The Psychologist December 2019 by The Psychologist

the psychologist

the

psychologist december 2019

december 2019

Allergy â&#x20AC;&#x201C; insider perspectives Khadj Rouf and Kathryn Evans kick off a special feature

alsoâ&#x20AC;Ś the Brexit psychodrama

www.thepsychologist.org.uk

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the psychologist december 2019

contact The British Psychological Society 48 Princess Road East Leicester LE1 7DR 0116 254 9568 info@bps.org.uk www.bps.org.uk the psychologist and research digest www.thepsychologist.org.uk www.bps.org.uk/digest www.jobsinpsychology.co.uk psychologist@bps.org.uk Twitter: @psychmag Download our iOS/Android apps advertising Reach 50,000+ psychologists at very reasonable rates. CPL, 1 Cambridge Technopark Newmarket Road Cambridge CB5 8PB contact Kai Theriault 01223 378051 kai.theriault@cpl.co.uk november 2019 issue 53,302 dispatched cover Napal Naps www.napalillustration.com/ environment Printed by Warners Midlands plc on 100 per cent recycled paper. Please re-use and recycle. Mailing bag is potato starch-based and fully compostable. issn 0952-8229 (print) 2398-1598 (online)

© Copyright for all published material is held by the British Psychological Society unless speciﬁcally stated otherwise. As the Society is a party to the Copyright Licensing Agency (CLA) agreement, articles in The Psychologist may be copied by libraries and other organisations under the terms of their own CLA licences (www.cla.co.uk). Permission must be obtained for any other use beyond fair dealing authorised by copyright legislation. For further information about copyright and obtaining permissions, e-mail permissions@bps.org.uk.

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the

psychologist december 2019

Allergy – insider perspectives Khadj Rouf and Kathryn Evans kick off a special feature

also… the Brexit psychodrama

www.thepsychologist.org.uk

The Psychologist is the magazine of The British Psychological Society It provides a forum for communication, discussion and controversy among all members of the Society, and aims to fulﬁl the main object of the Royal Charter, ‘to promote the advancement and diffusion of a knowledge of psychology pure and applied’

The Psychologist needs you! We rely on your submissions throughout the publication, and in return we help you to get your message across to a large and diverse audience. For details of all the available options, plus our policies and what to do if you feel these have not been followed, see www.thepsychologist.org.uk/contribute The main message, though, is simply to engage with us. Contact the editor Dr Jon Sutton on jon.sutton@bps.org.uk, tweet us on @psychmag or call /write to us at the Society’s Leicester ofﬁce.

Managing Editor Jon Sutton Deputy Editor Annie Brookman-Byrne Production Mike Thompson Journalist Ella Rhodes Editorial Assistant Debbie Gordon Research Digest Matthew Warren (Editor), Emily Reynolds, Emma Young

Associate Editors Articles Paul Curran, Harriet Gross, Michelle Hunter, Rebecca Knibb, Adrian Needs, Paul Redford, Sophie Scott, Mark Wetherell, Jill Wilkinson History of Psychology Alison Torn Interviews Gail Kinman Culture Kate Johnstone, Sally Marlow Books Emily Hutchinson Voices in Psychology Madeleine Pownall International panel Vaughan Bell, Uta Frith, Alex Haslam, Elizabeth Loftus, Asifa Majid Psychologist and Digest Editorial Advisory Committee Catherine Loveday (Chair), Emma Beard, Harriet Gross, Kimberley Hill, Deborah Husbands, Peter Olusoga, Richard Stephens, Miles Thomas

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psychologist december 2019

02 Letters Homework, birth trauma and much more

06 Obituaries Peter Banister 10 News From poverty to flourishing 18 Digest Resilience

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24 ‘We must turn the tide of Brexit psychodrama’ Michael Smith meets Brian Hughes to hear about his new book

28 Allergy – insider perspectives Khadj Rouf and Kathryn Evans on the challenges of parenting children with severe allergies

34 Growing up with allergy Audrey DunnGalvin

38 Can interventions make a difference? Rebecca Knibb considers attempts to reduce the psychological impact of allergy

42 ‘I haven’t said goodbye to my kids’ Béré Mahoney, Eleanor Bradley, Elaine Walklet and Steve O’Hickey on living with anaphylaxis in adulthood

48 Telling people together Nadine Lavan, winner of the Doctoral Research award, on voice perception

62 Books With Susan Cousins, Dean Burnett and more

68 Culture How would you feel if you couldn’t play?

74 Looking back Jonathon Rutherford shines a light on ‘what asylums were’

I write this the day after my eldest son was, for the third time, hospitalised with an allergic reaction. The first, when he was just three years old, nearly killed him. So much changed on that day. Living with allergy, as parents, is so fraught that I can barely hope to imagine what it’s like for him. So I’m pleased to see our collection of articles, starting on p.28, which consider psychological perspectives on growing from child to adult under the shadow of anaphylaxis. How do young people, and their friends and relatives, balance the urge to protect with the need for independence and to lead a normal life? There’s loads more on offer this month, as we close out a year in which we have sought to bring you 12 packed, diverse and engaging editions (plus more online extras than ever). After several years of building Content, Channels and Community, the Psychologist and Research Digest team is in good shape and looking forward to an increased focus on Structure, Style, Strategy… and our Society.

80 One on one …with Asweeni Jansdin Raj

Dr Jon Sutton Managing Editor @psychmag

52 ‘What really matters’ Ernesto Spinelli, a winner of the Award for Distinguished Contributions to Practice

56 Careers We meet Paul Grantham of SDS Seminars 58 Jobs in psychology

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John Harris/reportdigital.co.uk

From poverty to flourishing Ella Rhodes reports on the Society’s priority for 2020, voted for at the Senate

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ore than four million children are amongst the 14 million people living in poverty in the UK, the world’s fifth largest economy. Given the well-documented physical and psychological effects this can have, the British Psychological Society’s (BPS) Senate has voted to make poverty and inequality its policy priority for the coming year. Between 2008 and 2018 there was a 5146 per cent increase in the distribution of emergency food parcels, with a record 1.6 million food bank parcels given out by the Trussell Trust between April 2018 and March 2019. The increase in rough sleeping since 2010 has been estimated at 165 per cent. Around 800,000 children were lifted out of poverty between 1998 and 2011, but since that time numbers have flatlined. The number of children living in poverty is projected to rise to almost 40 per cent by 2021. Children who live their early lives in poverty have poorer mental health, wellbeing and physical health, underachieve at school and experience stigma and bullying as a result of their situation. The UN’s Special Rapporteur on extreme poverty,

Philip Alston, in his report on poverty and human rights in the UK, pointed to the ‘tragic social consequences’ of the coalition government’s austerity regime in place since 2010. Alongside rises in food bank use and rough sleeping, Alston pointed to the growing number of homeless families: ‘24,000 between April and June of 2018 – have been dispatched to live in accommodation far from their schools, jobs and community networks; life expectancy is falling for certain groups; and the legal aid system has been decimated… Government reforms have often denied benefits to people with severe disabilities and pushed them into unsuitable work, single mothers struggling to cope in very difficult circumstances have been left far worse off, care for those with mental illnesses has deteriorated dramatically, and teachers’ real salaries have been slashed.’ Consultant Clinical Psychologist Julia Faulconbridge, also Vice Chair of the BPS Division of Clinical Psychology, was involved in developing the poverty proposal taken to the Senate vote. She takes an interest in prevention and the impacts of systems on child development, and told me that poverty was possibly the biggest risk factor for

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the psychologist december 2019 news children developing problems. ‘Austerity measures have probably impacted more on children than on anybody else and it’s affecting, not just families on benefits, but so many families who are not able to earn enough money to be able to look after their children in the way they want to… people on zero hours contracts, people in the gig economy and people working two or three different jobs. When you stop to think about the number of families that are reliant on food banks, schools that are having to provide food and clothes for children so they can manage the school day, it’s almost unbelievable.’ Faulconbridge said the result of the general election will be crucial in tackling rates of poverty. ‘Basically, there are two issues: one is what can we do to actually highlight the reality of living in poverty, not only of the levels of poverty, but also how these actually impact on people. The second side of it is what sort of structures should we have in place, particularly around children, that could at least ameliorate some of the effects? What should we be doing in terms of what support we’re putting in for families right from the beginning? What sort of things should schools be doing? What sort of community facilities and support should be there? How can we build support within communities so they can help each other?’ In terms of the British Psychological Society’s role in tackling poverty and its effects, Faulconbridge suggested that we should not take psychological knowledge for granted. ‘I think we need to make the impact of poverty, in terms of psychological and physical health and wellbeing, so much clearer and explicit so that people who have the power will start to do something about it. It’s like the air we breathe, it’s so obvious to us, but whenever I go and talk about this sort of thing, even among people who are quite committed, they say afterwards I never actually put those things together. I think there’s something really important about making what’s currently invisible, visible, and helping people to connect the dots on the basis of psychological knowledge. ‘I think secondly we should look at how we may be able to support our members in what they might be wanting to do locally. There’s people who may be in a position, because of their positions in the health or voluntary sectors, to go and talk to their local councillors. It’s about empowering our membership to actually go out and work locally and where we are finding things that work it’s about making sure that becomes widespread.’ Educational Psychologist and tutor Dr Gavin Morgan (University College London), also Chair of the BPS Division of Education and Child Psychology, sat on the expert reference group for this year’s policy priority on the mental health and wellbeing of children and young people and helped formulate plans for this new priority area. ‘I think there’s sometimes a misunderstanding about what us as psychologists do. For example, mental health is often seen as an individual problem. I think sometimes people expect psychologists to work with individual people when we’re trying to address individual problems. I was at pains during this year to promote the idea that there’s wider contexts we need to be aware of, there are systemic factors that are influencing mental health, poverty clearly

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being one of them. We can’t escape those contextual and environmental factors that influence people’s mental health.’ In his work as an Educational Psychologist Morgan said he has encountered the effects of austerity and societal issues in many of the children he has worked with. ‘A mentally unhealthy child isn’t going to learn. Fundamentally we need to address the basic issues first. We need to address wellbeing needs before a child is able to begin to learn or begin to develop social skills or attachments with other children, we can’t have one without the other. I think because children sometimes aren’t in a place where they can learn this has wider ramifications for society, it becomes, sadly, a vicious self-perpetuating circle. So we need to break that and we need to begin with addressing fairness and equality as a starting point I think. We need a systemic approach, a holistic and joined-up approach, on education, health, local authorities and the government.’ Morgan said thanks to cuts to local authority budgets many specialist staff are no longer employed to support children – leading to an increased load on educational psychologists. ‘We’re picking up a lot of work other agencies would’ve done previously. We’re seeing more complex, more damaged children, we’re trying to do more with less and it’s having an impact on us. What we need Julia is increased budgets and resources for local authorities, Faulconbridge we need to ensure there are educational psychologists attached to every school. We need specialist teachers, we need to work with CAMHS and clinical psychologists and social care, we need a wider network of specialists we can work alongside and work with to support children and a joined-up approach from education, health and the government.’ Psychologists are already working on tackling the effects of poverty, Morgan said, particularly in community psychology through groups such as Psychologists for Social Change. ‘I think gradually psychology and psychologists are becoming more involved in a social justice agenda with the view that equality is the best therapy and that should be our starting point. I think through the poverty to flourishing campaign that’s what we’re trying to do. So rather than trying to have sticking plasters of therapeutic approaches… yes, it has its place of course… what we need is equality and I think that will lead to wider societal change.’ Morgan said he hoped the BPS could use the Dr Gavin Morgan momentum of the current policy priority area and be an advocate for psychologists. ‘I think it’s about trying to position psychologists as being key in our society and key drivers for positive change. Yes there’s disparate professions among the psychology community but we’re all fundamentally psychologists. I think this year’s been really positive and I’ve seen some really positive change in the Society recently. We need to be campaigners – we can’t shy away from political issues and we shouldn’t, we’ve got a responsibility to the wider community.’ er Interested in supporting the campaign? The Society is assembling an expert reference group – see p.47.

