promoting participation and privileging the voices of young adults. The case study approach used throughout the book also makes more sense in this section, with ways of working clearly illustrated. Chapters from Park on the Grid Elaboration Method and Hobbs on Narrative Therapy are
particularly interesting in the ways they position both the educational psychologist and young person. The final section, ‘Systemic responses to the extended young adult group’, continues the case study approach. Highlights include Atkinson, Hyde and Kelly’s ‘Working with care leavers: A model for effective transition’. Their use of Ryan and Deci’s social determination theory to develop their transition model is thoughtful and I really enjoyed seeing the ways in which young people such as ‘Byron’ assert ‘choice and control’. Atkinson et al rightly highlight issues around efficacy and validity but these debates should not distract from the justified call for more participatory approaches in our work. The book might have benefitted from a closing summary to synthesise key points from the rich content in the preceding chapters. I guess the editors felt that readers would be able to dip in and out in line with their interests. It might also reflect the lack of coherence, consistency and confidence across our profession when engaging with the 16-25 age group. Any future iteration could address some repetition across individual contributions, but overall this is a successful first step in promoting good practice. It should be of interest to all educational psychologists, not just those with a special interest in work with this age group. Reviewed by Dr Miles Thomas, Senior EP and Programme Director, Doctorate in Educational and Child Psychology, University of East London
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My shelfie… David Carless (Professor of Narrative Psychology, Leeds Beckett University) Boy Meets Boy David Levithan Research should show us what could be, as well as what is. This funny, big-hearted, joyous little novel offers a wonderful narrative map for how things could be – in this case for LGBTQ+ young people. David wrote it for his friends; publication came about because of their love for the story. It’s marketed as ‘young adult’ but reading it for the first time at 41 was still an overwhelming emotionfull revelation. A potent reminder how certain kinds of stories – and ways of
being human – have been written out of existence, sometimes for generations. A Thousand Mornings Mary Oliver I try to start every day with a Mary poem. Wise and beautiful, she has so much to gently teach psychologists. ‘I have refused to live in the orderly world of reasons and proofs/The world I believe in is much wider than that.’ We lost Mary this year, but she left us a lifetime’s poetry. It’s inspirational that she saved her best work ‘til last: she wrote most
of my favourite poems in her seventies. Perhaps the same could be true for us? If we can only keep body, mind, soul and spirit intact within the corridors of today’s academe. Schizophrenia: The Positive Perspective Peter K. Chadwick I stumbled on this book in the arts and social sciences library at Bristol University in the days when I still visited libraries to access journals. Peter’s work showed me a psychology I could believe in: one that tackled some of the most challenging areas of human experience in a wise, inclusive and humane way. Insomniac City: New York, Oliver, and Me Bill Hayes Part photo-montage, part diary, part loving hug, this unique book takes us into Bill’s life with the late Oliver Sacks. Like others in my list, this book helped disassemble my aloneness and taught me that there is time. Bill’s writings and pictures portray so beautifully the intimacy between men, while warning me anew of the dangers of dedicating oneself to an intellectual life. Sneaky Kid and its Aftermath: Ethics and Intimacy in Fieldwork Harry F. Wolcott Harry’s work was sane, thoughtful and quietly pioneering. I’m not sure I’d have got through my PhD without it. This book is an epic story of research methodology. Now that’s not a phrase I use often! Piercing, honest, challenging and thought-provoking, this is a book every qualitative researcher should read. 1Q84 Haruki Murakami I could have chosen any of Haruki’s masterful novels. But I chose this one because it’s the longest and because it features a delicious but quietly terrifying stereotype-busting gay character. Nine hundred and twenty-five pages of riveting, intriguing, irresistible journeying through the characters’ (and my own) interior worlds. If only psychology was this much fun!
