Letters

personality disorder; Milgram; NHS reform; benchmarking; and more

Challenge of the ‘pathway approach’

In May, consultation ended on the Offender Personality Disorder Pathway Implementation Plan, a Green Paper that proposes a radical review of how statutory services should respond to the needs of offenders with personality disorder. These opportunities and challenges are relevant to psychologists from many fields, given the wide social impact and highly complex psychological needs within this group of marginalised and socially isolated men; drug and alcohol use, suicide, significant health problems, traumatic head injuries, self-harm and other psychiatric diagnoses will often be present. All will have had experiences in childhood that disrupted ‘normal’ emotional and social development, and that will have led them to present a risk to the public.

The drivers for this review include the limited success, costs and reach of the Dangerous and Severe Personality Disorder Programme. It is proposed that the reconfiguration of services and reinvestment of money will support the development of a ‘whole systems’, ‘active pathway of intervention’. This stipulates the need for psychologists to support assessment, case formulation, sentence and intervention planning. Following treatment, it is expected that offenders will be supported by Psychologically Informed Planned Environments (PIPES), where there will be an emphasis on supportive, healthy relationships. This approach is in keeping with the general drive within the criminal justice system for practice to be psychologically informed. This year’s practitioner’s guide for criminal justice staff, Working with Personality Disordered Offenders, is heavily influenced by psychological theory and uses an attachment theory framework (appropriately, for a group of men whose problems are fundamentally associated with emotion regulation and early attachment difficulties).

The proposed ‘pathway approach’ will make it necessary for psychologists to work in a radically different way: they will need to contribute towards the development of a workforce to enable it to apply psychological theory and operationalise psychological principles. They will need to provide psychologically informed clinical leadership to maximise the capacity that criminal justice services have to empathise, to provide emotional containment and consistency.

As clinical leaders of two services, based in Leeds, that offer – amongst other things – consultation to criminal justice staff, we are acutely aware of the importance of this type of working. The application of psychological theory is essential to enable probation officers, for example, to think more accurately and creatively about risk issues as well as to help them understand some of the complex dynamics that prevent them from properly engaging with their clients and being able to work and plan as collaboratively as possible.

To psychologists like us, these opportunities appear exciting and timely. However, we suspect that, for many psychologists in clinical practice, they will seem irrelevant. Traditionally, psychologists in clinical practice do not see offenders as their business, due to the issues of risk and their perception that they lack the necessary skills to work with this client group. In addition, despite New Ways of Working and its emphasis on psychological leadership and team working, many psychologists (or managers) still prioritise individual therapeutic work or consultation to teams around individual cases. Contextualised by the NHS and its demands, psychologists often continue to view their skills as solely about alleviating symptoms and providing therapy for (often diagnostically defined) disorders. We have been unable to find emphasis in Society literature on how leadership and service development skills form part of the core competencies of the profession. Even in the BPS guidance on working with personality disorder, which welcomes the government’s policy of ensuring that people with personality disorder are treated in core services and have access to specialist teams, the emphasis remains on treatment and treatability rather than on equipping organisations and other service providers to work effectively with this client group.

Given this context, there is a danger that many psychologists will fail to embrace these opportunities. Indeed we are aware that in the Yorkshire/Humber region there have been difficulties recruiting psychologists to positions of clinical leadership in services that work with individuals with personality disorder. This is particularly important, given emerging evidence that this psychological expertise has a significant impact. The Impact team in Camden and Islington, for example, have significantly reduced the rates of recall to prison (by 40–50 per cent) for offenders (who are subject to probation supervision) purely through the provision of psychologically informed consultation (www.candi.nhs.uk/impactpdproject).

So what is needed to prepare psychologists for the opportunities and challenges that are likely to be presented by this emerging pathway? We would suggest that there is a need to revisit the core competencies for the profession so that clinical leadership and service development are explicit areas for development within training: move the debate on from roles and focus our attention on the skills necessary to work in this area. If psychologists lack confidence in their clinical skills and ability to work with this most complex and challenging client group, mentorship and professional support networks become vital.