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Launch of online communities Members of two of the British Psychological Society’s member networks can now keep in touch through dedicated online communities. These new forums will provide members with a place to network with each other, ask questions, raise topics of interest and share interesting content with colleagues.

The online community for undergraduate students launched at the end of October and will allow thousands of undergraduate students, both in the UK and those studying UK university courses online from overseas, to connect and collaborate. The beginning of November saw the launch of the Division of Clinical Psychology’s

CONNECTION PERFECTION By joining the BPS student online community you can connect with other psychology students across the UK. Access hundreds of exclusive online resources to help you with your degree, and discover great events happening near you.

Join the BPS student online community for free today

CONNECT.BPS.ORG.UK/STUDENTS 12

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online community, and more will be developed over the coming months to cover other member networks. British Psychological Society (BPS) Director of Communications and Engagement Rachel Dufton said a key role for membership organisations was to help members to connect. ‘Our 154 member networks already do a fantastic job of supporting members to network with like-minded people in various scientific, professional, regional and special interest groups but our lack of up-to-date technology has meant that it hasn’t always been easy for members to stay in touch with each other online. That’s why we’ve developed a new community platform which will bring our members together by giving them a dedicated online space to hold discussions, ask questions and share insights. It’s somewhere for members to meet others online who share their passion for psychology.’ Linda Corrie, BPS Digital Projects Manager, said the communities were designed to make networking, and reaching out to others, a simple process. ‘You can post discussions on any topic, ask other members questions, share documents and other content like videos, as well as sharing experiences through writing a blog. And the technology that sits behind the community makes the experience of taking part really straightforward. Members are invited by an email from the BPS and then just need to log on for the first time with their membership details and then it’s just a couple of clicks to enter the community from either your laptop, PC or smartphone. With the system’s built-in email notification system, members also receive emails about discussions they are taking part in or topics of interest, as frequently or infrequently as they like based on their notification settings.’ er

Student and DCP members can access their community by visiting connect.bps.org.uk/students or connect.bps.org.uk/dcp

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the psychologist december 2019 news

Presidents’ Award An internationally-renowned autism researcher has received this year’s British Psychological Society Presidents’ Award. Professor Francesca Happé (King’s College London) has led seminal work on the neurocognitive causes of social impairments in autism and more recently has begun investigating mental health in autism spectrum disorders and autism in under-studied groups, including women and older people. A previous winner of the society’s Spearman Medal, Experimental Psychology Society Prize, and the Royal Society’s Rosalind Franklin Award, Happé is widely recognised as one of the most distinguished developmental psychologists in the UK. She is also a fellow of the Academia Europea, the Academy of Medical Sciences and the British Academy. Happé said she was amazed and utterly delighted to receive the award, and that she felt particularly proud of the many students she has come into contact with over the years. ‘I’m most proud of my students’ achievements – when they get a wonderful paper accepted, pass their viva with no corrections, get their first prestigious job or promotion, or simply show admirable resilience against the knocks and set-backs we all have to face in academia. In terms of my career, I was incredibly fortunate to be President of the International Society for Autism Research and hugely privileged to have been Director of the Social, Genetic and Developmental Psychiatry Centre from 2012 to 2019.’ Looking to the future Happé said there were many fascinating open questions yet to be answered about autism which she hoped to investigate. ‘I’m keen to

explore, for example, whether autistic people are more vulnerable to developing PTSD, because of differences in cognitive style, and do so following things that non-autistic people might not consider traumatic. That work could have real impact to improve access to interventions that could really improve lives. I’m also passionate about research with under-served groups such as women and the elderly on the autism spectrum.’ Professor Daryl O’Connor (University of Leeds), chair of the Society’s Research Board, said he was delighted that Happé had won this year’s award. ‘This year we received a large number of truly excellent nominations, which made the award committee’s task incredibly difficult. However, we felt that Professor Happé’s distinguished contribution to psychological science over a sustained period and the outstanding quality of her research made her a worthy winner of this award.’ er Revisit our 2014 interview https://thepsychologist.bps.org. uk/volume-27/edition-10/interview-francesca-happe and a chapter from Happé’s recent book with Sue Fletcher-Watson, which looks to the future of autism: https://thepsychologist.bps.org.uk/volume-32/ november-2019/looking-future

A tricky balance Technology has changed how people work – from those whose homes are also their offices, to people working flexibly and staff working under zero-hours contracts or in the ‘gig economy’. Held in London’s Mansion House and organised by the British Psychological Society’s Division of Occupational Psychology and Society of Occupational Medicine, a recent conference saw discussions of the future of work and the psychological needs of these growing workforces. Peter Estlin, Lord Mayor of the City of London, opened the day’s talks emphasising the importance of digital intelligence and rapidlychanging modern working conditions and their impact on mental health and work-life balance. Business Psychologist Alan Bradshaw had

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personal experience of many of the issues discussed at the event – working remotely and flexibly as a self-employed workplace mental health consultant. After starting his career as a social worker in the 1980s, Bradshaw became interested in work-related stress and now works with large companies helping them to reduce and prevent stress risks. For those working remotely, or under precarious employment contracts, stress can be a major issue but Bradshaw also pointed out that these workers can also experience isolation, financial problems, unsafe working and presenteeism (working while ill). Bradshaw worked with a client which had offices throughout the UK to examine stress among its

remote and lone-working employees. He assessed which potentially stressful situations were faced by the company’s staff, and developed plans for helping them cope with these issues in the future. His work resulted in a prioritised list of stressful situations, from those with the most negative impact to the least. The first issue on the list was IT-related issues: remote workers are particularly reliant on technology and struggle to work when things go awry. Second on the list was isolation; third was working time, including work-life balance and hours worked without breaks; and the fourth was travel, particularly employees needing to visit remote areas then feeling they had to travel back home the same night.

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In trying to tackle some of these issues, Bradshaw said communication with managers was key. Feeding back some of the above problems led managers to realise that employees had made some assumptions about their work that were adding to their stress. Managers confirmed, for example, that employees weren’t expected to travel home late at night and could find a hotel for the evening instead. Some of the health implications of remote workers’ reliance on technology were outlined in a talk written by Professor Gail Kinman (University of Bedfordshire) and delivered in her absence by Dr Roxane Gervais. While increasing numbers of people work remotely – the number in 2015 was 2.4 million in the UK – research on these employees is still sparse. Although there are benefits to working from home (including lower operating costs for companies, increased productivity, and lower sickness absence), remote employees have little or no health and safety support and tend to work longer hours. There is also a tricky balance for those whose offices are their

Remote employees tend to work longer hours homes in achieving good balance between their work and home lives. Many organisations do not offer training on using technology in a healthy way, and some expect their employees to be available for phone or email contact even outside of contracted hours. Kinman has proposed a need for e-resilience among employers and employees, suggesting that remote working is expected to become the norm and a systemic approach is necessary to build e-resilience. She wrote that in building e-resilience, organisations should be aware of their duty of care towards employees, examine their email culture and what expectations

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More online Including: ‘They know they’re human’: Martin Turner and Andrew Wood with a rational approach to performing under pressure, around the Rugby Union World Cup Final.

Plus: Edge Hill University’s sport and mental health team help a sporting charity; Trainee Forensic Psychologist Ana DaSilva with a personal perspective on a ‘BAME in Psychiatry & Psychology’ event; the ‘Every Mind Matters’ campaign; and Brexit and mental health – how are you coping?, Victoria Tischler’s report from an event at Europe House in London.

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are placed on remote workers, and look into whether employees could benefit from time management training. For employees and other remote-working individuals Kinman said they should not let technology manage them. She advises reflection on habits, appreciating professional boundaries and using relaxation and mindfulness techniques to help cope with technology-related stress. She concluded that more research is needed along with a multidisciplinary approach, with a vision to create an e-resilience competency framework. er

For a chief psychology professions officer in the NHS Nine organisations including the BPS have come together to back the creation of a new post to oversee the expansion of the NHS psychological workforce. A letter signed by chairs and chief executives of the organisations and sent to key decision-makers in the NHS calls for the appointment of a chief psychology professions officer. It says the new post would put the psychological professions on a par with medicine, nursing and the allied health professions. Writing in Health Service Journal, Sarb Bajwa (chief executive of the BPS) and Dr Nick Waggett (chief executive of the Association of Child Psychotherapists) say: ‘The NHS long-term plan offers an opportunity to significantly expand access to psychological healthcare in all its forms and to deliver more integrated care for patients. But delivering this transformation means psychological approaches to healthcare must be “hard wired” into the NHS architecture at all levels – national, regional and local. Critical to achieving this will be having a chief officer for the psychological professions within NHS England/Improvement providing the strategic vision, leadership and coordination to make the plan a reality.’

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the psychologist december 2019 news

Schooling with compassion Teachers are, perhaps more stressed than ever; more than 20 per cent leave the profession within their first two years. The Education Support Partnership, a helpline for teachers, received a record number of calls between April last year and March this year; and student numbers are on the rise in secondary schools. While many initiatives take a focus on the mental health of pupils, Dr Frances Maratos has made steps to help teachers and school staff more generally with their stress, through a trial of compassionate mind training in schools in the UK and Portugal. In the last two years Maratos (Associate Professor and Reader in Emotion Science, University of Derby), and her colleagues Wendy Wood and Professor Paul Gilbert (UK), as well as Dr Marcela Matos and Isabel Alburquerque (Portugal), have worked with over 500 school staff in the UK and Portugal. They have developed a six-module course giving teachers information and techniques to help them understand and manage their emotions. ‘There is a lot of focus on student mental health, but if you had a parent who was looking after a number of children and that parent was quite stressed, or was having issues with wellbeing, you’d look into helping the parent manage their stress levels and their health. It’s not that teachers’ mental health is more important than that of the children, but if we help teachers and teaching assistants learn how

to emotionally regulate more effectively we know this will allow them to think better, and that will be beneficial to all the pupils they’re with.’ The compassionate mind training is run across one term with a session every other week. The six modules cover what compassion is, the brain’s evolution and its negativity or threat bias, as well as developing the compassionate self, mindfulness and breathing exercises. As well as standard measures of depression, perceived stress and anxiety, Maratos and her colleagues have also taken physiological measurements from the teachers and other school staff and collected qualitative and focusgroup data. So far the results are promising. A pilot of the course in Portugal found significant decreases in levels of depression and stress, and in an initial trial of 70 teachers in the UK the researchers found significant increases in self compassion and significant decreases in self-criticism. The physiological data, currently being analysed, so far seems to show decreases in blood pressure and total peripheral resistance – a measurement of how hard the heart is working. ‘Some of the feedback we’re getting from our qualitative measures is that staff are starting to use the techniques with their students – especially if they have more difficult students, they are taking them out of the classroom and teaching them breathing techniques. In Portugal the ethics system is slightly different so they’re looking at how the teachers being trained affects the children, which we’d like to do in the UK over the next year or so also.’ Recently Maratos has been working to train others to deliver this course in an attempt to reach as many teachers as possible, and soon she and her colleagues are hoping to run a second, larger, study of these techniques with pupils. ‘I’m a very firm believer that what works for adults doesn’t necessarily work for children, so we’re looking at a slightly different curriculum where we explore different emotions in more depth. A school counsellor, Rory Cahill, a further member of our UK team, ran a pilot study of the pupils’ curriculum with eight pupils at Roundhill Academy in Leicester last year. It proved so successful that they would like us to go back and do a full study with their school.’ On 8 November Maratos organised a conference for school staff to teach them more about compassion and mindfulness. The event, which drew in around 100 attendees, featured workshops from Professor Katherine Weare, author of Happy Teachers Change The World: A Guide to Cultivating Mindfulness in Education; Clinical Psychologist and founder of the Compassionate Mind Foundation Professor Paul Gilbert; and Consultant Clinical Psychologist Dr Mary Welford, who has also been involved in designing and implementing compassionbased interventions within school settings. er

Dr Frances Maratos

Further reading: tinyurl.com/y4qjze3y

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Raising the resilient child Emma Young digests the research to suggest five ways…

Editor: Dr Matthew Warren Writers: Emily Reynolds and Emma Young Reports, links and more on the Digest website

While some of us crumble in the face of adversity, and struggle to recover, others quickly bounce back from even serious trauma. Psychological resilience is undeniably important in all kinds of areas of life, so understanding what underpins it, and how to train it – particularly in children – is of intense interest to psychologists.

