Forum

diversity in clinical training; unnatural beliefs; psychopathy; and much more

Diversity in clinical training

Andrew Williamson’s letter (June 2010) raises key questions about the challenge to improve diversity in recruitment to clinical psychology programmes. Andrew comments on the particular barriers that stand in the way of more mature applicants who may have mortgages to pay and who may be parents. Such circumstances are likely to restrict the availability of assistant psychologist posts compared to younger applicants who are better placed to relocate when job opportunities arise. As Andrew points out, the aspiration to increase diversity is compromised when older applicants with family and financial commitments are disadvantaged.

The annual recruitment process invariably and inevitably involves challenges. An enormous number of very strong applications are received each year. That creates a situation where a large number of good applicants must be rejected. Like Andrew, many of those who do not gain a training place will have invested heavily in accumulating academic qualifications and work experience. A large pool of disappointed applicants is unavoidable in these circumstances.

We are scientists, and data has been gathered over many years. I’m aware that data exists about black and minority ethnic applicants but am not aware of data relating to age or disability. A recruitment process has to operate a system that helps to shortlist in a way that is fair to all applicants. Although we wrestle with these challenges, we have what may also be seen as an embarrassment of riches. Evidence tells us that the huge number of high-quality applicants invariably delivers very good trainees. Compared to other university programmes and to other health professions training programmes, drop-out from clinical psychology training programmes is exceptionally low and successful completion exceptionally high. After qualification clinical psychologists typically go on to long NHS careers.

Despite these successes the selection processes haven’t yet delivered on diversity, and these serendipitous riches should not distract us from the diversity agenda. We continue to review our processes. Andrew asks whether clinical psychology can learn from the South Yorkshire Police and remove the structural and process-related problems that are discriminating barriers to diversity. It’s a big question and one that has been a focus of national discussion for many years. I’m confident that examples of good practice in recruitment process from other professions would be helpful and would be received with interest by the profession.

I suspect that structural changes that may help with Andrew’s particular circumstances cannot be resolved by clinical training programmes in isolation. Assistant psychologist posts within the NHS and in private sector healthcare provider organisations are often advertised with fixed and short-term contracts. Unless regional strategies are developed that give a more secure career path through the pre-training career stages, and that include posts that link directly to local training programmes, then the structural barriers that Andrew has met are likely to remain.

The process barriers are probably a more fruitful focus for clinical psychology training programmes. Of course we want to recruit trainees who will help create a workforce that serves and reflects the rich diversity in our society. During the past 20 years a number of reports recognising the progress that is needed to increase diversity in the profession have been produced. Monitoring and initiatives to reach a more diverse audience for recruitment continues. I’m aware that there are passionate advocates within the profession who will ensure that the training community continues to develop processes to promote wider inclusion. It remains as a national issue that requires much more work. It’s my view that solutions will require actions that nurture interest long before the application stage of the process and that reach beyond the small group who are employed in training programmes.
Tim Prescott
Doctorate in Clinical Psychology
Teesside University 


A wise supervisor once explained to me that when confronted with hundreds of apparently able applicants, there is an innate tendency to make ‘safe’ decisions and to recruit people whose ‘face seems to fit’. I simply don’t know how else to explain the disproportionate number of assistants and trainees who are young, female, childless, able-bodied, who drive and who are conventionally attractive.

I think this is a case of a profession simply reproducing itself in its own image whereas in actuality people recruiting for such positions have a duty to rise above these kinds of bias and try to value people for their uniqueness and the fresh perspective they can bring.

I think the widespread attitude that the early stages of trying to be a clinical psychologist should involve immense personal sacrifice and that if you can’t do this you are just not ‘dedicated’ enough is very outmoded and offensive. However, I have seen this kind of ethos operate in selection for clinical psychology jobs and courses (‘this applicant hasn’t done enough voluntary work/mopped up enough sick/doesn’t even drive/won’t move around the country’). This was also the prevailing attitude during my training experience. There is often no acknowledgment that the ethos of martyrdom is actually deeply unhealthy to everyone and is toxic to diversity. ‘Non traditional’ assistants and trainees simply cannot all make the same sacrifices of time/travel/unpaid work in order to pursue this career route (people with disabilities, with children, etc.).

