'Autism can be of a positive type'

We meet Stella Acquarone as part of our autism special issue; Aidan Horner on his ‘negative CV’; and Nick Hatton on an unusual PhD setting

I arrived early at Finchley Road for my interview with Dr Stella Acquarone, founder and principal of three organisations in the field of child and infant mental health. I used up time by visiting Karnac Books, a shop specialising in psychotherapy and psychoanalysis titles, where I found Dr Acquarone’s Infant–Parent Psychotherapy: A Handbook. Walking to her house I passed blue plaques marking where the children’s book artist Kate Greenaway and classical musician Denis Brain lived. Dr Acquarone is as cultured as the area she lives in, talking quietly but passionately about her interests.

‘The baby is a passionate communicator’
‘I grew up in Argentina as one of four siblings. My mother was a science professor, my father an engineer and businessman with a national construction company. As a child I was shy and felt left out, though I had a happy childhood and a very supportive wider family. I became fascinated by social relationships because I found them so difficult to understand. My father had a huge library and, around the time I started getting interested in psychology, I was reading a book on autism in our garden, thinking “So that’s why I think and feel like that”. My father joined me and I announced, “I think I may be autistic.” He had read the book and said, “Me too.” Perhaps that’s why I’ve never thought of autism as a purely negative condition. Autism can be of a positive type when you are aware of it, learn to manage it, organise you life to take account of it. There is, of course, a negative version as well.’

Our conversation took a detour when I asked Stella if she’d started studying psychology to understand herself. ‘Yes, later on. But initially I didn’t set out to be a psychologist. I was a very good pianist, at concert level, and initially studied at the Conservatoire in Buenos Aires. The problem was I couldn’t face playing in public – I tried three times but it didn’t work. My parents said “You need to study something else”, so it was only then that I changed tack. My mother wanted me to become a medical student but psychology won.’

Stella studied at the Jesuit University in Buenos Aires. ‘In 1960s Argentina approaches to studying psychology were quite different from those we’re used to in the UK now. I’m glad 50 per cent of the course was medical so I got a grounding in neuroscience. A lot of people associated with psychoanalysis had moved to Argentina to escape the war so they were a strong influence on how we did things; Freud is still cited as a huge influence on many aspects of Argentinean life. On the other hand, the sort of psychology vs. psychiatry conflicts so prevalent in Europe at that time seemed less important. It was natural for me start studying psychoanalysis.’

Stella came to the UK and finished her training in child and adult psychotherapy at the Tavistock Clinic. ‘I wanted to do another PhD here after the one I’d done in Argentina but it was very competitive. I liked the UK straight away. People talk softly to each other, which suits me. I love living in north London which has huge numbers of associations with Freud and the psychoanalytic movement.’

Stella worked as a child psychotherapist in the NHS for 32 years. ‘I quickly realised that parents seemed to know what was happening with their children at a very young age, and were upset that professionals didn’t act on this. I started doing three hours a week outreach in clinics and GP surgeries, trying to calm fears if parents were projecting and identify issues in their children that could be treated. I worked with Katherine Aitkins, an astonishingly insightful community paediatrician. We opened up the field of working with mothers and children and began to see that parents were identifying unusual children – unsmiling ones, fearful ones, those who didn’t want to be picked up.’

On the website of Stella’s Parent Infant Centre (of which more later, and see p.785), www.infantmentalhealth.com, she describes a very wide variety of approaches including neurobiology, psychodynamics, behavioural, cognitive, humanistic, bio-psychological, socio-cultural. ‘Psychology is a way of understanding. It provides you with a range of approaches and these should not constrain you. They should help you to look at all factors. So I can use both what are seen as psychological and what are seen as psychoanalytic approaches as the client or situation requires. And I think any therapist should draw on other areas: I get insights from philosophy and poetry.’

Stella emphasises the influence other thinkers have had on her. ‘I was considered odd because I actually talked to babies. I felt that you should try to understand what very young children were trying to communicate. I was hugely influenced by the work of Colwyn Travarthen whose famous quotation “the baby is a passionate communicator” is central to what I do. And there are other influences too numerous to mention – including, Freud, Melanie Klein and, to some extent, John Bowlby, who was at the Tavistock when I was there, Allan Schore and Jaak Panksepp.’