1. Watch your language

According to Carol Dweck of growth mindset fame, to drive success in our children we should ‘praise the effort that led to the outcome or learning progress; tie the praise to it’, as opposed to praising effort more broadly, or achievement alone. Research led by Victoria Sisk and published in Psychological Science last year did challenge the idea that encouraging children to have a growth mindset (to believe that effort affects attributes like intelligence) increases academic achievement. However, there are certainly studies finding that focusing on a child’s actions, rather than who they ‘are’, helps them to withstand setbacks. As Emily Foster-Hanson and her fellow researchers at New York University note in a study also published last year, in Child Development: ‘Setbacks and difficulties are common features of children’s experience throughout development and into adulthood’, so it’s important to examine the effects of category labelling – like ‘being smart’ or ‘being a helper’. The team’s study of four- and five-year-old visitors to the Children’s Museum of Manhattan found that setbacks were more detrimental to a child labelled ‘a helper’ than a child asked ‘to help’. Children asked ‘to help’ with tasks in which they were set up to fail (by being asked to put away a toy truck that fell apart as soon as they picked it up, for example) were more likely to go on to volunteer to help with other demanding situations. In contrast, the ‘helper’ kids tended to avoid these and opt instead for low-effort tasks with a high chance of success, like putting away some crayons. Perhaps these kids were taking advantage of a quick, virtually-guaranteed way to restore a little of their dented ‘helper’ image – one they weren’t about to risk even further by going for a challenging task. So, if you do want your kids to weather inevitable setbacks, resist asking them to ‘be’ anything, like ‘my helper’.

2. Engage in ‘strength-based parenting’ 18

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Find our Research Digest at www.bps. org.uk/ digest

‘Strength-based parenting’ entails deliberately identifying and cultivating positive states, processes and qualities in a child, explains Lea Waters at the University

of Melbourne, Australia. ‘This style of parenting adds a “positive filter” to the way a child reacts to stress. It also limits the likelihood of children using avoidance or aggressive coping responses,’ she says. In 2015, Waters and her colleagues published a preliminary study in the journal Psychology that explored strength-based coping in a group of Australian primary school-age children. The team presented the kids with a few theoretical stressful scenarios – falling out with a friend over turns on a swing, and being the only one in class who hadn’t done a homework project that was due in the next day – and asked them to describe how they would respond. The children who came up with ‘positive’ responses (like taking deep breaths to help them to cope with the homework challenge, and reminding themselves of happy times with the friend, or ‘using their kindness’, and deciding to let the other child have more turns on the swing), and who indicated that their parents were aware of their strengths, and encouraged them to use them, also experienced less stress themselves.

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the psychologist december 2019 digest In 2017, Waters and her team reported that training in strength-based parenting could help parents, too. Parents who were taught how to identify and cultivate strengths in themselves and their children went on to feel more positively about their children and reported greater confidence in their ability to raise them successfully. Then in 2019, the team reported a link between strengthbased coping and enhanced academic perseverance in adolescents. This work suggests that a ‘strength-based’ approach may help with resilience to setbacks at school. To try a strength-based approach with a child, the team recommends consciously identifying and fostering their abilities, talents and skills, and encouraging them to use them when faced with difficulties.

considered to be a crucial aspect of self-regulation – had a greater tolerance for negative situations; in other words, they demonstrated greater resilience. Self-regulation involves analysing and setting specific task-related goals, monitoring and evaluating your performance, managing your emotions throughout, and learning from whatever went wrong. The recent study suggests that teaching children these kinds of skills could help with resilience, too. ‘The research shows the relationship between two essential non-cognitive skills: resilience and self-regulation, that are equally or even more important than cognitive aspects in the educational process of students at risk of social exclusion’, Artuch-Garde says.

3. Don’t shield them from stress

Dennis Charney, a biological psychiatrist at the Icahn School of Medicine at Mt Sinai, New York, has studied all kinds of people who’ve been through traumatic experiences – from being a prisoner of war to suffering assault, or natural disaster – and identified factors that explain why some people bounce back, while others don’t. (His 2012 book, Resilience, jointly-authored with Steven Southwick at Yale University, explains the findings in full. There’s also a podcast based on the book.) Being the kind of person who embraces tough challenges, rather than trying to avoid them, emerged as a key factor. To develop this, Charney recommends giving kids challenges that they can just about manage, and once they have achieved them, raising the bar a little each time. With his own five kids, he’d take them on long hikes, for instance, and get them just a little lost. During one of these trips, he recalls, one of his daughters told him that ‘out of her soul, she despised me’. (Now an adult, she willingly goes off hiking herself.) Exposing kids to controlled stressful experiences allows them to develop a ‘psychological toolkit’ of coping methods to draw upon in adulthood too, Charney maintains.

5. Focus on ‘quantity time’ and group activities

In 1998, Iceland launched a national initiative with the aim of slashing alcohol and drug use among teens (see tinyurl.com/iceslash and tinyurl.com/iceslash2). But the way the programme was set up meant that it did not only this, but much more. Through funded sport, art and music classes, teenagers were given alternative ways to feel good. Among new measures targeted at adults, parents were encouraged to spend more time with their kids (not just limited ‘quality time’) and to talk more to their children about their lives. National questionnaires showed a huge adoption of both these strategies between 1997 and 2012 – and during the same period, Iceland went from having some of the worst statistics for teen alcohol and drug use in Europe to having the best. ‘This is the most remarkably intense and profound study of stress in the lives of teenagers that I have ever seen,’ commented US-based consultant Harvey Milkman, in 2017. ‘I’m just so impressed by how well it is working.’ Towns and municipalities in many other countries have now adopted the model, and in 2019, Chile announced that it would roll out its own version of the Icelandic programme nationally. The Icelandic initiative was not set up to ‘train resilience’ but in bringing families closer together and increasing access to sport and cultural activities, it is producing physically and psychologically healthier teenagers – kids who find it easier to resist drugs, and who should be better equipped to cope with challenges in their lives. It couldn’t have happened, however, without the full backing of the government, local mayors, other public officials and schools. In other communities that are adopting the model, and that are seeing the benefits, local mayors and policy-makers have either instigated or come on board to drive similar programmes within their community. An individualistic focus on improving selfregulation, for example, in your own kids is one thing. But when everyone gets together to support all the teens within a community, or a country, the results can be remarkable.

4. Teach self-regulation skills

Explicitly teaching kids ways to regulate their responses to adversity builds resilience, helping them to do well in school and in life. This is the message from a 2017 study, published in Frontiers in Psychology, of 365 Spanish children and young adults, aged 15-21, all of whom struggled academically. In research conducted for her 2014 PhD thesis, Raquel Artuch-Garde at the International University of La Rioja found that self-regulation and resilience are key factors that can determine academic success or failure. For the more recent study, she and her colleagues gave the participants a resilience scale (which asked about their perceptions of support and their ability to tolerate negative situations) and a self-regulation questionnaire (which explored their ability to make and stick to goals and to persevere at a task). They found a clear relationship between scores on both. Participants who were better able to learn from mistakes – which was

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Find a Society briefing paper on resilience and character via www. bps.org. uk/newsand-policy/ briefingpaperresilienceandcharacter

05/11/2019 15:39

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Digest digested We eat more when we’re dining with family and friends than when alone, according to a new review. The ‘social facilitation’ of eating may have its roots in the way our ancestors ate, sharing meals to protect against future food insecurity, say the authors. The team also identified other important social factors: women tend to eat less in front of men, for instance. (The American Journal of Clinical Nutrition). The stereotype of the narcissistic only child can finally be put to bed. Researchers found that people do generally believe only children are more narcissistic than those with siblings. But when they looked at the personalities of 1810 Germans with and without siblings, they found that there was no truth to this cliché. (Social Psychological and Personality Science). Low reproducibility rates in psychology undermine the public’s trust of the field, a new study has found. And that trust may be hard to rebuild. The researchers found that trust did not improve after explaining the reasons behind the replication crisis or even after telling participants about recent improvements in research practices and reproducibility. (Social Psychological and Personality Science)

People would rather workers are replaced with other human staff than with robots – but it’s another story when it comes to their own jobs. When participants imagined their job was at risk, they said being replaced by a robot would be preferable and would provoke less of a negative emotional reaction. Robots pose less of a threat to our feelings of our self-worth than do other humans, the authors say. (Nature Human Behaviour).

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Aftermath of 2011 terrorist attack in Norway

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Point out hypocrisy Log on to Twitter and you’ll see how likely collective blame is to be placed on Muslims as a group for actions perpetrated by a few Islamic extremists. But a new paper in Nature Human Behaviour has found that asking people to consider the hypocrisy of collectively blaming Muslims, but not white Europeans, for terrorist attacks can reduce Islamophobia. The team asked white, Spanish participants to rate how much they blamed Muslims for individual acts of violence perpetrated by extremists. But some of the participants were

first asked to read descriptions of violence perpetrated by white Europeans, such as the 2011 terrorist attack in Norway, and rate how much responsibility they place on this group, and on themselves personally. Those who went through this intervention showed reduced antiMuslim sentiment and placed much less blame on Muslims for acts of terror than those who received no intervention. And these participants continued to express lower collective blame of Muslims a month and even a year later. Emily Reynolds

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the psychologist december 2019 digest

Making a public apology like you mean it Public apologies for misdeeds can be tricky. The usual advice to companies, politicians or celebrities is to acknowledge what you’ve done wrong, express regret, and promise never to do it again. However, the public can still often be sceptical and not particularly forgiving. Matthew Hornsey at the University of Queensland and colleagues wondered if it makes a difference if remorse is also conveyed non-verbally – by dropping to the knees, perhaps, or wiping away tears, as for example when Canadian Prime Minister Justin Trudeau issued a ‘tearful’ apology to indigenous Canadians in 2017. The team’s set of six studies, published in the Journal of Personality and Social Psychology: Interpersonal Relations and Group Processes, shows that such ‘embodied remorse’ can go down quite well – at least, among some groups. However, a consistent finding across the studies was that such gestures don’t actually improve levels of public forgiveness. These results are important in part because while some public apologies are minor – of the ‘TV star admits drug use’ type – they are also considered to be an essential part of the process of reconciliation after gross violations of human rights, and even genocide. The public response to such apologies can clearly have huge ongoing implications. For the first study, the team recruited 196 American