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Between the psychological and the extreme Sally Marlow
Warner Bros Entertainment
his was my first visit to the Design Museum since it moved from Shad Thames to its new Kensington home, and I couldn’t help but wonder why a Design Museum would host an exhibition on a film director. Moreover, what should you expect when you visit an exhibition which has a genius as its subject? Kubrick’s work ranges from war movies to science fiction, with horror, psychological explorations, and period drama along the way. How can Metro-Goldwyn-Mayer
Stanley Kubrick during the filming of Killer’s Kiss (1955)
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such an extensive body of work be represented in an exhibition in a way that captures the obsessive detail Kubrick was so famous for? The answer is, you probably need more than one visit. This is an excellent exhibition, but good lord, it’s dense, overwhelming even in its detail. You pass through an entrance of a montage of film clips (what else), and as I picked out highlights from 2001 A Space Odyssey, Dr Strangelove, Spartacus, The Shining, Lolita, Full Metal Jacket etc… already I was noticing those I hadn’t seen before (Paths of Glory, Barry Lyndon and Eyes Wide Shut, the latter absence in my viewing repertoire fuelled by an irrational dislike of Tom Cruise). The exhibition starts with Kubrick’s craft. Those of us who are researchers, as well I am guessing as those of us who are designers, cannot fail to be impressed by his methodological approach and attention to detail. Kubrick’s archives on a film on Napoleon stretch to over 250 books, systematic index lists, meticulously kept alphabetical cards in boxes, trunks full of copious papers, sketches, photos – all this for a film which was never actually made. The setting of the Design Museum starts to make sense. Kubrick was of course a director and a screenplay writer, but this exhibition demonstrates clearly how he designed his films, and was involved in every aspect of them, translating his overarching vision into the minute components, and bringing those components together to communicate that vision.
Ed Reeve for the Design Museum
Ed Reeve for the Design Museum
This micromanagement stretched to testing his personalised letterhead by typing ‘this is how it types’, and writing ‘this is how it takes ink’ – the proof is there in a glass cabinet in Kensington. This is not to say he neglected the macro – he preferred to create his big, ambitious worlds in studios, where he could control the environment, and when he had to venture further afield huge amounts of time and energy were spent researching locations and settings. The film was his in its entirety, from conception to finish. Nothing was edited without him, and again, he speaks to the researcher in me (as Matthew Modine and Stanley Kubrick on the set of Full Metal Jacket well as to designers) when he says: ‘Is it good or bad? Is it necessary? Can I get rid of it? modern and relevant – the stylising that was futuristic Does it work? When you’re editing you want to get rid of then remains futuristic now. The glossy, highly sexualised everything that isn’t essential.’ Korova Milk Bar visited by Alex DeLarge and his Droogs The exhibition then takes you through, film by film, before heading out looking for ‘a bit of the old ultrastarting with low budget B-movie film noir type movies violence’ would not be out of place in New York’s SoHo, made in the 1950s, with names like The Killing, and or in London’s Mayfair. The space age ferris wheel cum Killer’s Kiss. In 1957, however, Paths of Glory was the film gyroscope in 2001 A Space Odyssey, in which a woman which established Kubrick as a film maker of note, walks around and around, still mesmerises over 50 years with its tale of French soldiers in World War One executed later. by their superiors for so-called cowardice. A showreel of As I reached the section on The Shining, a note on the key scenes shows that this is a director who understood wall caught my eye, in which the film was described as people, power, frailties, but above all was humane. ‘an extraordinary balance between the psychological and It’s extraordinary to think that the same director could the supernatural, in such a way as to lead you to think also make A Clockwork Orange, with its shocking brutality. that the supernatural world will eventually be explained It is worth pointing out Kubrick was devastated by claims by the psychological’. Except of course it’s not. ‘Jack is that A Clockwork Orange had incited acts of violence, and mad’ is a neat explanation for the film, but it’s only even though the causal link was never proven, Kubrick partial. That balance between the psychological and the himself withdrew the film in 1973, and said it could not be extreme, be it war in Full Metal Jacket and Paths of Glory, shown in the UK in his lifetime. or future imagined worlds in 2001 A Space Odyssey and A Clockwork Orange had first been screened in 1971, A Clockwork Orange, or the supernatural in The Shining, and 2001 A Space Odyssey was screened before it in or even paedophilia in Lolita, is what makes Kubrick’s 1968. Looking at them now in 2019 they are incredibly work so compelling. That is why it was disappointing that I understood very little of the man in this exhibition. There are the obligatory interviews in film, audio and print, but beyond ‘I really was in love with movies’, there was no detail of who he was, and what drove him. We learn that he played chess obsessively, but even that comes back to the movies, as he describes how chess strengthened the mental discipline required for his films: chess, he explains, is about controlling initial excitement, and understanding that something that looks good at first glance may have repercussions which are not so good. Back to the design aspect again perhaps – this exhibition is not about Kubrick, it’s about his work as a director, a screenwriter, a researcher, and a designer. We see his craft, and we see his products. The man himself, however, remains elusive.