Perhaps our main hope is that psychologists in clinical practice across forensic and more generic adult mental health settings view this work as applicable and relevant to them. Clinically speaking, the dividing line between custody or forensic services and non-forensic adult mental health services is arbitrary and predicated merely on the commission of an offence. The task is to develop a psychologically informed workforce that is able to support a pathway across systems; through custody back to the community, reducing dependence on overstretched non-statutory agencies as well as in patient, emergency and crisis services. It is our hope that we can fully embrace the principles of partnership, joint working and shared responsibility to which this proposed whole systems pathway aspires.

Jo Ramsden Clinical Psychologist
Pathway Development Service, Leeds
Sharon Prince
Personality Disorder Managed Clinical Network, Leeds

Tendency to insularity

I read September’s excellent issue from cover to cover, yet two items caught my attention as suggesting our tendency to temporal and discipline insularity.

First, the suggestion that punishment can aid memory (p.636) is hailed as being the ‘first ever’ such demonstration, and ‘somewhat surprising’. The effect was I think first demonstrated by Muenzinger in 1934, and replicated in the UK by George Drew in a 1938 publication.

Second (p.632), the House of Lords Science and Technology Committee’s report Behaviour Change is cited as concluding that ‘there is not enough evidence showing how the science of persuasion and influence can be used in the real world to affect the behaviour of an entire population’. This neglects the subdiscipline of criminology badged variously as environmental criminology and situational crime prevention. This observation is not to criticise the distinguished psychologists who gave evidence to the committee, but it is a matter of regret that scholars such as Professors Ron Clarke, Gloria Laycock, Paul Ekblom and Richard Wortley (themselves all psychologists by training) were not also called to give evidence.

It would be nice if colleagues more consistently tipped the hat to long-dead pioneers in the discipline, and to colleagues doing complementary work in closely related disciplines.

Ken Pease

Stockport

Reference

Muenzinger, K.F. (1934). Electric shock for correct response in the visual discrimination habit. Journal of Comparative Psychology, 17, 267–277.

Benchmarking and social psychology

Fellow psychologists may know that the BPS in partnership with the ESRC recently conducted an ‘International Benchmarking Review of UK Psychology’. The Review had a section assessing the impact of British social psychology. This emphasised the very high quality of work in the tradition of experimental social psychology that made the UK world-leading in this tradition. However, this part of the review also dismissed the impact of what it called ‘pure qualitative/critical/discourse analysis approaches’. It asserted that ‘UK social psychology’s international impact is almost exclusively attributable to its mainstream experimental/ quantitative work’ (p.15).

We believe that this statement is both inaccurate and potentially damaging to qualitative/discursive work, which is in fact one of the strengths of British social psychology. When assessing international impact, the Review strangely seems to have ignored the obvious bibliometric evidence. Of the five most highly cited current UK social psychologists, three work within the discourse tradition. The situation is even more pronounced if we consider the citations for individual publications.

Of the five most cited publications by current UK social psychologists, four, including the top three, are in the general area of discursive psychology.

Hopefully, social psychologists will look beyond the inadequacies of this Review to see the wider picture. This is an excellent time to be celebrating the strengths, success and variety of British social psychology. It has had a major impact across the social sciences in the UK and around the world. Indeed, the way in which the different traditions have creatively inspired one another is not only a unique feature of British social psychology, but it provides a model that other nations might well consider following.

Michael Billig, Professor of Social Sciences on behalf of the Social Psychology Programme Team, Loughborough University

Charles Antaki, Carly Butler, Duncan Cramer, Derek Edwards, Alexa Hepburn, Alexandra Kent, Jonathan Potter, Sue Wilkinson and Cristian Tileaga

Professor Judi Ellis, Chair of the Society’s Research Board, responds:

This and other concerns regarding the assessment and reporting of other subfields are being addressed directly with the ESRC. Members will be advised of further developments. If you have any queries, please contact Dr Lisa Morrison Coulthard on [email protected]

Self-serving showman?

I was surprised and concerned at the positive and substantial treatment that Stanley Milgram received in these pages last month (September).

At the annual conference of the History and Philosophy of Psychology Section last April, Ian Nicholson presented a disturbing paper showing that Milgram was a self-serving showman who lied to his subjects, was cruel to them to the extent of causing many long-term psychological damage, and furthermore contributed nothing to our understanding of human compliance, beyond demonstrating what he demonstrated.