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and 229 Japanese participants, who read about the realworld apology by senior executives of the Tokyo Electric Power Company in the wake of the 2011 Fukushima Daiichi nuclear disaster. The researchers tweaked the texts, so that some read about how the executives knelt to the ground during their apology while the others didn’t. The first group also saw a photograph of the executives kneeling, while the second group saw a photograph of them standing with neutral faces. The embodied remorse group gave more positive appraisals of the executives, were more satisfied with their response, and also perceived less ulterior motive and more remorse. This was especially true for the American participants. However, the two groups didn’t show any difference in levels of forgiveness of the company. Additionally, some of the participants had been told that the apology was made in private, to victims, while others were told it had happened during a press conference. The results showed that whether the apology was private or public made no difference to any of these participants’ ratings. A subsequent study focused on the Sewol ferry disaster, in which 304 people, mostly children, died. Afterwards, the South Korean president publicly apologised for the government’s mistakes. This study, which involved 207 American and 190 Korean participants, found that crying had very similar effects to those found for kneeling: participants’ levels of forgiveness were unaffected when the president was portrayed as crying, but they did view her more favourably and perceive her as feeling more remorse. However, this was only the case for the Americans: the Koreans were unmoved by the tears. Exactly why there should be this difference is not clear. Next, the team turned to real-world transgression and public apologies in which an individual (rather than a group) was at the centre of a scandal. These cases included a swimmer who’d made a homophobic tweet, a scientist who’d committed fraud and a US politician who’d anonymously made racist comments on blogs. Again, the participants (in these cases, all American) believed the perpetrator to be more sorry when they were told that he or she had cried during the apology. They also reported more satisfaction with the apology and were more confident that the individual wouldn’t re-offend. But yet again, tears made no difference to levels of forgiveness. Overall, then, showing that you’re sorry, not just saying it, helps. Or, as the researchers write, ‘Put simply, embodiment of remorse mostly helped the transgressor; it never hurt them.’ Perhaps forgiveness is too much to hope for from a public apology, the researchers add. Depending on what South Korean President Park Geun-Hye weeps during an address to the nation about the happens next, that may come later. sunken ferry Sewol Emma Young

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05/11/2019 15:39

‘We must turn the tide of Brexit psychodrama’ Michael Smith meets Brian Hughes to hear about his new book The Psychology of Brexit: From Psychodrama to Behavioural Science

Out now on Palgrave Macmillan brianmhughes. com/books

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You’ve written books about controversial research practices in psychology and have published several papers on the psychobiology of stress. What inspired you to write a book about Brexit? Psychologists have always been good at exploring myths, not least myths relating to their own field. As a researcher in the psychobiology of stress, I have frequently encountered myths about physical illness that are widely believed. In more recent years I have been struck by the way psychologists themselves often believe such myths. It is why I have written a few books – and many blog posts – about the psychology of science and pseudoscience. I suppose I have realised that none of us are immune to reasoning error. The human proneness for falling for falsehoods helps explain why psychologists themselves engage in controversial research practices. So, as someone who writes about the way tenuous claims can come to consume entire communities – and to produce cascading catastrophic consequences – it is perhaps understandable that I would take an interest in something like Brexit. Brexit is a great example of mass panic, social groupthink, and tribal division. It is something worth examining in its own right. But it is also something we can use as a case study to learn about the psychological aspects of how societies function, and how we rationalise stressful experiences. In a nutshell, what is the book about? The various psychological aspects of Brexit: for example, the cognitive psychology of Brexit, the social psychology of Brexit, its cultural psychology, personality theory, and even how abnormal psychology comes into it. In short, while media discussions frequently ‘psychologise’ Brexit, much of that commentary is informal and ultimately pseudoscientific. I felt there was a need to show why

this is a problem, and how the formal perspectives of scientific psychology can help us think about what is going on more constructively. The subtitle of the book is interesting! What exactly do you mean when you state that ‘Brexit has unfolded into a fully-fledged psychodrama’? As I say, media discussions often psychologise Brexit. Talking heads make sweeping generalisations about dubious notions like the ‘will of the people’. Even intellectuals who oppose Brexit do this type of thing. I have seen academics in the media describe Brexit as ‘the last vestiges of imperialism working their way through the British psyche’. All of this reduces Brexit to a caricature dynamic, where political forces have human faces. It is essentially a form of anthropomorphism. In my view, very little of this stuff is scientific. These explanations fail the tests of science: they are unclear, unfalsifiable, and unparsimonious. There is no need for them. Better explanations are available. So my book aims to promote a scientific approach to discussing the psychology of Brexit. There is much that psychologists can say without sacrificing rigour or objectivity. You discuss how Brexit is often referred to in psychological terms, such as a national ‘self-harm’. The ‘self-harm’ metaphor has been particularly prevalent. In my view, it is interesting that commentators so freely refer to ‘self-harm’ with very little regard to the suffering of people for whom actual self-harm is a lived reality. It shows us how far we have to go to promote mental health awareness and sympathy. When political commentators refer to Brexit as a form of ‘self-harm’, it is far from sympathetic. It depicts Brexit as a reckless act of indiscriminate endangerment, hinting that we should all be afraid of people who are so afflicted as to harm themselves. The concern is not for the actor who is self-harming – it is for the welfare of bystanders. In short, people who say Brexit is a form of self-harm have little sympathy for Brexiteers. What concerns them is the collateral damage to Remainers. In other words, they are worried about themselves.

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the psychologist december 2019 brexit

Brian Hughes is Professor of Psychology, National University of Ireland, Galway. Find more from Professor Hughes, and more on Brexit, via https:// thepsychologist. bps.org.uk Michael Smith is Associate Professor of Psychology at Northumbria University.

When we think about this as psychologists, we should see it as a troubling reflection on how mainstream society talks about self-harm as a mental health issue. Why do you think the media, politicians and the public have adopted such psychological jargon for referring to Brexit? I think the media and others have adopted psychological language for a few reasons, all of which present concerns. Firstly, psychological language fills a vacuum of understanding. Remain-leaning pundits attribute Brexit to psychopathology – a kind of madness – because they simply cannot imagine how a rational Leave-voting person might feel. Secondly, psychological language is used because people don’t always realise that psychology is a real science and that its terms have technical meanings. It is another warning that psychology needs to work on its outreach and public understanding agendas. And thirdly, human beings are generally uncomfortable with uncertainty. They are driven to impose meaning on events that would otherwise be incomprehensibly complex. For centuries they did this by invoking spiritualism and mysticism. Today they do so by psychologising. What can we learn about human decision-making? One-in-ten voters in the original Brexit referendum turned up at the polling station without having decided how to vote. They made their Leave-or-Remain decision on referendum day. We should remind ourselves that human decision-making is often chaotic.

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For democracies, the concept of ‘rational ignorance’ applies and is very powerful. In short, it means that it is rational to remain ignorant about politics, because ultimately your single vote will be far outnumbered by the millions of votes cast by other people. For the vast majority of voters, there is no compelling motivation to spend time and energy on exhaustive research. In fact, to become fully educated on issues would be downright irrational, because the personal benefits of doing so would be far outweighed by the personal costs. As a result, it is logical to predict that most political decisions are shaped by uninformed viewpoints. You could tentatively argue that voting might work as a way to elect individuals, but it is clear that voting is a terrible way to crowdsource opinion on complex decisions. That said, largely the same issues apply to the way politicians make choices about Brexit in parliament and, no doubt, at the negotiating table. I think the way Brexit has proceeded through parliament has highlighted a real problem with rational ignorance. There is little reward to being factually correct or logically sound in a system where all that matters is who can whip a majority into line. From both sides of the argument, there are a lot of myths and untruths about Brexit. To what extent can Brexit inform the psychology of how myths and untruths are propagated? When it comes to politics, Brexit reminds us that events are determined not by who makes the best argument, but by who attracts the most votes. All votes

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are equal, and emotional voting comes more naturally than rational voting. Therefore the system rewards superficial persuasion, and punishes careful exactitude. This is very similar to the asymmetrical warfare that occurs between pseudoscience (which is easy) and science (which is hard). In public opinion terms, bogus arguments against vaccination are disproportionately successful compared to scientific arguments in favour. The arguments in favour are filtered through scientific peer-review, which slows them down. Brexit gives us many examples. Most psychologists will focus on pro-Brexit myths, such as the claim that Brexit would free up £350 million per week for the NHS. While that figure has been debunked, surveys suggest that, even in 2019, many people still believe it. Just hearing about it will precipitate an ‘anchoring effect’, where voters forget the details but remember an approximate factoid about EU membership being very costly. Most psychologists are themselves anti-Brexit. I don’t think it is controversial to state that academics are generally more left-leaning than the general population, or that most British academics think that Brexit is a bad thing. In reality, and without for a moment claiming that all sides have equal arguments, I think we should realise that there are Remain myths too.

‘If you were a betting man, informed by psychology, what would you say happens next?’ I discuss in the book how the impasse in parliament is similar to the Prisoner’s Dilemma as discussed by game theorists. Neither side will work with the other in order to reduce risk. From the point of view of game theory, it is no surprise that the system has now crashed. The forthcoming general election is an effort to reboot the government at the ballot box. However, I am not sure that switching the UK off and back on again will fix the problem. Such logjams result from poor reasoning, irreconcilable tensions, and toxic relationships. An election is unlikely to change these conditions. Everything we know about group polarisation tells Rebooting? us that competitive politics will only sharpen the divide. Without real collaboration between Leavers and Remainers – which right now seems inconceivable – the two sides will just become more entrenched. This will be true even if one side triumphs in the election and gets its own way on Brexit. The other side will simply be more aggrieved than ever, and bad feeling will permeate through society for years to come. 26

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We should also remember that one of the main findings from psychological research in this area is that voters are blind to their own biases. We suffer from a problem called the ‘third-person effect’, where we accuse our adversaries of making all the errors. There is also the problem of ‘out-group homogeneity bias’, where we consider our own in-group to be sophisticated and diverse, but see members of the opposing group as ‘all the same’. Overall, I think it is noticeable that both Brexit tribes throw corresponding insults at each other. What kind of ‘corresponding insults’ do you mean? Both sides accuse the other of deception, subterfuge, and stubbornness. Both sides consider their own position to be lucid and rational, but believe the other side to be deluded and emotional. Both sides see themselves as fair-minded, but the others as partisan. Remainers consider themselves to be the logical, evidence-based ones. And theirs are the voices we tend to hear most in academia. But Remainers do feel emotional about Brexit. They make emotional arguments for EU membership. Few Remainers can recite the economic statistics about EU budgetary flows, or specify what regulatory alignment means for, say, the pharmaceuticals industry – but they are visibly passionate about their view that Brexit is a mistake. That might be fair enough, but Remainers shouldn’t decry Leavers for being emotionally driven. In fact, from the Leave perspective, Remainers are the ones who are seen as emotionally afflicted (‘Remoaners’, ‘Project Fear’, etc.). And Leavers truly believe that their side is the one with the logical arguments. The problem here is echo chamber reasoning. Brexit presents psychologists with a vivid opportunity to study the nature of group polarisation. As voters, we tend to inform ourselves in a highly selective way, especially now that social media channels play such an important role in daily life. We end up accumulating wholly misleading feedback about the merit of our own arguments, because we restrict our social engagement in ways that ghettoise public opinion. Given that most psychologists are middle-class liberals, it is especially important to appreciate that we too occupy our own peculiar echo chambers. You discuss not only how Brexit can be a cause of mental illness, but also highlight the argument sometimes put forward by Remainers that Brexit itself is caused by mental disturbance. Is this a helpful view to take in terms of healing the immense divide that has been caused by Brexit? After the referendum, one British MEP criticised a local health authority for providing counselling to worried employees. She said that providing counselling to people who were upset by Brexit was ‘undemocratic’. In other words, she believed that people should be supported psychologically only if they had certain political views. As politics are pathologised, pathology is politicised.

