Reservations about NICE
The NICE guidelines for mental health conditions (some of which have been co-published by the BPS) are currently invested with enormous influence and authority – and are sometimes credited with helping to raise the profile of psychology and psychological therapies nationally and within government policies. Their influence is not entirely benign.
Clinical and counselling psychologists within the NHS are increasingly constrained to offer only therapies that correspond closely to empirically supported protocols approved by NICE. What is astonishing is how little objection there has been to this within the psychology professions. If a little time is spent perusing the various NICE guidelines, their drawbacks become readily apparent. The problem is not so much that cognitive behaviour therapy (CBT) is relentlessly recommended, to the near exclusion of any other approach – rather that there is minimal psychological content. ‘Therapies’ are recommended without regard for any understanding of the particular psychological nature of the target condition (or indeed of the therapy) – and thus there is no rationale offered to support the recommendation, other than that certain randomised studies have shown it to be helpful.
This lack of psychological content seems to encourage an unfortunate tendency for some GPs, psychiatrists, NHS managers and commissionersto perceive psychological therapies as analogous to pills that can be prescribed – e.g.‘a course of 16 sessions of CBT’, seen as an alternativeto ‘a course of six months antidepressant medication’. The careful work of understanding the complexities of the individual, which are often somewhat remote from the presenting symptomatology, is lost.
Even within the recommendations of CBT, the guidelines are misleading. For example, the one for OCD perseveratively advocates ‘exposure and response prevention’. Whilst this is indeed a classic (albeit not very effective) approach within the behaviour therapy tradition, there are many who recommend a more cognitive approach that reframes meaning and interacts with behavioural experiments, and report excellent results (Jones & Krochmalik, 2007; Salkovskis & Wahl, 2004; Schwartz, 1996).
Although NICE guidelines have their appropriate place as summaries of certain kinds of evidence, their idealisation is misleading, unscientific and cognitively stifling. I would be interested to know if others share my reservations about NICE.
- Phil Mollon
Mental Health Unit
Jones, M.K. & Krochmalik, A. (2007). Obsessive-compulsive washing. In R.G. Menzies & P. De Silva (Eds.) Obsessive-compulsive disorder: Theory, research and treatment. Chichester: Wiley.
Salkovskis. P.M. & Wahl, K. (2004). Treating obsessional problems using cognitive-behaviour therapy. In M.A. Reinecke & C.A. Clark (Eds.) Cognitive therapy across the lifespan. Cambridge: Cambridge University Press.
Schwartz, J.M. (1996). Brain lock. New York: HarperCollins.
Pleasure in hurting
As a contribution to the debate on the psychological processes involved when ‘ordinary’ people engage in sadistic acts, I’d like to draw attention to these words of C. Fred Alford, Professor of Government and Politics at the University of Maryland: Almost every free citizen explained the results of the Milgram experiment as Milgram does: People are naturally weak, conformist and cowardly, but they are not naturally sadistic. Most are simply too weak to say no, or too thoughtless to think about what they are doing. Every prisoner [imprisoned for murder or rape], almost without exception, explained the results of the Milgram experiment as citizens taking advantage of an excuse to express their sadism.
It was not my experience that the inmates in my group were more aggressive and sadistic than free informants. But the sadism of many inmates is more visible, more likely to go freelance. Indeed, this is virtually the definition of criminal behaviour. Not its violence…for who is more violent than the nation state and its armies? … It is not obvious that freelance violence is more evil, the motives behind it fundamentally different.If this is true, then evil, understood as pleasure in hurting, is more widespread and institutionalized than we know. We just don’t see it. (Alford, 2007)
This passage summarises from Alford’s own book Psychology and the Natural Law of Reparation (Cambridge University Press, 2006).
- John Raven
Alford, C.F. (2007). Evil be thou my good. The Good Society, 15, 2, 13–16.
Cultural lessons from the arts
Only relatively recently having completed clinical training, I cannot but welcome Dinesh Bhugra and Padmal De Silva’s advocacy of the use of cinematic and literary works as training tools (‘The silver screen, printed page and cultural competence’, September, 2007). Artistic takes on psychological matters can offer valuable and engaging insights that can complement some of the more ‘hard’ science aspects of applied psychology, as well as overcoming post-prandial drowsiness!