Alex DeLarge’s costume from A Clockwork Orange
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Warner Bros. Entertainmen
Ed Reeve for the Design Museum
the psychologist august 2019 culture
Reviewed by Sally Marlow, Associate Editor for Culture. The exhibition runs until 15 September. See https://designmuseum.org/exhibitions/stanleykubrick-the-exhibition
ﬁlm Dirty God Sacha Polak (director)
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Grappling for ways to survive her new identity Writer-director Sacha Polak’s English language debut is as notable for the intense psychological journey it prompted for first time actress Vicky Knight, as for Knight’s portrayal of acid attack victim Jade. The actress has spoken frankly about the personal challenge of taking on this role: aged 8 she suffered horrific burns in a fire that killed family members. Knight’s admitted that showing off her own scars (which were cosmetically enhanced for the role) and navigating her unresolved trauma vicariously through Jade was traumatic, though ultimately healing. Following lingering close ups of her scarred body and face over the opening titles, we see Jade leave hospital after many painful surgeries. Her mother has provided loving care to Jade’s two-year-old daughter Rae since the attack, but appears to have limited patience for her daughter’s on-going plight. Indeed, despite a well meaning but emotionally absent best friend Shami, only Jade can truly perceive the myriad ways her disfigurement renders her persona non grata. There is disgust everywhere she turns; frequent verbal abuse, and she can merely look on in envy at Shami’s intimate relationship. Even her own daughter fears her, and in a bittersweet sign of Jade’s desperate resourcefulness, she hides her face under a blanket and soothes Rae to sleep with a puppet show. It’s shocking watching the random cruelty meted out by strangers on Jade, who is surely a universal victim. But perhaps this says a lot about the long-standing cinematic trope of disfigurement equating evil; be it Freddy Krueger or Bond’s Blofeld. Fittingly, and apparently in response to Dirty God, the BFI has recently stated its refusal to fund movies that feature this lazy and damaging characterisation. The film’s major strength, apart from Knight’s performance, is being taken inside Jade’s daily
predicament and all it entails for a non-privileged young woman. There is no light bulb Hollywood moment of finding a way forward and things working out. It’s messy; Jade is erratic, angry and vulnerable, as a PTSD sufferer with inadequate support would likely be. She has nightmares and conflicting fantasies about her former partner and attacker. Ever hopeful of further surgeries that will improve her appearance, she is understandably frustrated by a doctor’s detached prognosis that ‘we’re where we need to be’. ‘Well I’m not’, Jade retorts, in a quietly angry cry for help that goes unanswered. Grappling for ways to survive her new identity, she desperately reaches out online for sexual contact and surgical options, only opening herself up to further vulnerability and abuse. It sounds relentless, yet Knight’s performance, along with a cinematic deftness from Polak, locates the humanity within this dire situation. At times it’s even playful, including a wonderfully clever scene - that surely only a female writer-director could create - where Jade experiences a joyful liberation as she ventures out in a burqa. For Knight, in lieu of any formal counselling, it is a relief to know she found her experience on set positive and psychologically helpful. However, in the light of the recent furore surrounding Reality TV exploitation (something that Knight herself experienced), Dirty God is a reminder that casting real life victims of trauma perhaps requires greater understanding or even regulation. Nonetheless, this film is a timely and powerful portrayal of what is, horrifyingly, an increasingly common type of assault in this and many other countries. Reviewed by Wendy Lloyd, film critic and final year undergraduate in BSc Psychology at the Open University www.wendylloyd.com
the psychologist august 2019 culture
Opening up rich conversations Art and Value, this year’s research exhibition at the Bethlem Gallery, brings together artwork from four artists in collaboration with researchers at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN) in SouthEast London. Using a rich mix of mediums including collage, audio and installation, the exhibition invites visitors to view mental health from different standpoints. The works expressively embody the bridge between the arts, scientific and clinical research, opening up rich conversations about how mental health can be understood more holistically. Artist Leon B explores the notion of quality of life. The way in which he defines the concept does not fit neatly into the pre-set boxes featured in standardised questionnaires such as the EQ-5D form, whereby the relevant items measure to what extent one has issues performing usual activities including work, study, housework, family or leisure activities. One of the works on display depicts a large floor lino pierced with