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the psychologist december 2019 brexit

Leavers often claim that Remainers are unreasonably upset and unable to move on with their lives (‘Remainiacs’). Meanwhile, Remainers often claim that Leavers are somehow mad, simply because they concluded that they wanted to leave the EU (‘Brexitreemists’). It is all absolutely unhelpful. Throughout the world, psychiatric language is used to delegitimise political dissent. When you dismiss your adversary as mentally unstable, you not only stigmatise them, you declare dialogue to be pointless. Such discourse guarantees division. Psychology is a scientific discipline. Psychologists should be able to advise on the power of social perspective, and the value of being able to look at things from different points of view. In the book you discuss ten lessons from the psychology of Brexit. Which is most important? The one about perspective: people make partisan decisions, but systematically overestimate their own logic and soundness. Both sides consider themselves resistant to delusion, while believing their adversaries to be deluded beyond rescue. In the book I spend a lot of time explaining how this happens, and how it applies not only to Brexit commentators, but to psychologists too. As someone who was born and lives in Ireland, could you reflect a little on the Irish perspective? Is there anything about the psychology of Brexit which is of particular relevance in Ireland? Ireland has been a close observer of Brexit and is perhaps the only country apart from the UK itself where Brexit ranks as a top-tier political issue. I think the Irish perspective is of interest on at least two levels. At a basic level, Brexit poses direct economic and social consequences for Ireland, to which people in Ireland will be required to adjust. For example, many Irish businesses sell into the UK, and for many sectors, mainland Britain is Ireland’s land-bridge to Europe. Eighty per cent of retail goods on sale in Ireland are imported from or through Great Britain. Tariffs and customs checks will definitely add friction to Irish trade, even though Brexit is not of Ireland’s making. At a more psychological level, Brexit is presenting many Irish people with conflicting emotions. Echo chamber reasoning and group polarisation come up again. There is a lot of intelligent media analysis of Brexit in Ireland, especially when it comes to law and economy. However, there is also much discussion that is very flimsy, and a fair amount of mockery directed at the British political class. Some Irish people derive satisfaction from Britain’s stress. Personally, I dislike this tendency and I have spoken critically about it in Irish media. The problem is that schadenfreude does nothing to prepare Ireland for the consequences of Brexit. In fact, a negative and unfriendly bias reflects exactly the type of tribalism that has caused such bitter conflict between Leavers and Remainers. As Irish psychologists, we can urge our fellow

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citizens to reflect on Brexit and to think about how all societies can descend into tribalism and social acrimony, no matter how sophisticated they consider themselves to be. None of us are above these problems. In fact, psychologically speaking, we are all susceptible to them. There is a nice quote where you refer to Brexit as a stressor which ‘wrecks society’s resting homeostasis’. Given the huge emotional, societal and economic upheaval caused by Brexit, how is homeostasis ever going to be restored? Well, it depends what you mean. As with psychological stress, homeostasis refers to a resting state in living systems where everything is balanced and steady. We talk about ‘restoring’ homeostasis after it has been disrupted by change, but often what happens is that a new homeostasis is created. Some of the changes to the environment will be permanent and there will be no going back. Furthermore, not all environments conform to our ‘just world’ assumptions. Social stability can reflect the perennial domination of elites over the subjugated and the powerless. In fact, many societies exhibit homeostasis of exactly this type. At some point in the future, political and social life in Britain will achieve some kind of homeostasis but it will not involve things ‘returning to normal’. This is why the mantra ‘Get Brexit Done’ is so misleading. The idea that political transformation can be quick and simple – like Trump’s ‘Make America Great Again’ or Putin’s ‘Lift Russia Off Its Knees’ – can be highly seductive. But it ignores the complexity of homeostasis. What do you hope the book will achieve? I hope the book can help convince people that psychological factors are supremely important in daily life. The resolution of Brexit cannot just be political or technical. It needs to account for people’s personalities, their emotions, and their sense of place in the world. In addition, as a science, psychology can help to provide insights that are reliable and valid. It offers a mental periscope through which we can view ourselves, and our assumptions, from different angles. The psychology of Brexit is important not only because it helps us to appreciate Brexit. It also helps us to appreciate the idea of humans having a ‘psychology’ per se. As much as we can use psychology to examine Brexit, perhaps we can also use Brexit to explain psychology. In my view, a wider public understanding of what it is psychologists have learned about human thoughts, feelings, and behaviour can only help us as a society. More than ever, society needs to be able to reflect on its impulses and biases. It would be great if psychologists could be at the forefront of this effort. Wherever there is a vacuum, it will soon be filled with psychobabble, pseudoscience, and propaganda. We must turn the tide of Brexit psychodrama, and I humbly hope my book can be part of that.

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Allergy – Insider perspectives Khadj Rouf and Kathryn Evans reflect on the challenges of parenting children with severe allergies.

ive years ago, we wrote for this magazine from the dual perspective of clinical psychologists and parents of children with severe food allergies. Prompted by the steady stream of contact we’ve had from parents and carers since then, we felt it was time for an update. Things are improving – there is better public understanding of severe allergy, steps forward in clearer food labelling, and a growing literature on the psychological impacts of living with allergy. Yet we argue for more contextual understandings of psychological impacts, particularly anxiety, both for parents and young allergy sufferers.

Demand outstrips supply Across Europe, there is an increase in allergic conditions that is predicted to continue (EAACI, 2016). The number of severe reactions is also rising – between 1992-2012, there was more than a 600 per cent increase in UK hospital admissions for anaphylactic reactions (Turner, 2015), a trend which has continued, with 4836 admissions to A&E in England between 2017-2018 (NHS digital, 2018). In terms of intervention, there is some promising research around graded exposure to allergens to build up tolerance to triggers. However, the main advice is to avoid allergens and make lifestyle adaptations. The rate of increase in allergic responses means that the demand for help, particularly to address psychological impacts, is outstripping supply. The NICE guidance for allergy was reviewed in 2018 but not updated; it still doesn’t contain enough information about the psychosocial impacts of allergy, nor psychologically-informed interventions to help people live well. For many, adapting their lifestyles is getting somewhat easier. Thanks to the tireless efforts of organisations such as the Anaphylaxis Campaign, there is now much clearer allergen labelling. However, tragic cases, such as Natasha Ednan-Laperouse’s death,

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The prevalence of food allergy is rising, and recent tragedies highlight that concerted action is still needed to help severe allergy sufferers. These are anxious times for sufferers and their families. Should we see such anxiety as an adaptive and understandable response to a society that has not yet figured out how to safeguard those with allergy? are a sobering reminder that eating food prepared by others in restaurants or food outlets, can be potentially catastrophic. Fatalities are often the result of accidents, where the allergy sufferer may have been reassured that food was safe, either by another person or food mislabelling. This has renewed discussions about food industry responsibilities and led to the planned introduction of ‘Natasha’s Law’. The discussion about parental anxiety and its potential negative impacts on children with severe food allergies often distils into a narrative about maternal over-protection (e.g. Chow et al., 2015). However, research can miss the wider social context for those trying to live in what can be a very challenging landscape (see O’Farrell, 2017, for a vivid account of navigating life with a child challenged by severe allergies). In reality, parents have to do a great deal of background work to enable their child to live safely. Everything happens within a context, and parental anxiety can be directly linked to micro-interactions across multiple relationships and settings. It is crucial

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the psychologist december 2019 allergy NAPAL www.napalillustration.com/

not to pathologise parents, and to understand that anxiety is influenced by developmental stages and relationships. Navigating family and social life We’ve adopted an ethnographic stance of ‘rendering strange what we take as given’ (Toren, 2003) to explain what it’s like to live with a child with severe allergy; this expands beyond the individual psyche, into the practical, emotional, relational and social impacts. We have tried to crystallise what can make it so stressful to adapt to life with anaphylaxis. Firstly, food plays a central role in survival. Humans need to eat. In society, rules around food preparation, including the separation of certain elements, are culturally sanctioned or normative. This engenders trust that others will observe those rules, and this trust and certainty is soothing (Wheater, pers. comm.). However, the main advice for those with severe allergy is avoidance of triggers; for some people,

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this includes not touching the allergen or breathing it in. Avoiding food is hard. Unless we grow our food and cook from scratch, we all rely to varying degrees on pre-prepared foods. Here the practical and stressful aspects of safety arise, such as checking and rechecking labels for hidden allergens and deciphering what specifically is meant by ‘may contain’. This is particularly stressful in the wake of recent tragedies or personal experiences of eating food deemed safe which has caused anaphylaxis. Suffering with allergy can impact on emotions, such as trust. A sufferer may experience a tense relationship with food if they aren’t confident of its safety, which can also challenge their relationship with their own bodily reactions, causing a feeling of invisible difference. Trust in other people and with social spaces may also be compromised. As Cridland (2017) said, ‘trust relating to food is personal and intimate, since it requires trusting another person to prepare food that will not cause harm as it is incorporated’.

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Mistakes and miscommunication will occur, especially if there are many links in the chain between consumer and manufacturer. Places that are not allergy-friendly ‘shrink’ for people with allergies; they can’t fully participate in them. According to Cridland (2017), ‘comfort, anxiety, safety, and trust can imbue spaces, leading them to be perceived as “spaces for me” or “spaces not for me”’. This impacts on the individual, but of course food has family significance too. Cridland (2017) said: ‘Food is social… food carries meanings and values, is symbolic, and communicates relationships between people and between individuals and society.’ Food is central to kinship – meals connect families through shared time, conversation and forging attachments. Meals are acts of memory-making; certain foods can be highly evocative of childhood and associated with emotions. Sharing food is also culturally and socially significant – personal cultural milestones or religious festivals are often marked with food. What we eat and what we don’t eat can signify faith or cultural identity. Severe food allergy disrupts some of the usual patterns and rituals around food. Practical impacts on family life may include the family changing its dietary habit entirely. Parents of younger children often have to plan ahead, anticipating the unexpected: a delayed journey can’t have a Plan B that involves spontaneously eating in a café. In addition to carrying food and back up medicines there may also be material impacts as

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Figure: A model for decision-making in safeguarding practice for psychologists

allergy-friendly foods can be more expensive. There can also be relational and emotional impacts, as parenting happens in a social and familial context. There has been focus on parental anxiety and its In

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impact on children, and the notion of adaptive anxiety – the ‘Goldilocks Principle’ – a ‘just right’ level of anxiety (Mandell et al, 2005). But this can be a difficult balance – parental anxiety needs to be viewed in a context that pays attention to gender, culture and an awareness of wider society. We’ve had both highly positive and negative responses to adapting. When children are very young, parents act as champions for ensuring the safety of their children around food. Gender biases in caring responsibilities still results in women carrying the bulk of this impact, and at times, the negative stereotyping of being ‘over-anxious’. The term ‘allergy’ covers a large territory from intolerance to anaphylaxis, which can cause stress in itself. Two people in conversation about allergy safety may not be talking about the same thing. Increased public discussions about food intolerance and selfdiagnosis of allergies may raise awareness on one level, making these more ‘mainstream’. However, it also leads to the assumption that ‘allergy’ means ‘intolerance’ or ‘preference’ rather than ‘medical danger’. Both public and scientific understandings of allergy are still in their early stages. Against this backdrop, representations of allergy in films and programmes can be unhelpful – allergy is often shorthand for being odd, faddy, eccentric or high maintenance. Anaphylaxis is often portrayed as comic, as in Hitch (2005), Alan Partridge (episode 5, 2019) and a criticised depiction in Peter Rabbit (2018). These stereotypes can make it uncomfortable to have discussions designed to keep children safe around food. We think it can also impact on how young people take up the reins of self-care around allergy

Key sources BPS. (2018). Safeguarding Children and Young People: Every Psychologist’s Responsibility. Leicester: BPS. Cridland, M. (2017). ‘May contain traces of’: An ethnographic study of eating communities and the gluten free diet. Lund, Sweden: Media-Tryck, Lund University, Sweden. Dunn, T. (2018). Managing anaphylaxis: a head teacher’s perspective. Paper presented at Healthcare Professionals Conference on The Psychological Impact of Allergy, The Anaphlaxis Campaign, Tuesday 13 November 2018. EAACI (European Academy of Allergy and Clinical Immunology). (2016). Tackling the allergy crisis in Europe - Concerted policy action needed. Brussels: EU Liaison Office. Demain, J., Portnoy, J., von Hertzen, L., & WAO Special Committee on Climate Change. (2013). The biodiversity hypothesis and allergic disease: world allergy organization position statement. World Allergy Organization Journal, 6, 3. Evans, K., & Rouf, K. (2014). Living with severe food allergy. The Psychologist, 27(5), 334-337. NICE. (2011). Food allergy in children and young people. Clinical Guideline no.116. London: Author. Full list available in online/app version.