This view accords with my own view derived from watching the shocking film of Milgram’s proceedings as an undergraduate in the early 1970s. My lecturers then seemed to think it was all a bit of a lark, whereas I thought Milgram’s actions constituted a serious abuse of fellow humans and were not only unethical, but also criminal.

If this is regarded as good and ethical science, as it seems to be by your authors, then we might as well shut up shop.

John Campion
Liphook, Hants

Reply from Steve Reicher, one of the curators of September’s special issue:

The issue of ethics in the Milgram studies is clearly one of critical importance. I hope the issue did not minimise or trivialise it. Certainly I am surprised that anyone could think of the research as ‘a bit of a lark’ on any dimension – practical, scientific or ethical. They raise critical and troubling issues. My feeling is that a one-dimensional response – whether it be unconditional praise or unconditional condemnation – does not help us resolve those issues.

On a scientific level, I would challenge the notion that the studies contributed nothing to our understanding of compliance. Indeed it is arguable that they have had too great an impact not only within but also beyond psychology. As Novick argues, Milgram (in combination with Arendt) transformed understanding and debate of everything from alcohol usage to the Vietnam war. We might – indeed we do – challenge whether that transformation was entirely in the right direction. However, I find it hard to deny that it occurred and was of massive importance.

In terms of Milgram as an individual, I am less qualified to judge. He clearly wanted to get his work noticed. He was adept at publicity and his interest in film-making was part of this. But equally I think it is pretty clear that, while an element of individual glory may have been involved, he also cared deeply about the ideas and wanted to publicise an important argument. In other words, as with many people, he was probably complex and contradictory. There was an element of the self-serving showman in him, but also of the serious scientist and the man of principle.

Finally – and most importantly – in terms of the ethics, I think the issue is again complex. While I think, quite rightly, that they would now be unacceptable, it is important to recall that Milgram was instrumental in developing the ethical sensibility and ethical practices which led us to that conclusion today. He initiated debriefing procedures, he pioneered follow-up studies of participants. And he made a number of highly creative suggestions for dealing with ethical issues that we still have not caught up with.

As for the impact of his studies on participants, I would be delighted to know of more recent research. From what I can see from the figures provided in Obedience to Authority, again the picture is confused. There is not much sign of severe damage. But there is evidence of people being troubled and going over the experience in their minds. Having said that, I do accept that there is sufficient evidence to warrant the ethical prohibition on such research. It may even be that, for some people, the studies were cruel. But to label Milgram himself as cruel does not follow.

In sum, then, I think it is possible to mark the critical importance of Milgram’s work and even to celebrate its progressive aspects without hiding problems and without suggesting it is ethical science. That is what we sought to do.

Little Albert – were we all duped?

Little Albert has recently been in the spotlight again in The Psychologist (e.g. ‘Finding Little Albert’, May 2011; Letters, August 2011). Despite the number of times the Little Albert story has been retold, one particular detail is routinely overlooked. The Little Albert experiment was not the straightforward conditioning study it is often thought to be.

In the original paper (Watson & Rayner, 1920) there is an interesting addendum. In a section titled ‘Incidental Observations’ Watson and Rayner report: ‘During the course of these experiments, especially in the final test, it was noticed that whenever Albert was on the verge of tears or emotionally upset he would continually thrust his thumb into his mouth. The moment the hand reached the mouth he became impervious to the stimuli producing fear. Again and again while the motion pictures were being made at the end of the thirty-day rest period, we had to remove the thumb from his mouth before the conditioned response could be obtained’ (p.13). Watson and Rayner further reported that Albert only sucked his thumb in the presence of the noxious stimuli.

This, then, is a curious conditioning paradigm. Rather than Watson and Rayner demonstrating a tidy sequence of conditioned stimulus - conditioned response, it seems that the sequence was something like conditioned stimulus - prevent individual’s coping response - conditioned response. It is tempting to speculate how our understanding of anxiety and other mental health conditions might have developed if Watson and Rayner had focused on the way in which Albert coped with adversity rather than on the conditioning they wanted to demonstrate.