However, in an article that rightly emphasised the need for cultural competence, I was surprised to find reference to ‘cultural groups’ which appeared to somewhat confuse concepts of culture, ethnicity and minority ethnic status. Whilst some of the groups referred to seemed to be formed around membership of minority ethnic groups within a particular country (e.g. Asians in the UK, African Caribbeans in the UK), others seemed to take in whole vast swathes of humanity on the basis of geography or skin tone (e.g. Latin Americans or Caucasians).
As culture varies on so many continua, any such grouping is bound to be to some extent flawed as there will be great variation within these groups, but at least in the first two there might be some similarities in terms of experience of racism, acculturation, locality, etc. However, other groups (particularly ‘Caucasians’ but possibly also ‘Latin Americans’) s eem so broad as to be hopelessly reductionistic.
Do six North American films offer us any particular insight into the life of a Caucasian person living on a Czech council estate, or even one living in Windsor Castle? Probably not any more than The Cosby Show told us about life in downtown Kampala (or Los Angeles!)
Culture is too multifactorial to be encompassed by crude racial categories. Factors such as social class, sensory ability, religion, education, region, experience of discrimination, nationality, and many others, are key to understanding a person’s culture, and are often as important, if not more so, than their ‘race’. Some of these factors are indeed broached in the main body of the article. However, I fear that a list that apparently confounds culture and ‘race’ cannot fail to miss half of the story, which is a pity, as there are some good stories which ought not be missed.
- Luke Koschalka
Dinesh Bhugra and Padmal De Silva are to be congratulated on their use of cinema and literature to assist psychology students to understand other cultures and individual dynamics and psychopathology that they may not be able to know directly (September 2007). I would like to make a recommendation and a caution.
The recommendation is for The Abnormal Personality Through Literature (Prentice-Hall, 1966) edited by Alan A. Stone and Sue S. Stone. This remarkable anthology illustrates psychiatric conditions and personality types through excerpts from the classic American, Russian, English, German and French masters in understanding of the human condition, such as Shakespeare, Dostoevsky, Thomas Mann, Henry James, and Tolstoy.
Films also need to be represented by the masters, not according to the assumed characters in them. Actors and scriptwriters may not understand the characters that they represent dramatically, and so distort realities with stereotypes and exaggerations. People are more complex than a syndrome they may be taken to represent. Selection of dramas needs care, and discussions should always consider the validity and scope of each representation. The best of them help students to recognise the common humanity of all, however afflicted.
- Valerie Yule
I enjoyed the Bhugra and De Silva article on the relationship between film, psychology and cultural competence (September 2007). The relationship between psychology and culture is not new. Freud of course was a great student of Shakespeare and used the insight into human nature given to us by the great playwright in much of his work.
Film has also been used to portray a number of developmental conditions. The most obvious examples are Dustin Hoffman’s role of a man with autism in Rain Man and Tom Hanks’s account of the life of a man with Asperger’s syndrome in Forest Gump. The characteristics of Asperger’s syndrome – lack of social understanding, lack of empathy with others, lack of social timing and inappropriate allocation of motive in others – have all been used a great deal by the recent generation of comic performers. I would argue that Rowan Atkinson’s Mr Bean, Steve Coogan’s Alan Partridge and Sacha Baron-Cohen’s creation of Borat all fit the criteria for Asperger’s syndrome.
The fact that Sacha Baron-Cohen is cousin of one of the leading experts in the field [see e.g. ‘Transported to a world of emotion’, February 2007], is intriguing. I wonder if they compare notes at family gatherings and who gets most out of the encounter?
- Jeremy Swinson
Misunderstanding Doing Research with Children
The review by Margaret Clark of my co-authored Doing Research with Children (Sage, 2007, 2nd edn) demonstrates a serious misinterpretation of the purpose, nature and contents of the book.
Firstly, the original textbook published in 1999 was never meant to be one of the ‘few simple books dealing with the issues in undertaking research “with” children” as stated. The book was, in fact, the very first of its kind, developed specifically for students beginning the new degrees in Early Childhood Studies, of which two of the authors were pioneers.
Secondly, the original text was unintentionally ahead of the times in the use of the expression research ‘with’ children. There was, in fact, little notable research ‘with’ children at that time and even today, not all research is ‘with’ children. This is rather a more recent development and the book has new chapters on consultation and participation with children, and also on qualitative methods, dedicated to these topical issues.
Thirdly, the book was never meant tobe ‘simple’. The few existing texts in the 1990s were largely designed for trainee nursery nurses or teachers that were considerably dumbed down both theoretically and ethically. Methods were made very simplistic with field observation being the gold standard of approach.