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when parents pass on responsibility to their children. These changing dynamics will need thought across the lifespan. (See also Audrey DunnGalvin’s article in this issue). Contextual anxiety Anxiety for sufferers and carers is affected by everyday interactions between people. Our 2014 research identified ‘having confidence in others’ and efforts to ‘keep life normal’ as themes based in relationships and contexts. But if micro-interactions involve being misunderstood, minimised, catastrophised or even mocked, it’s understandable that parental anxiety can heighten. Whilst home can be a safe haven for children, going into social spaces can become very stressful. For example, a 12-year-old with a peanut allergy suffering an airborne reaction to peanuts at school could result in the whole class crowding round to see what happens. Positive micro-interactions include teachers conducting joint risk assessment with parents in advance of residential trips, communicating about menu choices and an emergency drill. Cridland’s (2017) ethnography of Celiac Camp suggests that supportive spaces where allergy is the norm can be very helpful, re-codifying communal eating into a source of comfort, rather than anxiety. Yet exclusion can occur – anecdotally, children withdraw and don’t want to ‘make a fuss’ during allergic reactions, to avoid social embarrassment. These behaviours can reduce parental confidence that the child will seek help during medical crisis. Wider relationships, such as those with extended family and friends, also influence life with allergy, including likely discomfort in adapting to postdiagnosis life. Parents may feel more self-conscious, and friends more worried about their role. For instance, cooking for others, ‘traditionally seen as a source of social bonding, is even seen as a source of stress and anxiety’ (Cridland, 2017). There can be lasting negative relational effects on both sides, including feeling different or self-conscious, or missing out on social events. Social relationships may reconfigure and be asymmetrical, as the impact of severe allergy can spread into all areas of life. The Anxiety Seesaw Given the contextual, relational and developmental aspects of living with allergy, there are times when appearing ‘over-anxious’ is adaptive. Anxiety may fluctuate depending on life transitions, but also in daily micro-interactions where parents are expected to entrust the care of their children to others, who may know far less about allergy. This can lead to what we call The Anxiety Seesaw [see over]. Low allergy awareness in another person can lead to high anxiety in a parent. If this is pathologised, parents can feel that they have to avoid situations, such as eating out. High

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allergy awareness in others can lead to lower anxiety for parents and sufferers, because they feel that the other person ‘gets it’ and will be helpful. Shared responsibility for allergy management can create good ‘psychological safety’. Framing parental anxiety in terms of the probability, cost, coping and rescue anxiety model developed by Beck et al. (1985) provides an opportunity to think about what makes social spaces, and the rituals within them, safe for allergy sufferers.

physically safe environment. The British Psychological Society’s 2018 Safeguarding document Dr Khadj Rouf is a Consultant embeds Reason’s thinking and Clinical Psychologist at has potential applications within Psychological Services, Oxford different settings. The diagram NHS Foundation Trust illustrates the multi-systems Khadj.Rouf@oxfordhealth.nhs. approach to safeguarding, also uk applicable to young people living with allergy and moving across different systems, such as schools. Whole school approaches Allergy: everybody’s business ensure a resilient and sustainable Since allergy rates are predicted to response to allergy (Dunn, 2018). continue rising, people need help Schools should be well-informed navigating the myriad impacts of and include pupils and parents Dr Kathryn Evans is a severe allergies across a number of in co-produced strategies. Risk Consultant Clinical Psychologist domains. This requires looking at assessment tools need to be clear at the Oxford Institute of context and the need for adapted and ensure that allergy is thought Clinical Psychology Training and and inclusive social spaces. Given of in every domain – how can Research, Oxford Centre for the potentially fatal nature of children be included in every Psychological Health, Warneford anaphylaxis and the catastrophic sphere through adapted and safe Hospital, Oxford consequences of seemingly ‘minor’ means? This example chimes with Kathryn.Evans@hmc.ox.ac.uk accidents, responding to allergy Cridland (2017) on reconfiguring should be treated as a safeguarding social dynamics: there may issue. This means shifting opinions, and proactive, inevitably be tensions, but such an approach can lead psychologically informed risk assessment requiring to productive new routines and rituals, which ensure prevention, as well as emergency responses. that inclusive community activities continue. In Jim Reason’s words, ‘the single most important factor is trust’. Creating safe cultures benefits everyone, not just one group. Safe environments are reflective Still much to be done and they learn. They are inclusive – everyone has a We’re struck by the positive improvements over stake in creating and maintaining a psychologically and the last five years, but there’s still much to be done. Responding helpfully to people affected by allergy involves the interplay of issues which are deeper than apparent in emerging research on allergy. Sufferers can Higher anxiety associated with face the difficulties of living with invisible disability, low awareness of others with and the relational issues which are raised with one’s shared responsibility for allergy own body, with food and with community. For parents, management (creating poor manifestations of anxiety can be the result of poor psychological safety) experiences at practical, material and relational levels. We call for a more nuanced perspective on anxiety within a social context, and for more help for families making adjustments and negotiations across the lifespan. Our experiences, combined with emails from parents and carers asking for advice, and the predicted increases in allergy rates, convince us that more action Lower anxiety associated with is needed to expand UK allergy services – and to high awareness of others ensure that psychologists are employed within them. with shared responsibility for We hope this collection of articles might stimulate allergy management (creating discussion about how psychologists working in good psychological safety) different settings might respond to the needs of children, young people and their families living with severe allergy. The Anxiety Seesaw – a relational representation of anxiety

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Presidential Taskforce on Diversity and Inclusion In September 2019 the Board of Trustees approved the creation of a Presidential Taskforce to develop and oversee initial implementation of an action plan to address three key objectives: 1. To make the Society a welcoming place for members from minoritized/ marginalized groups, and to promote their engagement at every level of the Society. 2. To promote diversity and inclusion within the profession and discipline of psychology through increasing entry of under-represented groups and ensuring that training reflects diversity and meets the needs of diverse groups. 3. To advise on the most effective form and function of a permanent body, reporting to the Board of Trustees, to monitor and advise the Board on issues relating to equity, diversity and inclusion issues at the end of the lifespan of the taskforce. Following the appointment of Prof Binna Kandola as Chair of the Taskforce, recruitment of taskforce members is now underway. The taskforce will be recruited to ensure experience/expertise in relation to a range of minority/marginalized backgrounds including Black and Minority Ethnic groups, LGBTQ+, physical disability, mental health difficulties, and also low-income backgrounds. It is intended that the taskforce will include members from across practice, research and teaching and, include members at different stages of their career including students/psychologists in training. The lifespan of the taskforce is will be 12-18 months and it will undertake significant engagement with Society members, potential members, and other stakeholders during this time. Full details of how to apply will be available on the BPS Website and a Statement of Interest form can be obtained by contacting Kelly Longmuir via email - Kelly. longmuir@bps.org.uk. Closing dates for submissions will be on Friday 10th January 2020. They must be submitted directly to Kelly Longmuir using the same email address as above. Informal enquiries can be made to Taskforce Chair Prof Binna Kandola or Society President David Murphy. If you do wish to ask questions please submit them via email to Kelly Longmuir using the email address above and she will facilitate a response.

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More and more parents, children and teens are having to learn to live and cope with food allergy. Can an awareness of the reciprocal effects of food allergy and the developmental process provide novel perspectives for prevention and intervention?

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the psychologist december 2019 allergy

Growing up with allergy Audrey DunnGalvin considers the impact of severe food allergy on the quality of life and development of children and adolescents.

include breathing difficulties and a drop in blood ood allergy is a major public health pressure, or shock, which are potentially fatal. Typical concern, affecting an estimated allergy medications such as antihistamines work too 20 million Europeans, with high slowly and cannot reverse the effects of chemical costs to public health services. mediators. The adrenaline auto-injector (AAI) is The unintentional consumption the treatment of choice and must be administered of an allergen is common, causing promptly. Those living with allergy must read food frequent reactions. Admission rates ingredient labels; pay attention to potential crossfor anaphylaxis have increased contamination from other foods; be constantly vigilant approximately three-fold between 2005 and 2017 in in a variety of social situations and activities; explain most western countries. If you live with a life-threatening allergy, prevention safety needs to friends, acquaintances, teachers, staff at food venues; and carry or have immediate access to an is (in the words of Hugh Sampson) ‘the cornerstone AAI. of therapy’. You’re reliant on complete avoidance of Inevitably, all this has an impact the allergen, alongside emergency on quality of life for children, teens, management in the form of ‘the adults and parents. Research in the pen’ of injectable epinephrine “Evidence shows last decade has placed the concerns if you do accidentally ingest it. that quality of life in and needs of patients and family at Because food is such an integral food allergy is impacted the centre of research and practice. part of everyday life, the impact The Food Allergy Quality of Life extends far beyond ‘mealtimes’. by a range of Questionnaires (FAQLQ) have Allergens such as peanuts, nuts, psycho-social factors” been developed to assess the impact milk, eggs and soy, can be found in of food allergy on quality of life for many foods, and in different forms. all age groups (and for parents) and Precautionary allergen labelling are the most frequently used psychosocial measures. (PAL) is often inconsistent, false or misleading, and Evidence shows that quality of life in food allergy is public awareness and understanding is generally low. impacted by a range of psycho-social factors including Now imagine you’re a child. Your health is a uncertainty and fear of reactions; food anxiety, and product of complex, dynamic processes: family, dietary and social restrictions. Quality of life may also social, and physical factors, alongside genes, biology, be influenced by age and gender, country and culture, psychology and behaviours. Children are rapidly severity and type of allergy. changing and developing in response to these The most significant short term impairment seen interactions. So what does the research have to say in research on the psychosocial impact of food allergy about how certain biopsychosocial factors associated for all age groups, is the persistent fear of an adverse with food allergy can influence wellbeing and reaction. Food allergic patients – and their families development, in both the short and long term? Could – can experience food allergy related fears 24 hours a developmental perspective be key to prevention and a day, 7 days a week, while on holidays, at parties, intervention? using public transportation, at school, and even at home. Thus, the risk of reaction is ever-present but the ‘when’, ‘how’, ‘what’ leads to uncertainty, fear, anxiety, The impact of food allergy on quality of life embarrassment, and frustration. Many individuals Symptoms may develop within seconds after ingestion and families avoid enjoyable activities like dining out, of a food allergen, with the vast majority of reactions travelling, shopping and other everyday activities that occurring in the first hour. The most dangerous