Even at Albert’s young age he was able to comfort himself in the presence of trouble and unpleasantness. While the effectiveness of treatments that were spawned from this research should not be discounted, has our understanding of the development of anxiety and its subsequent treatment been unwittingly limited by the illusion of Little Albert’s uncomplicated conditioning. Would our research and treatment have followed a different path had we been more aware of Albert’s stoicism? Might we have focused more on resilience, coping, and strengths than on dysfunction and disorder? Would we have understood the active role of the client much sooner and developed ways of learning from clients and following their lead rather than taking an initial stance of building up their (apparent) deficits?

Little Albert has contributed greatly to psychology. Could that contribution have been even more profound with a different emphasis and more accurate reporting by Watson and Rayner?

Timothy A. Carey

Centre for Remote Health and Central Australian Mental Health Service

Reference

Watson, J.B. & Rayner, R. (1920). Conditioned emotional reactions. Journal of Experimental Psychology, 3(1), 1–14.

Moving on

We are grateful to Joanna Nowill for her timely letter ‘Status of counselling psychology’ (September 2011). Catherine Coe’s previous letter (August 2011) regarding similar issues was equally appreciated. We were pleased to see pleased to see the response by Carole Allen, Chair of the Professional Practice Board, and now BPS President. We have been heard, and now is the time to move on constructively.

The challenge now is to recognise and act on the equality but diversity of competences of all applied psychologists. We all need to work with plurality without letting difference slide into hierarchy or stereotype. The BPS, through its Membership and Training Board, and HPC in regulating practitioner psychologists have established in the particular case of clinical and counselling psychologists that they are both qualified at doctoral level. If the clinical and counselling psychology competence descriptors are placed side by side they appear much the same, even if worded slightly differently. This issue needs to be reflected in psychologist appointments, where there needs to be careful consideration of the specific competence needs of a specific post, and the present broad-brush approach of recruitment solely by adjectival title is proving unsatisfactory and sometimes unfair.

Both DCoP and DCP, along with other Divisions working in health and social care and in conjunction with Unite the union have been working together to challenge those who exclude any applied psychologist from applying for NHS posts (see http://dcop.bps.org.uk for NHS posts letter, Preceptorship letter and September 2011 statement re advertising of posts).

We urge that the Society joins with the applied Divisions within its ranks and sets a good example in exemplifying the values of prioritising what is best for the end user, while at the same time celebrating the diversity and equality of superb practitioner skills and philosophies.

Peter Martin, Chair DCoP

Susan van Scoyoc, EFPA Standing Committee for Psychotherapy

Antony Vassalos Chair, Unite’s Applied Psychologists’ National Occupational Advisory Committee

Time to speak out on NHS reform

Dave Harper and 98 others (Letters, July 2011) call for the Society to take a clear stand on those big public policy issues of the day that threaten to have profound psychological effects. I agree.

At or near the top of the list of such issues must surely be the privatisation by stealth of the NHS. Amongst the latest government moves towards privatisation is, according to my newspaper (the Guardian Weekly), the opening up of psychological services for adults in primary care to private or other non-NHS providers. We cannot continue to hide behind the argument that the Society must avoid taking a political position. There is no neutral stance to be taken on this issue. Either the Society stands out clearly against the breakup of the NHS system of universal, equitable, free, state-provided health care and warns about the dangers of a more fragmented, competitive system that is likely to increase health inequalities, or it will be seen as a professional organisation that supports its members in taking advantage of new opportunities to sell psychological services. Does the Society stand for the social solidarity of which the NHS is such an outstanding example, or does it stand for the commercialisation of psychology, in support of the psychopreneurs?

I would argue that the future of the NHS is such an important issue that the Society cannot hold to both of those positions simultaneously. It must decide and must make its decision publicly very clear.

Jim Orford

Emeritus Professor of Clinical and Community Psychology

University of Birmingham

HPC standards anomaly?

