The Department of Health’s consultation over smoke-free premises ends next month (see tinyurl.com/of437). A recent survey suggests that up to third of mental healthcare staff oppose a smoking ban in their settings (McNally et al., in press) and the inclusion of psychiatric wards in any imminent smoke-free legislation has been described as ‘unrealistic and unethical’ by some mental health organisations. Will they be exempted? And is the debate about human rights, or as much about ‘rites’, relating to the customs and traditions within the culture of mental health care?
Within mental health settings, smoking rates are very high among both patients and the staff that care for them. Smoking rooms are frequently the social hub of a mental health unit and cigarettes often act as ‘the mechanism for many of the rules of interaction, and procedures and actions taken in the settings’ (Lawn & Pols, 2005). Studies have also reported that mental health staff may often use cigarettes in order to appease or engage patients (Mester et al., 1993).
Indeed, resistance to a smoking ban may reflect the fear that smoking is a stabilising factor, and that cigarettes keep patients calm (Dickens et al., 2004). However, smoking bans have rarely been found to lead to increased aggression and adverse incidents, and in fact, have even had a positive effect on ward functioning in many cases (el-Guebaly et al., 2003), particularly if accompanied by the delivery of smoking cessation support by staff.
One view is that we cannot implement a complete smoke free policy in mental health units. Why? Because patients are often detained against their will and the mental health unit is their de facto home. The other view is that we must implement smoke free policy in mental health units. Why? Well, because patients are often detained against their will and the mental health unit is their de facto home. And the right to live and be cared for in a safe, healthy environment must surely override the right to smoke.
But it is not just human rights that are being defended here. Smoking is part of the culture in mental health care, and its removal inevitably threatens long-standing ‘rites’ and traditions that are perceived to maintain stability and calm. In this way, the mental healthcare system is as addicted to cigarettes as any individual patient. And quitting is never easy.
Wandsworth Teaching Primary Care Trust
Andrew J. Hayes
Regional Public Health Group
Wandsworth Teaching Primary Care Trust
Dickens, G.L., Stubbs, J.H. & Haw, C.M. (2004). Smoking and mental health nurses: A survey of clinical staff in a psychiatric hospital. Journal of Psychiatric Mental Health Nursing, 11, 445–451.
el-Guebaly, N., Cathcart, J., Currie, S., Brown, D. & Gloster, S. (2002). Public health and therapeutic aspects of smoking bans in mental health and addiction settings. Psychiatric Services, 1, 53(12), 1617–1622.
Lawn, S.J. & Pols, R.G. (2005). Smoking bans in psychiatric inpatient settings? Australian and New Zealand Journal of Psychiatry, 39, 874–893.
McNally, L. et al. (in press). A survey of staff attitudes to smoking-related policy and intervention in psychiatric and general health care settings. Journal of Public Health.
Mester, R., Toren, P., Ben-Moshe, Y. & Weizman, A. (1993). Survey of smoking habits and attitudes of patients and staff in psychiatric hospitals. Psychopathology, 26, 69–75.
Juggling with more than intuition
WHAT a pleasure to read the article ‘Clowning about in the brain scanners’ (July 2006).
A few months ago, we introduced juggling on an acute inpatient psychiatric ward as part of the CBT depression group programme. We were looking for a way of demonstrating to inpatients how activities have the potential of not only stimulating the body, but also giving the mind a rest from worrying thoughts. At the same time, it was desirable that activities offered the possibility of learning new skills, whilst also being enjoyable. Intuitively, juggling seemed to offer many of the above. We knew that it involved concentration, new learning, hand and eye co-ordination, and physical activity. In addition, juggling was fun. It could be done together with others, hence it was a ‘social’ activity, and it was safe, cheap, easily taught and learnt.
We carried out a quality improvement project, which implemented and evaluated activity scheduling in the depression group at the same time. Five of 16 participants, who scored as severely depressed on the Beck Depression Inventory, wanted to do juggling. All five reported that they found juggling very useful because it increased their cognitive functioning. They said it ‘helped concentration’ and ‘distracted from difficulties’. In addition, they all enjoyed it and said that it impacted positively on their mood. Interestingly, this lasted after juggling had finished.
When reading Craig Aaen-Stockdale’s article we were able to support our intuitive undertaking with psychological evidence.