‘The issue is the potential, not the harmful’
Stella stopped working in the NHS seven years ago (‘this happened when I was no longer allowed to work with health visitors’), concentrating on the two organisations she set up in 1990 and also a third, more recent one. The Parent Infant Centre, runs a linked clinic and training organisation. The clinic offers help and therapy to parents and infants with all sort of difficulties from postnatal depression to sleeping and also social and communication difficulties. The School of Infant Mental Health trains professionals working with infants and parents, such as psychologists, health visitors and paediatricians, in the approaches Stella has developed and provides more intensive training for professionals working with parents and children 0–5. More recently, the Centre has become associated with ipAn, the International pre-Autistic Network – which increases autism awareness, promotes early identification and intervention, and raises funds for treatment and research, 

Given Stella’s description of her own problems in social interaction I suggest this move to managing organisations must have been difficult. ‘It was, but my father was a business man and I learnt a lot from him. We try to keep things simple. Most of the people I work with are freelance rather than employed. I travel around the UK with trainings
for the Centre, and some of my work involves looking for grants, for instance. Our aim now is to gain greater national coverage. In April our training goes online, giving us greater reach. We already provide certain services through Skype, which allows us to reach beyond London and the South East while still keeping it a personal and confidential service.’

Have your overall objectives changed? ‘No. To go back to something I mentioned at the beginning my aim has long been to help those troubled by their autistic tendencies – to help them become positive autistics. I don’t want to get rid of autism, if that was even possible. The issue is the potential, not the harmful. The approach is to help people to think about autism, to help what we call “pre-autistic” children structure their mind to allow cognitive and emotional development to occur. Too often people go too quickly with various treatment and therapeutic approaches, for all sorts of reasons. In my view you must first create the foundations which will allow treatment regime to work and be able to feel emotions. The book I am writing now is about Re-Start, an intense infant–family programme, and will emphasise this issue.’

You started out on a journey to understand yourself. Has your career helped you? ‘Yes, particularly studying the autistic mind. We know a lot more than we did about the whole topic, and media coverage has raised public understanding, even though it’s tended to emphasise the negative aspects. But there’s still more to learn. You can say that I’m a work in progress. I can speak in public now and I’ve been told I do it quite well. It’s important for me to see listeners’ faces if I am to do that.’ There was a piano in the room where Stella and I talked so I asked her if she could play in public now. ‘No. it’s a private act, a sort of meditation. I have particular composers who I play to myself.’

If there was one book, apart from your own, that you would recommend to readers of this interview as an introduction to your very syncretic approach to treating families, what would it be? ‘Ben Bradley’s Visions of Infancy is a wonderful introduction to child psychology. It looks at a huge range of thinkers from Darwin to Bowlby and beyond and argues that child psychology is an interpretative discipline rather than part of natural science, perhaps a useful makeweight to some present attitudes.’

On my way back after the interview I see the house of Alma Tadema the Victorian painter and divert to Abbey Road recording studios where the Beatles recorded. In truth, I’d just met a fascinating psychologist in a fascinating area.


Finding reward in rejection 

Aidan Horner (Institute of Cognitive Neuroscience, University College London) presents his ‘negative CV’

When asked to judge the success of a football team, the first thing we might want to know is how many games they have won in the past season. However, some teams may have played more games than others. If team A has won 15 games but played 50 whereas team B has won 10 but only played 12, the number of games won suddenly looks like a useless statistic. The ‘win rate’ would be more revealing: in this case team B has a better win rate of 0.83 compared to team A’s 0.30.

However, when academics (and non-academics) apply for jobs they are judged on the quality of their CV. Any individual’s CV is, in essence, the number of times they have won. It summarises the jobs they have successfully obtained, the grants they have been given and the academic prizes they have been awarded. It makes no mention of the numerous failures that anyone within academia will have undoubtedly suffered along the way. If team A and B were judged on their CV alone, we would conclude team A were the better team.

One possible issue with this situation is that whereas we have an in-depth knowledge of our own failures, we know very little of other people’s. We might hear about a colleague failing to get a job interview, but we are unlikely to know of every failure and setback they have experienced. I think this situation is somewhat corrosive, and may add to the feeling of ‘impostor syndrome’ experienced by many throughout their career – the feeling that they are frauds and do not deserve the success they have achieved. (Incidentally, I have never felt this phenomenon more acutely than writing this piece: who am I to dispense career advice to others?).