A conscious decision was made not to patronise our students, who, having demonstrated an ability to attend a university degree course, and including already established professionals, would be expected to enjoy challenging and informative range of material.
Clark complained was that there was not enough theory in the book ‘early on’ and about the examples given. The book is in fact packed throughout with the most recent theories including, unusually, actual research exemplars extracted from the published practice research of the authors themselves (e.g. autism, literacy, attachment, mental health and counselling in children and young people are only some of the areas with current publications). Choosing which exemplars to use and where to locate them in the book was given much consideration. Evaluative papers were those that presented the range of issues which students would need to master at this stage of their studies in research.
I am curious why Clark (and a surreptitious colleague) referred to a photographic figure, quite out of context. The figure is actually embedded in a chapter that clearly explains the illustration, the uses and abuses of children’s drawings in research together with an entire section on guidelines.
Finally, I am astonished that Clark appears to be complaining that parts of the book are the same as the first edition. Surely the point of a ‘second’ edition is the continuity of the text, otherwise we would have ‘new’ edition. This second edition was appropriately updated to reflect advances in research methods in the last decade and to relate to children of all ages. Five independent reviewers provided feedback to Sage to guide the second edition.
Given Clark’s misunderstanding of this book, it is obvious that her reading of it was not ‘lively and engaged’ and this perhaps says more about her general approach to the book than it does about the book itself.
- Anne Greig
Colgrain Community Education Wing
With ESRC funding, myself and colleagues at Loughborough University are organising a seminar series on migration and career. The aim is to provide a forum in which academics, practitioners and policy makers can examine the implications of migration (of both people and work processes) for career. If you think you could contribute to and benefit from these seminars, and would like to participate, please contact me by 9 November 2007.John [email protected], 01509 223121
I am a counselling psychology trainee at the University of East London completing my doctoral thesis. I am interested in hearing from any qualified therapists (clinical psychologists, counselling psychologists, psychotherapists) who provide therapy for individuals aged between 13 and 19 years old who self-cut. I would like to interview you for approximately one hour at a place of your convenience about your understanding of self cutting and the therapeutic relationship with young people who harm themselves.
This could be an opportunity for you to express your thoughts and opinions on this complex phenomenon that may have a significant and important impact on our future practice.
The study has been ethically approved by the University of East London. If you are interested and would like to find out more, please do not hesitate to contact me.
- Amy Bloxham
We are offering honorary placements for second- to third-year trainee counselling psychologists in an NHS primary care brief intervention psychology service in surgeries in Loughton/Epping, Essex (good rail and transport links). Minimum of 150 hours clinical experience is desirable. Regular supervision provided.
E-mail a brief CV or contact me for more information.
- Kate Scales
Against the spirit of the advertising code?
It was heartening to read Gustav Jahoda’s piece on the science behind superstition and belief in the October issue. Whilst I greatly admire Professor Dawkins’ evangelical zeal for the scientific method, it has always seemed incongruous to me that such a devotee of science remains mystified by the apparent unwillingness of people at large to behave in a rational manner. The psychological science behind ‘the God delusion’ and other superstitions can be modelled from the neuronal level, through learning theory to societal explanations. It is good to see psychologists contributing to the debate.
I was therefore surprised to read an advert for a ‘Diploma in Soul Therapy, Level 1’ just a few pages on. The advert invites participants to ‘integrate practical spirituality into your 21st century work, combining systemic psychotherapy and CBT skills with spiritual healing and other subtle energy techniques’. Participants will apparently be able to enrich their current clinical practice with ‘an awareness of ancient wisdoms and methods of interpersonal healing techniques’. The course is convened by a ‘registered spiritual healer’.
I am aware that The Psychologist does not endorse the adverts contained therein, but the Society does have a code of advertising which clearly states that advertisements should be for ‘relevant products and services’ and that advertisements should not offend recognised standards of psychological practice’ (paragraph 6). Is spiritual healing a recognised standard in psychological practice? When we are trying to obtain statutory regulation, advertisements such as these in our professional publication can only damage the cause.
- Sallie Baxendale
Institute of Neurology
University College London
The Editor, Jon Sutton, replies: The Soul Therapy advertisement has been discussed at length by the Psychologist Policy Committee in the past. Although minor changes to wording were sought and agreed, the conclusion was that ‘in general The Psychologist is happy to expose to its readership alternative areas and views and accepts that many readers have an interest in these areas.’