Little Brook Hospital
What interests parents
I WAS interested in the August special issue ‘Nipping criminality in the bud’. For the last two years, I have been working for the Braintree Children’s Trust, a multidisciplinary team that works both to prevent antisocial behaviour and to help children with low-level mental health concerns. The Children’s Trust offers a range of twelve-week interventions, both working with individual families and with groups using models including the Webster Stratton Incredible Years programme and a programme based on the ones used in the Youth Offending Service. The team’s experiences support the usefulness of short-term interventions, the need for both practical advice and emotional support for parents, and the importance of evaluating services with both parents
and child-based outcomes.
However, I was disappointed that the evidence that the articles suggested we should look to did not include outcomes that would have higher ecological validity for our partner agencies, who for the most part deliver the actual outreach and group work that the interventions rely on. None of the partner agencies or board members working closely with Children’s Trust were in the least impressed
by figures relating to improvements on well-validated scales like the Goodman SDQ or the Eyeberg scales. What interested parents, funding sources, DfES, social care and CAMHS services were softer figures, including the 11 per cent decrease in children being put into care in Braintree, the only district in Essex with a Children’s Trust, compared to a 1 per cent increase across Essex as a whole, with smaller gains in police call out rates and levels of truancy.
Whilst I acknowledge that these figures do not establish that Children’s Trust is the sole cause of the improvements and would not be scientifically acceptable for publication in
a journal, they make far more sense to all of our partners.
I feel that there must be a way of meeting the needs of other agencies as well as the need
we have for scientific validity.
Speed of impact
THE 2005 impact factors have just been published. A journal impact factor (IF) is calculated as the ratio between the number of citations in a given year to any item published in that journal in the previous two years and the number of research items published in the same journal in the same two years. It is widely acknowledged as the standard measure for scientific quality. IF places great emphasis on current research, favouring fast moving disciplines, while penalising slower moving topics; the latter would fare much better were the citation interval longer.
We use neuropsychology (slow-pacing discipline) and neuroscience (fast moving discipline) to illustrate this point by comparing the 2005 IF and the cited half-life (CHL) – which is the age range of 50 per cent of the journal’s cited articles; i.e. a measure of citation survival – of five journals from each discipline as selected by colleagues attending an international conference. Independent samples t-tests revealed significant differences in means for both IF: neuroscience = 5.84 (1.58), neuropsychology = 2.98 (0.94); and for CHL: neuroscience = 5.66 (1.22), neuropsychology = 8.74 (1.50).
The result of casually accepting a measure of quality which severely penalises a discipline may have unwanted practical consequences, including unfair comparisons of candidates competing for the same job position, authors choosing to submit their best manuscripts to journals outside their core discipline, and libraries basing their subscriptions solely on IF.
We propose that slow-moving disciplines, including psychology and neuropsychology, should adopt a longer citation interval (i.e. five years) as their gold standard to evaluate the quality of their research output.
Sergio Della Sala
Human Cognitive Neuroscience
University of Edinburgh
School of Psychology
University of Aberdeen
Developing scientist practitioners in the NHS
I SHARE Sallie Baxendale’s concerns about the current clinical psychology doctoral training not producing ‘prolifically publishing NHS clinicians’
as might have been expected, and the implications of this for the profession (Where are all the scientist practitioners?, Letters, July 2006).
I recall having a great sense of curiosity about human nature and development which led me to pursue formal study of psychology. Over the course of three degrees, however, I recognised that this natural curiosity with which I was to embrace research activity seemed to get lost somewhere amongst anxieties about fulfilling course requirements and the dry accounts of sampling, random variables, statistics and the like I received in research methodology courses (maybe things have changed since my day). Little of this material was presented in such a way that showed one how to convert inquisitiveness about a particular phenomenon (surely a necessary prerequisite for doing research?) into a viable piece of research. What I acquired instead were beliefs I unwittingly picked up through the hidden curriculum. Namely, research is often so theoretical and esoteric that it has little relevance to immediate clinical work (see Nancarrow & Tinson, 2006); research is about publishing in journals in order to gain kudos with peers and prospective university employers; research can instil a lifelong dread of statistics so as to preclude the undertaking of independent projects in the future; research is punitive – no research project, no degree. Needless to say, my posts after qualification were purely clinical ones. There was, of course, no real motivation to pursue research in these settings as most departments paid only lip service to their clinicians being involved in research as productivity was measured by client contact.