With these issues in mind, I recently wrote a blog outlining all of my academic failures (tinyurl.com/ahornercv). My hope was that revealing the amount of failure that has gone hand-in-hand with the limited level of success I have so far achieved might provide insight for those at the very beginning of their research career. For instance, whereas my CV says I started my PhD in 2006 following an MSc, it makes no mention of the fact that I originally applied for several PhD places in 2005, at the end of my undergraduate degree, but could not obtain funding that year. As a result of this, I joined an MSc programme and applied again the following year. The second time round I was obviously successful. Similarly, my CV outlines my postdoc positions since completing my PhD in 2010. This again appears seamless, moving smoothly from one position to another. In reality, I was rejected from a further eight advertised postdoc positions and fellowships.

This list could go on. I could outline the number of papers I have had rejected from various journals or the number of scientific prizes I wasn’t awarded (though this is obviously slightly disingenuous, as I was at least nominated for them in the first place). The question is why might this information be useful for others, and what nuggets of wisdom, if any, can be extracted from my track record of failure?

First, rejection is endemic in academia. If you don’t deal with it well, you might want to reconsider a career in academia. That said, rejection gets easier. No single rejection is likely to result in the complete destruction of your entire career. It was actually surprisingly difficult to piece together all the rejections I have experienced largely because I had forgotten about them. The rejection you just received may seem incredibly important the day you receive it, but in six months’ time it is unlikely to seem quite so salient and career-threatening.

Second, I admit to being nervous about posting the blog. I wrote it several months ago, but only recently felt secure enough to actually post it. It is one thing to admit to failure in front of your friends, another to admit to it publicly where prospective employers might read it.

The key point though is that all of us, no matter how successful, have been rejected numerous times. Often the individuals that are the most successful have also suffered the most rejection. It is the manner in which we deal with the rejection, not the amount of rejection suffered, that is more likely to determine our future level of success. The realisation that you’re likely to be judged on your successes, rather than your failures, can be liberating.

Finally, I believe we should be more open about our failures and successes. The ‘open science’ movement is dedicated to making science research accessible to all. I think part of this approach should also involve openly discussing ‘being in’ science, as well as the science itself.

Many on Twitter are already openly discussing career paths and being very honest about their individual experiences. In particular, the fortnightly #ECRchat (http://ecrchat.wordpress.com) created by Katie Wheat (@KL_Wheat) can be hugely informative about a range of issues concerning early career researchers. Sharing our experiences in such a manner can be both useful and supportive. I was overwhelmed by the positive responses I received from many undergrads, PhDs, postdocs and lecturers, simply for writing a detailed list of my failures.As with all ideas, someone has always had them before you. Bradley Voytek actually lists his failures on his official CV (tinyurl.com/voytek-cv) and Melanie Stefan has previously espoused the virtues of keeping track of your failures (tinyurl.com/knuypx7). I also know of at least one person who has followed suit and published his own list of failures since I uploaded my original blog post (tinyurl.com/nwaafa6). It seems a few of us have struck on to the idea that keeping track of our rejections and failures can, perversely, be rewarding. I’d encourage you to do the same. Don’t dwell on your failures at the expense of your achievements, but do make a list. You don’t need to openly publish yours, but the ability to look back over your failures and realise you have achieved, despite such setbacks, can be fortifying.


Taking the medicine

Nick Hatton on his unusual career destination

Inspired by stories of others’ career paths using their psychology degree, I wanted to tell people about my slightly less conventional route into PhD study. I am currently involved in a multidisciplinary clinical research project at Hull York Medical School. In an environment of people trying to find cures for cancer, drugs for HIV and map the human genome, there is a danger that the contribution of psychology can be seen as trivial. However, I would argue that the skillset provided by undertaking a degree in psychology makes us an asset to any research group and indeed an indispensable part of healthcare provision.

In the current climate of cutbacks and ‘restructuring’, psychologists and other professionals have been required to demonstrate flexibility; in their roles, in their working patterns and in their overall career ambitions. After a few periods of unemployment, I was becoming frustrated at the lack of opportunities available to me in the big wide world. The only advice that I could seem to get from academics and people working in the field was to get more experience. Having worked in mental health for over three years, managed to get my name on two research papers and undertaken voluntary work until I could no longer afford it, this seemed like a never-ending cycle. I obtained respectable grades on my undergraduate and master’s degrees. I had a broad base of technical and ‘soft’ skills that I was keen to develop further. So why wasn’t I getting the break that I needed?