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to 25 years and is vulnerable to those of us without food allergy experiences and environmental take for granted. Restrictions on influences which affect not only the diet also affect children’s nutrition, amount of brain cells – and number school and extracurricular of connections among them – but activities. In Italy, 20 per cent of also the way these connections are young children living with allergy ‘wired’. have never attended a birthday We carried out two qualitative party, and 40 per cent report having studies with the aim of creating a monotonous diet. Dr Audrey DunnGalvin is Ass. a developmental model, called In school, reactions can be due Professor, School of Applied the Food Allergy Coping and in part to uncertainty around food Psychology, University College Emotions (FACE) model. The safety from school authorities. Cork, and CEO Anaphylaxis first phase of development took Risk is sometimes managed by Ireland. place within Ireland and we then excluding or restricting the child A.DunnGalvin@ucc.ie validated the model in a large data from certain activities and setting set from six countries (Ireland, them apart from others during England, Scotland, US, Italy, Australia). The qualitative lunch and treat times. This gives rise to a feeling of model illustrates on the experiences, emotions and difference, stigma and certain peer behaviours, such as management styles of children and teens growing up teasing and bullying. and living with food allergy. In our analysis, we paid Perceptions of risk around allergy do not develop particularly close attention to any external and internal or take place in a vacuum, but in the environmental mediators between emotions and coping. context of everyday life. There are two main Briefly, the FACE model describes how the dimensions: cognitive (how much people know about emotions attached to living with food allergy and understand risks), and emotional (how they feel about them). The issues around Precautionary allergen (including embarrassment, fear, anger, frustration, worry, anxiety, and confusion) drive a search for labelling (PAL) illustrate how an environmental factor ‘normality’. This in turn gives rise to particular types can influence perceptions of risk, along with health of coping strategies, including anxiety/avoidance and wellbeing. Such labelling is meant to inform consumers about and frustration/risk. The link between emotions and coping is influenced by external and internal mediators a demonstrable and significant risk to an individual (including context, developmental stage, type of with food allergy. Yet current (mainly voluntary) allergen and experience of reactions, food allergy practices have led to variations in the wording of these beliefs and perception of disease intrusiveness). labels, and indeed whether or not they are used at all. The themes were present and consistent across A product with a PAL may be correctly labelled on the basis of an adequate risk assessment, or just be labelled countries, with remarkably similar wording and phrasing used by participants, although these to minimise a producer’s liability. A product without differed according to age. Both genders had broadly a PAL may be completely safe or the unintended similar coping styles, although males felt less able presence of an allergen may not have been considered. to communicate their fears to friends and peers, An incorrectly mislabelled product causing a reaction particularly in adolescence and young adulthood. can result in a loss of credibility in PAL (and in the science underlying it) creating anxiety, uncertainty, mistrust, and dread. PAL therefore not only adversely The forgotten years impacts on quality of life, but also acts as a barrier to The ‘First Five Years of Life’ campaigns have made us effective management. all aware of the impact that early childhood has on a child’s future. Between birth and six years, children feel a strong sense of protection from parents (primarily) Reciprocal effects of allergy and development and other adults (such as teachers). However, ages 6 to The impact of any chronic disease on everyday life 12 – sometimes called the ‘forgotten years’ – are also a (and on management) is mediated by our psychology critical period that carries long-lasting influence. – focusing just on ‘medical issues’ is not an option. In middle childhood, children’s social networks Developmental theory provides an important insight start to change from networks in which children into how certain biopsychosocial factors influence primarily interact with adults to networks in which the way children respond to chronic disease on the children primarily interact with other children. That pathway to adulthood. Theory and evidence from studies of children’s cognitive, emotional, memory, and means exposure to social comparison and competition in school classrooms and peer groups. Children brain development have pointed to particular points with food allergy need to cope with these normal during which structure, organisation, and flexibility developmental changes alongside their condition, in coping processes are likely to undergo significant placing increased stress on daily social interaction. qualitative and quantitative shifts. We now know that Chronic diseases with dis-regulation of inflammation, brain development (and hence adolescence) continues

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such as food allergy, are particularly susceptible to modulation by stress and emotion. Significant feareliciting experiences in middle childhood can disrupt the typical development of stress regulation as well as learning, memory, and social behaviour. The long term impact on the psychology of patients can be profound.

Key sources

physiologically, psychologically, socially and environmentally. DunnGalvin, A., Koman, E. et al. Harmonised approaches should be (2017). An examination of the Food developed based on a multilevel Allergy Quality of Life Questionnaire intervention perspective. In the performance in a Countrywide American Sample of Children. Journal of Allergy past, research efforts in general and Clinical Immunology, 5, 363-368. (and in food allergy) concentrated Adolescent challenges DunnGalvin, A., Chan, C.-H. et al. (2015). on single-level analysis, yet these Adolescence is characterised by significant biological, Precautionary allergen labelling. Allergy, ignore the environment in which an physical, and psychosocial changes marking the 70, 1039-1051. individual operates or how changes beginning of adulthood. For example, the ongoing DunnGalvin, A., Gaffney, A. & Hourihane, at the organisation, institution and maturation of neural connectivity leads to increased J.O’B. (2009). Developmental pathways in food allergy. Allergy, 64, 560-568. policy levels impact the individual vulnerability for risk taking. Enhanced amygdala DunnGalvin, A. et al. (2018). Preliminary and vice versa. There have also reactions to emotional stimuli means that the development of the Food Allergy been debates in health contexts adolescent brain perceives emotions at two- to fourCoping and Emotions Questionnaires about the merits of ‘upstream’ times greater intensity than adults, yet control systems for Children, Adolescents, and Young versus ‘downstream’ approaches and are still developing as late as 21 years of age. There is People. JACI-P, 6(2), 506–513. whether funding and focus should also a heightened stress/threat response. Adolescents DunnGalvin, A., & Hourihane, J.O’B. (2016). Health-related quality of life in be at individual or population-level face a ‘tension’ as they attempt to balance a search food allergy. Springer-Verlag Berlin approaches. These arguments ignore for safety with integration and positive identity. The Heidelberg. the importance of the interaction PAPRIQUA study (an online cross-sectional survey between the two. conducted among people with peanut allergy in the Full list available in online/app version. Awareness of the reciprocal UK) found that adolescents had worse quality of life effects of food allergy and than both children and adults with peanut allergy development can provide novel (Gallop et al., 2018) and results from the PALISADE study (assessed using the FAQLQ) has similar findings. perspectives for prevention and intervention and can provide some answers to how we can help and Adolescents (12- to 25-year-olds) with food allergy support patients living with food allergy. For example, are also at the highest risk of fatal food-induced decision-making in adolescence is optimised for anaphylaxis, with the majority triggered by food attaining specific developmental goals. However, the consumed outside the home. In France and Belgium, environment plays a strong role in whether adolescent the MIRABEL study also found severe/potentially vulnerability is translated into actual risk behaviours. severe reactions more common in teenagers and Risk-taking is not a simple process, and is not only adults than in younger children. Adolescent decisionaffected by attitudes toward known risks, but also making typically occurs within social environments by attitudes toward situations, in that often involve complex which the likelihoods for positive motivations. These motivations “When adolescents and negative outcomes are not can compete and conflict with one another and include maintaining meaningfully understand known. It is not that adolescents choose to engage in status with peers, achieving goals a risky situation, they are actually risks: rather, they are willing to in academic, athletic, or other even more risk averse gamble when they lack complete arenas, finding independence, knowledge. When adolescents and maintaining harmony within than adults” meaningfully understand a risky the family. For example, sharing situation, they are even more risk food has an important social value averse than adults. and uncertainty about PAL does Adolescence also means a high receptivity to not help in a teen’s attempts to negotiate the tricky learning; idealism; a natural inclination to novel balance between keeping ‘safe’ and developing an problem solving; and an eagerness to assume individual sense of identity and a sense of autonomy new challenges. Therefore, it presents an ideal that are important tasks of this period of development. opportunity for health care professionals to support Therefore, we see increased risk-taking behaviour healthy behaviours, encourage independence and (such as failure to carry an AAI), failure to avoid active decision making, and successfully transition triggers, and use of alcohol), coupled with reduced adolescents into the adult-centered healthcare system. ability of parents to manage exposure risk. To conclude, food allergy experiences and management are psychologically mediated. Understanding the challenges and opportunities of Working with development the developmental process can help us to engage with A growing number of studies have shown the multichildren, teens and young people. We need to work dimensional adverse impact on the quality of life of with rather than against development. children and teens living with severe food allergy –

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As a Health Psychologist working in research and practice around allergy since 1995, it has become clear to me that food allergy is quite unique as a long-term condition, in its presentation and managementâ&#x20AC;Ś

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the psychologist december 2019 allergy

Can interventions make a difference?

Rebecca Knibb considers efforts to reduce the psychological impact of food allergy.

hose with food allergy do not suffer from symptoms day-to-day but they do live continually with the risk of a severe or life-threatening allergic reaction. The risk of dying from an anaphylactic reaction related to food is relatively low: around 20 people per year die from an allergic reaction to food in the UK (Pumphrey & Gowland, 2000) compared to around 1100 deaths from asthma (Asthma UK). But given the impact food allergy can have on quality of life, the development and delivery of interventions has the potential to significantly improve the lives of those affected.

intervals from a nurse trained in self-regulation for chronic disease management. The intervention group reported improvement in feeling anxious about food allergy; frustrated by others not knowing about food allergy; worried they can’t help their child experiencing a reaction; and frightened that their child might have a reaction. Self-efficacy and confidence in being able to manage their child’s food allergy as measured with a non-validated questionnaire did not improve. Validated self-efficacy scales now exist (DunnGalvin & Greenhawt; Knibb et al., 2015) and would be useful tools to further explore intervention effectiveness. These low-level intervention studies have small participant numbers and don’t report whether effects are clinically meaningful or long-lasting, yet they may be helpful for parents who need a little guidance to reduce anxiety.

Educational interventions As yet there are no randomised controlled trials (RCTs) – the gold standard in intervention studies – of patients Cognitive Behavioural Therapy (CBT) pilot study with food allergy. There are however some promising CBT is a relatively short-term therapy aiming to observational cross-sectional questionnaire studies, change behaviour and thoughts in order to improve and RCTs with parents. A freely available online food feelings, so may be more beneficial for parents with allergy educational programme was developed for high levels of anxiety, depression, worry and stress parents (www.cofargroup.org), and has increased than educational programmes. Given CBT’s excellent the number of correct steps for Adrenaline Autoevidence base for a range of Injector activation, and decreased mental health issues, I sought to the number of allergic reactions investigate whether it was a suitable (Sicherer et al., 2012). A half-day “the development and therapy for food allergy in a pilot workshop with five- to sevendelivery of interventions study with mothers recruited from year-olds with allergies and their has the potential to allergy clinics (Knibb, 2015). Five parents resulted in increased ‘parent mothers had one hour of CBT a perceived competence in coping’ significantly improve the week for 12 weeks in their home and decreased ‘burden’ four to lives of those affected” or at the local University, and six eight weeks later (Le Bovidge et al., mothers who did not want CBT 2008). completed questionnaires for An intervention with a comparison. The box provides an example case study firmer basis in psychological theory applied a selfof some of the difficulties faced by the mothers I saw. regulation model to guide discussion between I developed a model to describe how the feelings healthcare practitioners and parents (Baptist et al., and behaviours of parents had developed, what was 2012). Parents were encouraged to acknowledge maintaining them and what could be changed to help their allergy concerns, discuss the likelihood of that concern occurring, critically appraise potential barriers parents feel better (Knibb, 2015). Let’s turn to some examples of the targets to dealing with the situation, and discuss coping parents had, and the CBT-based techniques used to mechanisms. Attendees were randomly assigned to a help them. If a target was ‘I would like to feel less control group who received a phone call two weeks anxious about my son having a bad reaction and later to have questions answered, or an intervention more confident in knowing what to do if he does’, we group who received three phone calls at two-week