Thankfully, with unhelpful beliefs challenged and curiosity restored, I am attempting to square up to my responsibilities as a scientist practitioner having gained funding to undertake a small NHS research project in the area of Cancer and Palliative Care. I do find it ironic though that now that I am prepared to tackle my research demons, the process demands even more motivation than ever before: thanks to the current system whereby all research being conducted in the NHS must go through a standardised procedure involving a lengthy online application and approval of both the local research governance and ethics committees. As an independent clinical psychologist who has sessions dedicated for research,
I did wonder how anyone with a full clinical caseload would fare trying to complete such a time-consuming process without tremendous resources and support from their workplace.
In the course of sharing my frustrations around the research application and approval process, many colleagues have expressed to me their reluctance to become involved in research. It has made me curious to know just how many other clinical psychologists out there may feel unmotivated or disempowered to fulfil their ‘scientist’ role (another research project there, I wonder?).
If the scientist practitioner model is worth upholding it is important to examine trainees’ and clinicians’ experience of doing research and their discourses around it and for the NHS to provide more in the way of supporting research from clinical psychologists.
Nancarrow, C. & Tinson, J. (2006). Academic-practitioner symbiosis. QMiP Newsletter, 9–12.
Useful voluntary guidelines for volunteers
I have much sympathy with James Bywater’s views on the potential exploitation of assistant psychologists (Letters, August 2006); indeed it is a viewpoint I have long held myself. Nevertheless I have recently begun to question it. What seems to be missing in Mr Bywater’s analysis is a consideration of any benefits which might be gained by a volunteer.
Work within a clinical psychology (or similar) department might offer a wide range of opportunities for learning and training: the volunteer might meet clients with a range of problems and challenges far greater than they might expect to meet in day-to-day life; they could observe experienced therapists ‘in action’, discuss cases, and be offered formal training and supervision. In return they might be expected to ‘earn their keep’ by providing help with tasks that a department might otherwise have difficulty getting done. One also assumes that as an honorary member of staff any volunteer would be able to claim expenses.
There are also advantages to voluntary status over paid employment status: one would expect any voluntary contract to have greater flexibility, allowing, for example, someone to hold down a paid job, while volunteering for a short time each week. Equally one could be less tied by a voluntary contract to working specific hours or days per week.
Of course all this depends on the integrity of the employing department. I would suggest that, in the absence of a formal code of practice in this area, the following, though not exhaustive, could be taken as some useful guidelines:
l Any contract should be fair, in that it offers concrete benefits for both parties.
l Volunteers should not be used to do jobs which a paid person would normally be expected to perform.
l Voluntary contracts would be expected to offer non-monetary benefits (e.g. in the balance of work to training) and freedoms (e.g. flexibility of hours) that exceed those of paid posts.
l There should be independent oversight of the fair employment of volunteers.
l Grievance procedures
should be clear, and equivalent to those of paid employees.
l Volunteers would be expected to adhere to the same professional standards as all psychologists (this raises the question of what means of censure or discipline are available should a volunteer breach such codes; perhaps membership of the BPS should be a requirement for employment).
l Access to volunteer opportunities should be fair and unbiased. Local Equal Opportunities policies might well be applied or adapted to selection and recruitment of volunteers.
Mr Bywater argues that ‘if these trainees are doing a useful job…you should pay them’.
I would argue that training and supervision is payment in kind, and that exploitation can be avoided by the implementation of careful checks and balances. Given the growing demand for assistant psychologist posts, volunteering may be a growing part of the scene in clinical psychology. Perhaps the Society should begin to consider its regulation.
Department of Psychological Services
West Cumberland Hospital
- THE Higher Education Academy Psychology Network has developed an online Postgraduates who Teach Survey to explore the practice and support for postgraduates involved in teaching in psychology to provide evidence against which future developments in the support of postgraduates who teach can be measured. If you are a psychology postgraduate with teaching-related responsibilities, we invite you to complete this survey, at: www.psychology.heacademy.ac.uk/survey/pgwt/pgwt.asp.
Institute of Psychological Sciences
University of Leeds
- I AM a final-year psychology student looking for voluntary research work with alongside a clinical psychologist or other psychologist, in and around the Manchester area. I have experience with SPSS, Microsoft Office, working alongside adults with severe mental illnesses, and full CRB clearance.