If my own experience is anything to go by we have already made disproportionate sacrifices to gain relevant experience by the time we reach clinical training anyway. It is a source of deep sadness to me that my son still remembers my training years when I once shouted at him for losing a tooth in the middle of my urgent assignment and the hours he was left to ‘just go and watch telly mum can’t play with you’. And this was after years of chasing jobs that didn’t want me, dealing with bullying supervisors, endlessly having to explain why I don’t drive and ‘yes I’d be happy to pay for my own cabs, just give me a chance’, etc. It is no wonder we have such issues of not representing our client groups and inadvertently filling the profession with people who are ‘safe’ i.e. homogeneous in terms of background and experiences. It desperately needs to change!
Ilona Singer
Manchester



While sympathising with Phil Boyes’ frustration (Forum, July 2010) about the contentious nature of selection for trainee places on clinical psychology courses, I wonder whether the argument about who is selected for clinical training is more complex than simply about fulfilling the stipulated criteria of NHS experience and good qualifications. Since these are mandatory requirements just for consideration onto courses, does it not make them a necessary but not sufficient requirement and thus, as the process ratchets up, practically irrelevant as the rounds ratchet up? Is it rather about what the candidate has learnt and understood through practical, personal and academic pursuits that becomes central to the selection process?

I suppose the issue comes down to what kind of potential clinical psychologists are current clinical psychologists trying to recruit? What characteristics are they looking to foster in potential trainees? What frustrates Phil perhaps is that it appears that these characteristics are not uniform across institutions. The question then is what characteristics are favoured within the discipline and valued amongst selectors?

I am a first-year clinical trainee. I too am older (39 at my next birthday), with a variety of (clinical and non-clinical) experience. I am a qualified A-level psychology teacher with experience with children with behavioural problems. I have some in-patient adolescent mental health experience, a first class psychology conversion diploma and a good master’s degree from LSE. 

While I consider my master’s an achievement, I have come to realise that in my cohort of 32, having one is not the exception, but the norm. Most of those without master’s have a 2.1 (or above) degree from Oxbridge and the like. Given the level of competition for places, minimum requirement selection criteria are just insufficient to guarantee training.

The first day of the course was a slap in the face to me. Not only was I the oldest in the cohort by some years (in the second and third years, there are a few trainees who are indeed older than me), some trainees were barely into their twenties. I too questioned how wise the selection process had been in deeming such young graduates suitable for training. Over the months since the course’s inception I have however come to admire the rigorous critical thinking skills of my fellow trainees, as well as the breadth and depth of their clinical knowledge. Almost to a (wo)man, all had significant experience of assessments, therapy and/or outcome evaluations prior to training. With a remarkable capacity for empathy and insight, I am frequently awed by the realisation that youth does not equate to absence of maturity or ability, and I believe all these trainees will make excellent psychologists. Is it possible that the degree of competition between younger applicants fosters a new level of rigorous undergraduate and postgraduate psychology education that makes younger candidates stand out academically? I have come to appreciate exactly why each and every one of the trainees in my year group was selected for training.

Is the debate then about gender? There are 31 women and one man in my year group, with a not dissimilar proportion in the second and third years. Having taken part in the selection process for next year’s trainees, I understand that given that only a small proportion of men apply, a more-or-less representative proportion presents to interview. From anecdotal evidence I understand however that this proportion is consistently smaller than those that are finally offered a place. I have been told by those involved that this is the result of the way in which men interview. At the risk of making gendered assumptions, I wonder whether this may be because of the socialisation models that men are provided with. With regard to questions about self-reflexivity and personal responsiveness in relation to working within mental health, all candidates struggle in interview. I know I did.