Readers of this publication will know that the work of practitioner psychologists is now regulated by the Health Professions Council (HPC). To this end they publish thresholds of competency known as ‘Standards of Proficiency’. These help protect the public by describing minimum skills that professionals must meet before registration. Understandably, given the range of different practitioner psychologists, there are both generic and profession-specific standards of proficiency. One section of these standards deals with the delivery of psychological treatment and therapy. Here generic thresholds are understandably few because professional groupings differ in the extent to which they work in this area. However, it is a comparison across different professional groups that prompts this letter.

In the standards the minimum skills in treatment and therapy for clinical and counselling psychologists are described first (Standard 2b.4, see tinyurl.com/ycmddul). At the time of registration the HPC expects both groups to be proficient at implementing psychological treatment and therapy appropriate to the presenting problem and to the individual needs of the client. Hopefully, this is relatively uncontroversial, as it is one of the core skills of clinical and counselling psychology. New applicants to these professions currently hone these skills during three years of doctoral training, which includes months of supervised therapeutic practice. On the next page the threshold competencies for health psychologists are detailed. Curiously, the standards are nearly identical skills to those of clinical and counselling psychologists. For this to be the case you might assume similar levels of training in delivering psychological treatment and therapy. However, to the best of my knowledge, the advanced qualification in health psychology syllabus does not include therapeutic work as a compulsory unit. Equally, my understanding is that when the BPS described health psychology to the HPC in March 2008 it did not refer to psychological treatment and therapy as being a core skill of the profession.

Please do not misinterpret this concern. I am not suggesting that health psychologists should not deliver treatment or therapy. I have worked alongside very talented health psychologists with excellent therapeutic skills. My concern is that the standards of proficiency represent minimum thresholds of competence that must be met before registration with the HPC. It does not seem clear that all health psychologists necessarily have these skills by the end of their training. Of course, many will undergo extra training as part of continuing professional development, but remember: the standards of proficiency are to be met before registration.

In summary, the HPC appears to suggest that all health psychologists are able to deliver psychological treatment and therapy, at a level similar to clinical and counselling psychologists, at the time they finish their training and join the register. At the extreme, some may argue that the HPC is inadvertently putting the public at risk by suggesting a professional group has a level of skill that their training might not deliver. More moderately, I raise this issue for debate and ask the readers of this publication to consider whether this area needs further discussion and clarification.

Miles Thompson

Margate, Kent

Editor’s note: The Division of Health Psychology have been invited to respond in the next issue.

Teaching of statistics

Teaching of statistics to undergraduates, and even to graduate trainees in practice or research, can sometimes blur the distinction in learners’ minds between analysing numbers and measuring psychological processes. In response to continuing controversy over these issues, I have been asked for the references to my three entries to the competition on ‘Tricky Stats’, which ran in The Psychologist between July 1994 and May 1995. Pre-1997 articles are not routinely archived on The Psychologist’s website, and so I have put the submitted manuscripts in a PDF online under my name at http://epapers.bham.ac.uk

The three topics that were set in the Tricky Stats series are hardy perennials. They include supposedly differing sorts of scales and the misuses of p values. First comes a concept basic to qualitative research as well as observational and experimental research – that of confounding between different constructs or processes.

David Booth

School of Psychology

University of Birmingham

A case for revision

Matt Jarvis’s article, ‘Defending the honour of psychology A-level’ (September 2011), was interesting. However, most of it was directed towards comparing psychology with other A-levels, and I’m not convinced that merely ensuring sixth-form psychology isn’t as bad as the majority of other subjects goes far enough.

I was on the BPS Psychology Education Board at the time of the Annual Conference in 2010, when we invited representatives of the exam boards to a meeting about the state of psychology A-level. One representative opened the meeting by telling us that the new specification ‘isn’t education; it’s just box-ticking’. Research may have shown that it’s above-average-quality box-ticking, but it will be difficult for us to promote A-level psychology as a worthwhile qualification if even the people responsible for it have little faith in it.

As someone who has taught psychology at both A-level and degree level, I agree with Jarvis’s concluding statement about there being a case for revising the A-level so that it fosters better development of meaningful academic skills, and I hope that the BPS is able to take a more central role in this than it has been allowed to in the past.

David Mingay

Headcorn, Kent

For more, please download the PDF

BPS Members can discuss this article

Already a member? Or Create an account

Not a member? Find out about becoming a member or subscriber