Looking back, part of it was fussiness on my part. I didn’t want to rush in to doing a PhD on a topic that I wasn’t sure about, or make a commitment that I didn’t know whether I could fulfil. Furthermore, I didn’t want to put myself in a position where, in three years’ time, I would once again be at the mercy of the jobs market. So I made the decision to get as wide a variety of work experience as possible.

On finishing my master’s degree in 2010, I received numerous offers of short-term research-based positions at my former university. Not understanding the jobs market at the time, I naively relocated and undertook these jobs with the best of intentions, only to be informed after a few weeks/months that they could no longer afford to keep me. Following two years of this, I decided that a different approach was necessary. After a brief stint working in finance, I relocated again and took on a diverse series of ‘low-level’ jobs that helped to rebuild my confidence and prepare me once again for the workplace. Of these, working in health promotion allowed me to use the ‘soft’ skills gained during my degree. It also gave me experience of working with other health professionals and an insight into another aspect of medicine. During this time I also qualified as a lifeguard and swimming instructor. Whilst this may seem a little ‘off the wall’ in relation to a career in psychology, this gave me first-aid skills, communication skills and most importantly kept me in employment.

So, why a PhD in medical science? A number of people that I had studied with previously had gone on to study graduate medicine. However, for me, the rewards of working in research had always appealed beyond anything else. I didn’t want to leave behind my background as a psychologist, with the firm grounding in research methods and statistics that my BSc had given me. For my master’s I had studied neuroimaging, which gave me knowledge of anatomy and a diverse skillset directly applicable to medicine. I hadan interest in other aspects of health (e.g. cardiovascular) from other jobs that I had done, so when the opportunity arose I was delighted to take it.

The SEDA Research Group that I am currently involved with specialises in palliative medicine. There are clear applications of psychology, and I am not the only psychology graduate in the department. However, there are also major contributions from fields as diverse as sociology, chemistry and health science. In terms of clinical experience, I am surrounded by doctors but there are also research projects involving registered nurses, physiotherapists and pharmacists.

It can be a little daunting working with successful doctors with intercalated research degrees on top of a degree in medicine. Many have also managed to obtain a wealth of clinical experience. However, it is important to remember that everybody is fallible and they are in need of our skills and experience as much as we theirs.

I have developed an immense respect for the medical profession through undertaking this research. In psychology, a conflict is sometimes seen between a ‘medical’ and a ‘psychological’ model of treatment. However, this way of thinking obscures the aim and the purpose of all healthcare professionals: better treatment, interventions and outcomes for those most in need.

In terms of my own project, the field I am working in has lain dormant for years, and in my view is in great need of some psychological input.
I have long had an interest in psychopharmacology. The opportunity to apply this in a way that may improve the lives of cancer patients was too good to turn down. So many of us are affected by cancer every year, either directly or through family (my own included). To undertake research on the psychological effects of the drugs given to these patients is vital to inform clinical practice.

Problems with the work in the area currently include methodological issues familiar to many of us: poor sample size/power, lack of ecological validity due to difficulties in recruiting cancer patients, and inferior testing tools and instruments. Many of the studies looking at cognition in cancer patients have used clinical tools such as the Mini Mental State Exam (MMSE). Whilst this is great for diagnosis of conditions such as Alzheimer’s disease, it is known to lack sensitivity. The MMSE has a skewed distribution and  is therfore poor at picking up ‘milder’ forms of cognitive impairment. In addition, it is inefficient at detecting deficits in frontal-lobe function and spatial working memory. These two aspects of cognition have been shown to be affected by psychoactive drug use in other populations.

Better information in this area will go some way to alleviating phenomena such as ‘opiophobia’. This is a reluctance on the part of clinicians to prescribe such drugs, based on excessive concerns about ill effects. Similarly, the research will also aid in the design of more effective treatment regimens for patients.

So, my ‘take home’ advice? Do not underestimate the breadth of options that your degree in psychology gives you. Whether you want to work with people, or would be happier sitting at a desk number crunching, your skills can be used virtually anywhere. Looking back, the main thing that held me back as a fresh-faced graduate was the ability to ‘market’ my skills effectively. If you’re entering the jobs market, my advice would be that a little bit of shameless self-promotion goes an awfully long way.

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