Could the issue be related to the route taken into training? As I understand it, many but by no means all of my fellow trainees have worked as assistant psychologists. The rest have a variety of experience. Given this variety, what does constitute sufficient experience? My experience was deemed sufficient to warrant two interviews, but insufficient to warrant four, and resulted in only one offer. I believe that the two universities that offered the interviews were those that value diversity, self-reflexivity and personal experience over demonstrable clinical experience.

Is it the application process? I applied for the first time last year. Being from a different discipline (education) and indeed different culture (South Africa) meant that I had no idea about the notoriety surrounding the application process. I had not tailored my career with applying in mind. Did my naivety allow me to brazenly advertise my talents without an appreciation of the consequences of failing?

I believe the reasons that I, and others, have been offered a place on training are myriad. I believe that selection criteria are a complex interplay between the personal, professional and academic and that any attempt to reduce them to a model of the formulaic perfect applicant is simplistic and unrealistic. It misses the point of what psychology is.
Tina Siobhan Cohen
Surrey University


Unnatural beliefs

Am I the only reader who enjoyed the irony at the heart of the article by Stuart Wilson on the ‘Naturalness of weird beliefs’ (July 2010)? The thrust of the article is that we are hard-wired to believe, and we have to work hard to turn off our ‘natural urges’ to credulity; but the article fails to appreciate that a belief in natural urges or hard wiring is itself lazy thinking. Psychology seems unable to let go of the idea of an essentialist human nature.

The central idea of such a view is that we come into the world with our mind in some way preformed. The terms for such preformation have changed, instinct is no longer in fashion, hard wiring is still in use (e.g. ‘our minds may be hard-wired to be predisposed toward certain types of odd belief’), but the favoured term now I think is evolved cognitive mechanism. For many contemporary psychologists, we are simply the sum of our evolved cognitive mechanisms. However, developmental biologists have rubbished the idea of any kind of hard wiring for even quite simple aspects of organisms, let alone cognitive capacities (Oyama, 2000). The arguments against such preformationism have been around for many decades (Haldane, 1932) and remain remarkably robust in the face of scientific advance.

I have a far simpler explanation than Wilson’s for the persistence of wrong-headed beliefs. An essentialist idea of human nature, particularly in its current incarnation of evolutionary psychology, is attractive in its simplicity and association with a very important and credible scientific theory (i.e. evolution by natural selection); everyday folk such as Cosmopolitan readers, and even grant reviewers from other disciplines get it. Genes were selected in the environment of evolutionary adaptedness for cognitive mechanisms controlling such things as mate selection that manifest themselves in interesting ways in the contemporary environment. Buller (2009) coined the term pop evolutionary psychology for the promulgators of such a view. Any sane person would count themselves as an evolutionary psychologist, but not in this all too common simple-minded way (see Laland & Brown 2002, for an informative commentary on this issue).

I am an atheist myself, but I still find extremely arrogant the idea explicit in Wilson’s article that a belief in God or the supernatural is down to the fact that ‘Regardless of any individual differences in the analytical tools required to do so, many people just don’t have the time, desire or inclination to go against the grain in such a way’. Wilson is gracious enough to acknowledge that belief in God is not the result of ‘poor cognitive ability’, however, to replace an explanation of stupidity with laziness is hardly progress. The notion that Thomas Aquinas believed in God because he did not have the time or desire to think about it in depth and that he just went with the grain, leaves me almost but, as you can see, not quite speechless.