Neuroplasticity, by Sarah Carpenter
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colourfully painted cut-outs. Walking up and down the ward to keep his fitness levels up, Leon B focused this attention on lino cut-outs, usually readily discarded and replaced as they get worn out. Each brushstroke offered him agency and autonomy, notions which more candidly reflect his quality of life at the ward. ‘He was trying to express his individuality through artwork and I’ve been trying to identify what it means to be a person living with mental illness through scientific research’, IoPPN researcher Dr Faith Matcham reflects upon her experience working with Leon B on the project. She further adds, ‘We were both trying to get at the same narrative, but using completely different mediums. Together we can put forward a stronger, more impactful message.’ Sarah Carpenter’s artwork also speaks of the ‘one size fits all’ concept. One of the pieces employs the well-known square circle hexagon nursery game. Placing different objects inside the wooden checkbox silhouettes in a literal way, the artist encourages the spectator
to metaphorically and somehow ironically think ‘outside the box’. The gaps created by the misfits are a refreshing space for reflection. The work comes in response to conversations with researchers about the Clinical Record Interactive Search System (CRIS), which helps to ‘look at real life situations on a large scale’ and therefore ‘see patterns and trends’, as the researchers involved explain. Through her artwork, Carpenter brings perspective in the present age of data overload: ‘A lot of my work is about connecting the dots’, the artist explains. The exhibition is completed harmonically by interactive work from artists Beth Hopkins and Robert Smith. Hopkins directly asks the spectator what art means to them, inviting them to be part of the creative process, while Smith documents his journey from patient and participant in psychosis studies to co-researcher and explores the value of understanding different life perceptions brought by neurodiversity. The artworks exhibited are powerful in and of themselves. Yet a shared narrative prevails, in spite of the artists and researchers having worked separately and within different areas, reminding us how narrow the divide between disciplines can be. The exhibition opens new avenues of mental health research, unfiltered by the necessity to squeeze life experiences into standardised measures. In doing so, it celebrates the merits of taking a more integrated, multi-disciplinary approach.
exhibition Art and Value Bethlem Gallery 12 June – 31 August
Reviewed by Alina Ivan, King’s College London
We dip into the Society member database and pick… Caroline Foster, Consultant Clinical Psychologist, Surrey and Borders Partnership NHS Foundation Trust One book I would recommend Small Great Things by Jodi Picoult. This profoundly written fiction book provides an illuminating social psychology narrative, exploring power and prejudice as this relates to racism. It’s a reminder to be curious and inquisitive about what we don’t know, while speaking to the most unpleasant and the most admirable qualities we have as human beings. Picoult also weaves in poignant lessons on fallibility, grief and love, so it would be difficult not to be touched by or learn from this book.
and young people. This is something that the recent Parliamentary Ombudsman has called for, and it’s something I hope won’t be overlooked in the allocation of promised monies from the NHS Long Term Plan for the transition age group (18- to 25-year-olds).
One place I have fond recollections of travelling to Yangshuo in China while I was completing my undergraduate psychology degree. This was more than 20 years ago now, so I don’t know to what extent the area has changed, but the ethereal beauty of the mountain scape created an impression which has stayed with me. More recently, I trekked up Adam’s Peak in Sri Lanka which is known for the Sri Pada, ‘sacred footprint’. You can enjoy the stunning sunrise from the top. I found the gentle ambience on the climb awe-inspiring, and the change in climate at the summit is quite something.
One piece from The Psychologist Matthew Pugh’s article ‘Pull up a chair’ (July 2017) is a comprehensive and accessible overview of the history of the development of chair-based interventions, and their empirical basis. What I find enthusing is the scope for creating belief change at emotional as well as at intellectual levels; the potential for broadening the repertoire of the experiential techniques at our disposal. There is increasing appreciation that the more we can effectively use multi-sensory techniques, the greater the prospect for consolidating behavioural change, and for sustainably diminishing people’s emotional distress.