Because the person offering the service is a member and chartered psychologist,the first avenue of complaint would be as a disciplinary matter if there is a suggestion that the person is breaching the Code of Conduct. If there is no such suggestion, there seems no good reason to reconsider the inclusion of the advertisement.
Psychologists and national security
Karen Carr, of the Defence Academy of the United Kingdom, argues against Burton and Kagan’s view that psychologists should have nothing to do with national defence and security, and that psychologists should serve ‘legitimate, democratically controlled defence and security activities’ (Letters, October 2007).
May I point out that the invasion and occupation of Iraq was not decided on democratically and its legitimacy is very much open to doubt, and that our current security activities include passive support for kidnapping and use of evidence obtained under torture, and that much security activity is not openly scrutinised by Parliament.
Therefore, by Karen Carr’s standards, Burton and Kagan are entirely justified in calling on psychologists not to become involved with the state security apparatus.
- John Rowe
The IQ rise
A year ago Patrick Rabbitt (‘Tales of the unexpected’, November 2006) described the increases in intelligence that have occurred during the 20th century in many economically developed nations as ‘small’, and now in response to my observation (Letters, August 2007) that an increase of approximately 27 IQ points over the period from 1917 to the present can hardly be considered small, he writes (Letters, September, 2007):
‘I need better evidence than I can currently find to assess the derivation of Richard Lynn’s estimate of “over 27 IQ points”.’
As others may also be interested in how such a large increase can be calculated, I will explain. Tuddenham (1948) compared the IQs of men conscripted into the American military in 1917and in 1943 and reported an increase of 11.5 IQ points, representing 0.44 IQ points a year. Nearly 40 years later Flynn (1984) calculated from successive standardisation samples of the Wechsler and the Binet that the American IQ had increased by 0.3 IQ points a year from 1932 to 1978. More recently, Flynn (2007) has calculated that the American IQ continued to increase by approximately 0.3 IQ points a year up to 2001. Thus, Flynn’s calculated gains spanning the years 1932 to 2001 represent an increase of 20.7 IQ points. To this should be added Tuddenham’s calculated gain of 6.6 IQ points for the years 1917 to 1932, making a total of 27.3 IQ points from 1917 to 2001. Similar gains have been calculated for Britain and Japan (Lynn & Hampson, 1986).
This massive increase in IQ raises intriguing questions. Is it credible that the average intelligence of our great-grandparents was 27 IQ points lower that that today, and therefore that about half of them would be considered borderline mentally retarded by today’s standards? Or are intelligence tests not a valid measure of intelligence? These questions have not been resolved but one thing at least is certain. This is that the IQ increase cannot be called ‘small’.
- Richard Lynn
University of Ulster
Flynn, J.R. (1984). The mean IQ of Americans: Massive gains 1932 to 1978. Psychological Bulletin, 95, 29–51.
Flynn, J.R. (2007). What is intelligence? Beyond the Flynn effect. Cambridge: Cambridge University Press,
Lynn, R. & Hampson, S.L. (1986). The rise of national intelligence: Evidence from Britain, Japan and the USA. Personality and Individual Differences,7,23–32.
Tuddenham, R.D. (1948). Soldier intelligence in world wars 1 and 11. American Psychologist, 3, 54–56.
Psychology research in the UK – Healthier than ever
The UK took a rather slow start in psychology as an independent scientific discipline, crowded as it was with empirical philosophers and evolutionary biologists.
In 1897 W.H.R. Rivers would be appointed Lecturer in Physiological and Experimental Psychology at the University of Cambridge. At that time, 13 countries already had laboratories of experimental psychology.
Although the UK would catch up rather rapidly, psychological research for most of the 20th century was heavily dominated by the US. To find out how the UK’s share in psychological research has evolved over the years, I analysed the number of articles on psychology published in the Web of Science. I discovered that the contribution of the US dropped from 66.3 per cent in 1975 to 49.3 per cent in 2005. In contrast, the UK’s share rose from 9.6 per cent in 1975 to 18.3 per cent in 2005.
This share is even more impressive when a correction is made for the number of inhabitants. In 2005 the UK published 73 articles per million inhabitants against 38 for the US. This number is among the highest in the world and is only topped by New Zealand (79 per million) and the Netherlands (78 per million).
Readers of The Psychologist may take some comfort out of these figures the next time they have to complete the RAE forms, apply for yet another grant, or simply cope with the administrative side of their university.
If you take a bird’s-eye view, we are not doing that bad at all.
- Marc Brysbaert
Royal Holloway, University of London
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