Psychology is in a sorry state at the moment carved up into a pseudo-science where evolutionary psychologists decide what evolved mechanisms there might be, cognitive psychologists describe what they are and neuroscientists tell us where such mechanisms are located in the brain. Much mainstream thinking in psychology demonstrates a profound ignorance of genetics (e.g. the ‘norm of reaction’) and developmental biology; these disciplines reveal the deep complexity involved in the ontogeny of even the most simple of organisms. The only explanation I can come up with for the persistence of the belief in an essentialist human nature, is that many academic psychologists just don’t have the time, desire or inclination to go against the grain.
Paul Morris
University of Portsmouth

References
Buller, D.J. (2009). Evolution of the mind: Four fallacies of psychology. Scientific American, 300, 74–81.
Haldane, J.B.S. (1932). The causes of evolution. London: Longmans.
Laland, K.N. & Brown, G. (2002). Sense and nonsense: Evolutionary perspectives on human behaviour. Oxford: Oxford University Press.
Oyama, S. (2000). The ontogeny of information: Development systems and evolution (2nd edn). Durham, NC: Duke University Press. 


Stuart Wilson has contributed to the sea of confusion that is modern religion with his article ‘The naturalness of weird beliefs’ (July 2010). He has not defined ‘religious belief’ and has assumed that it is equated with superstitious beliefs. My understanding, which comes from reading around the six major world religions (Judaism, Christianity, Hinduism, Sikhism, Islam and Buddhism, in no particular order) is that religions are the result of human attempts to create social systems that work by uniting people with a common code of behaviour (religio is Latin for ‘I tie together’). These codes could also be called morals.

Supernatural events are included in the literature associated with some of these religions but the main focus is on learning to live in ways that are mutually beneficial, as for example the Judaeo-Christian understanding that it is wise to try to ‘love your neighbour as yourself’.

It is certainly intriguing to try to understand why humans are quick to catch on to irrational beliefs (see The Life of Brian for a wonderful illustration of how this works!) and wish to include ‘fate, destiny and an overarching purpose to existence’ in their belief systems, but wouldn't it be much more useful to humanity to look at how difficult it is to access the higher levels of religious thinking where the individual is encouraged to discard all fantasy about past present and future and become more able to live in the present moment? All the six religions I have listed describe this in their holy books as the ultimate goal of living.

If Stuart Wilson is free to express scepticism in the 21st century should he also be free to present information in such a distorted way?
Gabrielle Maughan

Wing, Rutland


Guest Column - The real world
We are writing on the morning after the afternoon before. The afternoon that England were dumped out of the World Cup by Germany – England’s worst ever defeat at the finals. By common consent it was an inept performance, a pitiable display. But does it matter? For sure, a lot of people will be upset in the short term. For certain there will be an increase in hospital admissions and in absenteeism for a few days. But that probably has more to do with the amount of alcohol drunk and lack of sun lotion applied during the match than with the match itself. Will England’s defeat have an impact at the collective level? Will it affect the mood of the nation? Will it feed into other domains – the political and the economic? And will the effects endure?

Already the inquests and the diagnoses have begun. The front page of The Guardian sports section carries a quote in huge font that nicely links footballing failure to a more general post-imperial decline: ‘only the details and venues change in the story of how England impersonate a serious international power…’. Certainly there is a widespread belief that national sporting performance both reflects and shapes the state of the nation more generally. The clearest example of this is the oft-repeated claim that England’s World Cup success helped Harold Wilson to power in 1966. This is a very good point – undermined only slightly by the fact that the election took place before the World Cup victory.  

So can we reject this linking of sport and society? Are we making too much of what, after all, is only a game? As Bill Shankly famously quipped, ‘Football isn’t a matter of life and death – it’s much more important than that’. No, Bill. Football means far less to those of us who are not football managers.

So does World Cup success mean everything or does it mean nothing? Perhaps the problem lies less with the answer than with the question – that is, with how we think about the way that events like this might impact on society. Rather than searching for mechanistic and direct relationships, it might be better to think in more metaphorical terms.

That is, England’s footballing prowess (or lack of it) can be worked into a vivid story about the nation in general which can then be used to make sense of other social phenomena. For instance: ‘bloated salaries and poor performance are ruining the nation, we need to work more and pay ourselves less if England is to flourish’; or ‘divided team, failed nation, that’s the story of Cameron’s Britain’; or even ‘too many foreigners, no space for the English to flourish in our own clubs’. Note that there is nothing inevitable about any of these metaphors. Importantly, though, they define the phenomenon in very different ways and therefore have very different social and political implications – for supporters of Conservative, Labour or BNP agendas.