- I AM seeking research on any cognitive effects of ghetto-blasters, electronic throbbing that resonates for blocks, and drums and percussion with repetitive beat but no rhythm. Are these an unmonitored global mass experiment? I can find research on cognitive effects of other environmental noise, but not on this. Noise researchers contacted know of none, and would also be interested. It must be somewhere. In modern psychology textbooks?
- I AM a BSc Hons and MSc postgraduate in psychology with 18 months clinical ork experience on a Crisis Resolution Home Treatment Team in the North West area, with full CRB clearance and four years voluntary part-time work experience at a day hospital. I am looking for work experience in a clinical psychology setting in the North West.
- I AM a psychology graduate with a 2:1 and am pursuing a counselling psychology MSc in September 2007, followed by a clinical psychology PhD focusing on BED. I am looking for a voluntary position as an assistant psychologist or work experience related to counselling or clinical psychology. Preferable area is Sussex but will travel further. I am enrolled on a counselling course starting September 2006 and am pursuing voluntary counselling roles in the clinical setting, as well as participating in self-help groups for eating disorders.
- I AM a graduate psychologist (2:1) looking for any relevant voluntary experience in the field of clinical psychology. I do have some mental health experience and I am searching for any available experience, whether research based or any relation to clinical psychology in the Yorkshire area.
- FINAL-year psychology student looking for a voluntary part-time job in clinical psychology. Central London area.
Blockages on clinical training in the NHS
IT has recently been noted in The Psychologist that there has been a block on recruitment of clinical posts in the NHS, including posts in clinical psychology (see the letter from Adrian Skinner in the August issue). I wonder though whether similar blockages on training and CPD have been taken by Trusts across the country as have been taken by the Trust for whom I work? I have recently returned from attending the International Neuropsychology Society Conference which was held in Zurich in July this year. In order to go there though I had to use my own leave since we are prevented from attending conferences in our Trust. For some time now we have seen our training budget being reduced and much of the training on which I go has been funded by myself. Being a reasonably well paid consultant neuropsychologist I have not really objected to that, but I do think that having to utilise my annual leave allocation to attend conferences really is getting to the stage where things are becoming unacceptable. Clearly, if other trusts are doing the same, this will have a marked effect on one’s wish to go on continuing professional development courses. Nevertheless, it is important to update one’s skills, acquire new information, as well as talk with other practitioners within the same specialty if one wishes to remain up-to-date. It might also have a direct effect on an individual’s ability to move through the various gateways which have now been put into place through Agenda for Change, not to mention completing one’s own CPD log. To my mind having to use one’s annual leave to attend conferences as well as training events goes against the spirit of Agenda for Change and
I wonder whether it is in fact legal. I would be interested to know whether this is becoming the rule in all trusts as management takes a hard line on balancing the budgets. Incidentally, going to the conference in Zurich allowed me to hear about the recent and fascinating research in neuropsychology which is being carried out in all different parts of Europe, something which I would be unlikely to find out about simply by reading journals.
Ian S. Burgess
Bristol General Hospital
New ways of working
THE first Stakeholder Conference of the Joint BPS/NIMHE (CSIP) New Ways of Working for Applied Psychologists took place on Friday 14 July. The conference provided the opportunity to consult with a range of stakeholders from the Divisions and other members of the BPS, carers and service users, representatives from other professional groups and representatives from organisations employing psychologists including health, social services, education and prisons.
There were several key points of discussion that we would like readers’ input on:
l Should we move to a more generic base in the first phase of training (one or two year) for all the applied psychologists before moving on to a more specialist second phase?
l Do we need to provide more coherent and transparent career pathways and training for pre qualification applied psychologists (i.e. assistants, associates)?
l Do we have examples of innovative psychological practice and new ways of working to share nationally?
l What contribution can applied psychologists make to providing better access to psychological therapies for service users?
l What are the leadership development needs of applied psychologists across their careers?
l What contribution should psychologists make to multi-disciplinary team working?
l What are the principles underpinning good leadership of psychological services and what are the leadership development needs of applied psychologists across their careers?
l What are the roles/tasks required of applied psychologists in the revised mental health legislation and what training is required?
l Is the current Divisional structure fit for purpose for the future?
l Should we establish a College of Applied Psychology?
Go to www.bps.org.uk/7dc6 to post your comments, and see www.bps.org.uk/v5tc for more.
Salomons, Canterbury Christ Church University
National Workforce Programme Director
NIMHE, North East Yorkshire and Humber
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