One enjoyable thing about my job In my current role as the Psychology Lead for the Adult Eating Disorders Service, one of the most enjoyable and challenging aspects relates to working with the Management Steering Group to develop the interface care pathways. Eating disorders is a dynamic and diverse field, ranging from managing transitions across care settings, to working with often severe physical and mental health co-morbidities. Physically this includes management of the risks associated with starvation and purging behaviours, but also meeting the particular needs of specific client groups such as those with eating disorders and type-1 diabetes. Psychologically the breadth of co-morbidities is also eye-opening.
one on one
One thing I would change I think it would be wonderful to see parity for adult eating disorder services alongside that of eating disorder services for children
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One inspiration The story of Paul Kalanithi, Neurosurgeon and author of When Breath Becomes Air. His courage in the face of the adversity and his positive resolve for life is more than humbling.
One hope That we can get more people better, or enjoying an improved quality of life, quicker. We must all make our own small contributions to balancing research and advances in treatment, with the management of dayto-day service demands; particularly in settings where service need is high, and responsiveness is crucial. It’s a challenge we’re well placed to further rise to. One thing about the Society I find the opportunities for networking, sharing ideas and problem-solving invaluable. Whether we are deliberating gaps in service provision or our training requirements, the informed reflective space and peer support I think makes all the difference; particularly in clinically challenging times.
coming soon… a special collection on efforts to ‘school the good citizen’; plus all our usual news, views, reviews, interviews, and much more... contribute… reach 50,000 colleagues, with something to suit all. See www.thepsychologist.org.uk/ contribute or talk to the editor, Dr Jon Sutton, firstname.lastname@example.org, +44 116 252 9573 comment… email the editor, the Leicester office, or tweet @psychmag to advertise… reach a large and professional audience at bargain rates: see details on inside front cover maybe you missed… …August 2016, William Todd Schultz, ‘Behind the masks’ …Search it and so much more via www.bps.org.uk/thepsychologist psy 08_16 pofc_Layout 1 12/07/2016 10:45 Page 1
psychologist vol 29 no 8
Behind the masks William Todd Schultz offers a psychobiography primer
Brexit poll 590 news 598 interview 632 careers 638
heroes and villains 610 off the beaten track 620 poetry competition 630 a door to minds and emotions 652
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Society Trustees (as of 1 July) www.bps.org.uk/about-us/ who-we-are President Professor Kate Bullen The British Psychological Society was founded in 1901, and incorporated by Royal Charter in 1965. Its object is ‘to promote the advancement and diffusion of a knowledge of psychology pure and applied and especially to promote the efficiency and usefulness of Members of the Society by setting up a high standard of professional education and knowledge’.
President Elect David Murphy Vice President Nicola Gale Honorary General Secretary Dr Carole Allan Honorary Treasurer Professor Ray Miller Chair, Education and Training Board Dr Juliet Foster Chair, Practice Board Alison Clarke Chair, Public Policy Board Vacant Chair, Research Board Professor Daryl O’Connor Co-opted Trustees Chris Lynch Dr Helen Nicholas Professor Jill Wilkinson Professor Carole McGuiness
Chief Executive Sarb Bajwa
Change Programme Director Diane Ashby
Division of Sport and Exercise Psychology Annual Conference St John’s Solihull, 2-3 December See p.7 Award for Equality of Opportunity 2019 See p.21 Technical Support in Psychological Teaching Award 2020 See p.21 Technical Support in Psychological Research Award 2020 See p.21 Psychotherapy Section Annual Conference London, 18 October See p.29 CPD workshops 2019 See p.36 BPS conferences and events See p.57
Director of Communications Rachel Dufton (Interim)
Find out more online at www.bps.org.uk psy 0819 p72 motm b.indd 73
Director of Corporate Services Mike Laffan Director of Finance Harnish Hadani Director of Policy Kathryn Scott Director of Qualiﬁcations and Standards Karen Beamish (Interim) Governance Manager Christine Attfield
The Society has offices in Belfast, Cardiff, Glasgow and London, as well as the main office in Leicester (St Andrews House, 48 Princess Road East, Leicester, LE1 7DR).
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