More generally, we should think of ‘events’ and of history less as a determinant of the present and more as resource that we can draw upon to build our own futures. Human beings are fundamentally sense-making creatures and those who best master the craft of sense making – who are best able to weave past performance into pertinent parables – are best able to craft the society we live in.

But don’t worry. As we turn off the football, we can immediately turn on the tennis. We can look forward to more metaphors and narratives of British grit or of Scottish independence. The sense-making never stops!

Steve Reicher is at the University of St Andrews. Alex Haslam is at the University of Exeter. Share your views on this and other ‘real world’ psychological issues – e-mail [email protected].

 

Guest Column - web chat
After three years in the peer-review wilderness, an article by Jennifer Skeem and David Cooke that’s critical of the dominant tool for measuring psychopathy – the Psychopathy Checklist Revised (PCL-R) – was finally published in June in the journal Psychological Assessment (http://bit.ly/atpbFi). The crux of the paper revolves around the degree to which criminal behaviour should be considered a vital part of the psychopathy construct.

The reason for the paper’s delay had been revealed a month earlier in a commentary for the International Journal of Forensic Mental Health (http://bit.ly/daCHiD). Norman Poythress and John Petrila described how Robert Hare, the creator of the PCL-R, had threatened legal action back in 2007 if the critical Skeem/Cooke paper in its current state was not pulled from publication. ‘It seems clear from our review,’ Poythress and Petrila concluded, ‘that such threats strike at the heart of the peer review process, may have a chilling effect on the values at the core of academic freedom, and may potentially impede the scientific testing of various theories, models and products’.

By mid-June the affair had reached the news pages of Science, Scientific American and the New York Times. But the blogosphere had got there first. The story was first picked up in a 30 May posting ‘Psychopath guru blocks critical article’ (http://ht.ly/242AK) on the blog ‘In the news: Forensic psychology, criminology, and psychology-law’ written by the forensic psychologist Karen Franklin. Later on 17 June, Franklin published an update and gave her verdict. ‘After analysing all sides of the issue, I find that the Skeem and Cooke article is an important and timely contribution to the field, and that threats to sue over such publications set a dangerous precedent.’

The ‘all sides’ that Franklin refers to includes a rebuttal to the Poythress and Petrila commentary, which Robert Hare published on his own website on 12 June (www.hare.org). In the 14-page document Hare argues passionately that Poythress and Petrila failed to seek his side of the story. He emphasises that he didn’t resort to legal threats as a means to suppress Skeem and Cooke’s scientific arguments, but rather because ‘I believed that the misrepresentations of our [his and Craig Neumann’s] published work (and that of other authors) fell outside the bounds of acceptable scientific and academic discourse.’

Specifically, Hare argues that he and Neumann do not see criminality as essential to the construct of psychopathy and that Skeem and Cooke had ‘misrepresented our position by selectively changing words and the meanings of our statements (e.g. problematic to criminal)’.

According to Hare, the dispute over the Skeem/Cooke paper was actually resolved as early as 2008 by which time a revised version of the Skeem/Cooke paper, his response and their retort were ready for publication. He says he doesn’t know why it’s taken two years for the three papers to see the light of day. ‘I would hope that this whole affair serves to send a chill where it really belongs: Authors who misrepresent and distort the published work of others, and commentators who uncritically pass on the misinformation among themselves.’


Screening for PTSD
I am writing about the comments made by the Veterans minister, Andrew Robathan, in June regarding post-traumatic stress disorder (PTSD) in returning UK soldiers. As a mental health researcher, I am surprised by his comment that there is ‘no scientifically robust way’ to screen for mental health problems such as PTSD.

Research has shown many scientifically robust ways of screening for PTSD. A number of questionnaires have been developed that can accurately test for PTSD (e.g. Carlson, 2001; Kimlerling et al., 2006). A recent study found that a questionnaire of just six items could identify those with PTSD with a specificity of .92 and a sensitivity of .80 (Thoresen et al., 2010). In other words, asking returning troops six quick questions could correctly identify 92 per cent of those with PTSD. Similarly structured interviews have been developed that have high inter-rater reliability (Watson et al., 1991). Research has even shown that completing a quick questionnaire one to three weeks after a traumatic event can predict the later development of PTSD with 85 per cent accuracy (Walters et al., 2007).

Mental health problems in returning soldiers are unfortunately very common. Estimates from the US are that 44 per cent of soldiers returning from Afghanistan and Iraq report some symptoms of depression and/or PTSD and 20 per cent require mental health treatment. Active combat served increases the risk of PTSD three fold, and mental health problems such as this more likely still in those who have been injured, and in those who have killed in action. Thus it is possible to identify those at risk. A number of psychological interventions such as trauma-focused cognitive behavioural therapy are effective for the treatment of PTSD and for prevention in high-risk individuals (All references available on request.)

Thus PTSD can be effectively assessed, treated, and even predicted and prevented. Andrew Robathan claims that ‘most expert opinion is that you should not screen people for mental health issues’. I would imagine that most clinicians reading The Psychologist would argue that you should screen for mental health problems as soon as possible as early detection and intervention improves long-term outcomes. In relation to the comment that ‘the downside of suggesting that people have mental health problems when actually they do not have, is actually quite immense and of great concern’, I believe that most would agree that while screening for mental health problems may occasionally cause offence, it rarely leads to serious problems. Overall scientific research has demonstrated that the benefits of screening for PTSD far outweigh the risks.
Thomas Richardson
Mental Health Research and Development Unit
University of Bath

References
Carlson, E.V. (2001). Psychometric study of a brief screen for PTSD: Assessing the impact of multiple traumatic events. Assessment, 8, 431–441.
Kimlerling, R., Ouimette, P., Prins, A. et al. (2006). Utility of a short screening scale for DSM-IV PTSD in primary care. General Internal Medicine, 21, 65–67.
Thoresen, S., Tambs, K., Hussain, A. et al. (2010). Brief measure of posttraumatic stress reactions. Social Psychiatry and Psychiatric Epidemiology, 45, 405–412.
Walters, J.T.R., Bisson, J.I. & Shepherd, J.P. (2007). Predicting post-traumatic stress disorder: Validation of the Trauma Screening Questionnaire in victims of assault. Psychological Medicine, 37, 143–150.
Watson, C.G., Juba, M., Mainfold, V. et al. (1991). The PTSD Interview: Rationale, description, reliability, and concurrent validity of a DSM-III-based technique. Journal of Clinical Psychology, 47, 179–188.

Synchronicity

The July editions of two of the periodicals to which I subscribe, namely The Psychologist and Fortean Times, had articles on the meeting of minds between Carl Jung and Wolfgang Pauli. An example of synchronicity? Possibly, but as a good empiricist I will reserve judgement as to whether there is an atemporal causal connection until I receive my next copy of Narrow Gauge and Shortline Gazette.
Dougal Julian Hare
University of Manchester

I am a Dutch filmmaker, currently developing a feature-length documentary film about synchronicity, or meaningful coincidence. Jung defined it as the simultaneous or temporally proximate occurrence of two or more events, which appear to be connected, without there being any demonstrable causal link. In addition, the individual experiencing this synchronicity finds important personal significance in the concurrence of these events, sometimes even to the extent of it being a life-changing experience.

Have you experienced this phenomenon? I am looking to interview some respondents and possibly reconstruct your stories of synchronicity as part of my film. Your material will be treated in complete confidence and with absolute integrity.
Jan Diederen
Amsterdam
[email protected]

 

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