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proof of concept study requiring might deploy graded exposure to further investigation, the use information about anaphylactic of CBT does appear to improve shock to reduce anxiety, including psychosocial outcomes, and CBT watching educational videos; is now being used and tested in psychoeducation about what clinical settings. might happen if a child goes into anaphylactic shock; roleplay using a trainer AAI with the CBT in clinics parent and therapist, and by the Dr Rebecca Knibb is a Reader in The first RCT of a CBT-based parent with their child. A target Psychology at Aston University approach provided 200 to reduce phone checking might r.knibb@aston.ac.uk mothers with a CBT-based risk lead to an experiment testing communication session by out the consequences of that. If clinicians with training in CBT (Boyle et al., 2017). a target was to worry less about the child becoming After six weeks, there was no overall difference in more independent and to trust them to take more anxiety between the CBT group and the control responsibility for their allergies, we might suggest group, but mothers with medium to high anxiety a ‘Worry Tree’ and other exercises showing the had significantly reduced anxiety. Mothers reported consequences of suppressing thoughts. This might be coupled with an experiment to see what happens if the feeling that their child was at lower risk of having a child reads their own food labels and decides what they reaction, and salivary cortisol (a measure of stress) was significantly lower. can eat, and a roleplay with the child showing their It is clear then that parents with high levels of friends how to use the trainer AAI in an emergency. stress and anxiety do seem to benefit from a CBT-based The pilot study resulted in improved quality of life approach, but UK funding for dedicated psychologists and reduced stress, worry, anxiety and depression at to work with allergy patients is very limited. Two the end of therapy. The mothers who received therapy allergy clinics that do have dedicated psychological were no different to the comparison group on any services are at Southampton General Hospital (since measure by the end of therapy. While this was a small 2014) and the Evelina London Children’s Hospital (since 2016). These services are very popular; in the first six months 71 new referrals were made to the ‘Her greatest fear is that her son will die’ psychology service at the Evelina and 43 patients had been seen for treatment. Demand on the service is so high that all referred patients are triaged and a ‘stepped John is a nine-year-old boy with allergies to very small quantities care’ system is in place to deliver treatment. of peanut, milk and egg. He also has asthma which is generally well Both services treat patients and families through a controlled. For his food allergies he has an Adrenaline Auto-Injector mix of telephone support, workshops and one-to-one (AAI) and anti-histamine. John had one serious anaphylactic reaction individual or family therapy. Patients and parents come when he was five years old and had to be taken to hospital. This was with a wide range of issues such as difficulty adjusting a very scary event for John and his parents, and since then, John’s to the diagnosis; anxiety related to eating, food mother Kate has felt increasingly anxious about her son’s allergies. challenges and use of the AAI; anxiety related to eating Kate likes to have control over John’s allergy management. She at school and outside of the home; low mood; low selfgets worried if John is not with her and is very anxious if she has to esteem; anger, frustration and feeling different; poor ask a friend to look after him. She believes that if he has a reaction social functioning; distress following an anaphylactic when she is not there it will be her fault and no one will know what to reaction; sleep problems; and bullying. Initial do to treat John. evaluations of these services show that they are much Kate does all food shopping, reading of food labels and cooking needed and help patients and families reduce distress herself. They don’t eat out very often but when they do Kate looks and live a better quality of life (Knibb et al., 2019). online to check out where they are going to eat and talks to the chef at Not all regions in the UK have the benefit of such the restaurant. They rarely go out on social occasions as it is too much services. Much of the vital work to help patients and effort to plan and they never go on holiday abroad. families is provided by doctors, nurse specialists and Kate feels anxious about her son lot of the time and worries that dieticians, who do not have training in delivery of he might eat something that will kill him if she is not around to make psychological interventions and have limited time in sure he is ok. She is terrified of the thought of having to give him clinic. Support groups and patient organisations often his AAI. She isn’t sure if she would know when to do it and how. She fill the gap to provide information and support once a constantly checks her phone when John is at school, in case school diagnosis has been made. The Anaphylaxis Campaign ring. She doesn’t trust that school would know what to do if John and Allergy UK, the main patient organisations for had a reaction and she is worried he might be bullied because of his allergy in the UK, facilitate local support groups, run a allergies. Kate often asks John if he feels ok after eating and regularly helpline and have useful and accurate information on checks his appearance to make sure he has no swelling or rash. Her their websites, with help sheets. According to a recent greatest fear is that her son will die. study, being part of a support group helped adolescents

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the psychologist december 2019 allergy

to share their experiences, which reduced feelings of isolation and being different, improved their selfesteem and enabled greater confidence in managing their allergy and communicating about it with adults (Jones et al., 2018). No clear pathway Funding for dedicated psychological services for food allergy is much needed to ensure families who need support are seen in a timely fashion. Early intervention in food allergy management is vital to prevent escalation of anxiety, which can result in severe restrictions on a patient’s life. The stepped care approach adopted by the Evelina London Children’s Hospital is likely to be the most cost-effective way to help patients and families. For those without the advantage of a dedicated service there is often no clear pathway to referral, and those who do get referred can have a long wait to be seen. Robust evidence that CBT-based approaches work will enable NHS Trusts to build a business case for funding dedicated psychological services. RCTs need to be supported by the ongoing qualitative work to explore what CBT should comprise of for this group. Funding for posts may also encourage more health and clinical psychologists to work in this fascinating area to support the growing number who really need our help.

Key sources Baptist, A.P., Dever, S.I., Greenhawt, M.J. et al. (2012). A self-regulation intervention can improve quality of life for families with food allergy. Journal of Allergy and Clinical Immunology, 130, 263-265. Boyle, R.J., Umasunthar, T., Smith, J.G. et al. (2017). A brief psychological intervention for mothers of food allergy can change risk perception and reduce anxiety. Clinical and Experimental Allergy, 47, 1309-1317. Cummings, A.J., Knibb, R.C., King, R.M. & Lucas, J.S. (2010). The psychological impact of food allergy and food hypersensitivity in children, adolescents and their families: A review. Allergy, 65, 933-945. Knibb, R.C. (2015). Cognitive Behaviour Therapy for mothers of children with food allergy: a case series. Healthcare, 3, 1194-1211. Knibb, R.C., Halsey, M., James, P. et al. (2019). Psychological services for food allergy: the unmet need for patients and families in the UK. Clinical and Experimental Allergy. Manuscript under review. LeBovidge, J.S., Timmons, K., & Rich, C. (2008). Evaluation of a group intervention for children with food allergy and their parents. Annals of Allergy and Asthma Immunology, 101, 160-165. Weiss, D., & Marsac, M.L. (2016). Coping and post-traumatic stress symptoms in children with food allergy. Annals of Allergy and Asthma Immunology, 117, 561-562. www.anaphylaxis.org.uk www.allergyuk.org www.cofargroup.org www.getselfhelp.co.uk Full list available in online/app version.

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05/11/2019 16:18

Béré Mahoney, Eleanor Bradley, Elaine Walklet and Steve O’Hickey on the hidden challenges of living with anaphylaxis in adulthood.

www.napalillustration.com/

‘I haven’t said goodbye to my kids’

People diagnosed with anaphylaxis in adulthood face unique, but largely ignored, psychological challenges. Psychology offers insights for understanding their needs, and the development of interventions to help this growing group live with severe allergies.

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the psychologist december 2019 allergy

n allergy presents psychological and social challenges for individuals and their families, and research on such challenges has focused on common, severe allergies among those who may be more physically vulnerable; namely, food allergies in children and young people. Yet the number of people in the UK diagnosed with anaphylaxis – the severest and potentially life-threatening type of allergic reaction – is growing, and the challenges they face have been underresearched. To address this, the Anaphylaxis Campaign – the UK’s largest charity dedicated to supporting individuals at risk of severe allergic reactions – launched their ‘Year of the Adult’ in 2017, to improve support for the growing number of adults who have been living with anaphylaxis since childhood, as well as individuals who have developed the condition in adulthood. We greeted this with interest, as we have been conducting research with individuals with adult-onset anaphylaxis since 2014. Despite the wealth of psychology research which focuses on the role of psychological factors in treatment adherence, we know little about how adults manage their anaphylaxis in their daily lives or the psychological factors associated with these management strategies. Medical and nursing colleagues from allergy services told us of differences they noticed when supporting individuals diagnosed with anaphylaxis in adulthood compared to those encountered with younger patients and their families. They asked us to help them find out more about what it is like for this group and their families to live with anaphylaxis, and how they could improve the support they provided. Different for adults? We found some common psychological challenges for children, young people and adults. Failure to carry an adrenaline auto–injector (AAI) is commonplace, and many individuals and family members are unable to demonstrate correct use of their AAI. False optimism, in which individuals believe their risk of further anaphylaxis is reduced over time, is a potentially unhelpful health belief that can be held by individuals with anaphylaxis. The very nature of anaphylaxis exacerbates the likelihood of false optimism, given that individuals may have spent long periods of time without experiencing anaphylaxis or, indeed, may only ever experience a single severe episode of anaphylaxis. Family anxiety about how to support the individual

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with anaphylaxis (adults, children and young people) is also very common. But we did also uncover distinct and relatively hidden psychological challenges faced by those living with anaphylaxis diagnosed in adulthood, their families and the staff supporting them. Here, we describe insights from two of our research studies – one involving interviews with people referred to a specialist NHS allergy clinic with adult-onset anaphylaxis, along with family members and specialist allergy nursing staff, the other a mixed methods evaluation of our training workshop for health care professionals on psychological barriers and facilitators to self-care adherence when working with anaphylaxis. Existential searching

‘I’m gonna die here and I haven’t said goodbye to my kids’

We found that health professionals sometimes assume that adults are more able to accept their anaphylaxis and consequent treatment recommendations, due to their relative psychological maturity. As one health care professional told us, there may be an assumption that adults with anaphylaxis are the ‘easy… Epipen and go’ patients. Our research suggests that this is often not the case. Simply put, adults have more ‘psychological baggage’ than children. Adults have years of commonsense reasoning and beliefs about life, death and health that they use to make sense of their anaphylaxis. As with other long-term conditions, this can lead to unhelpful beliefs and behaviours around their anaphylaxis, which may shape their reactions to it. There are long-lasting implications for their management and self-care behaviours. For example, we have found that people diagnosed with anaphylaxis in adulthood experience existential rumination in response to their original anaphylaxis episode and in subsequent self-management of their condition. An episode of anaphylaxis, similar to other near-death or life-threatening traumatic encounters or events, can be accompanied by near-death experiences (NDEs). Bruce Greyson, an American Psychiatrist and researcher on NDEs, describes these as ‘powerful psychological experiences typically occurring to an individual close to death or in a situation of intense physical or emotional danger’. Research with adults, children and young people who have undergone anticipated and unanticipated near-death medical events, suggests that their NDEs have core affective, cognitive, transcendental and paranormal components.

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Indeed, some findings from the literature on NDEs echo our findings from people with adult-onset anaphylaxis. In our research, most reported being unconscious during anaphylactic shock, but a small number reported that they’d had thoughts about how their family would cope if they died. This fits what we know about other unanticipated life-threatening health events – people who experience these report more cognitive experiences, such as reviewing their life, whereas those whose life-threatening event is anticipated (e.g. linked to a pre-existing health condition) are less likely to report such thoughts. Notably, evidence suggests that posttraumatic growth following a life-threatening health event, whether anticipated or not, seems more likely if the individual reports these sort of NDE thoughts. However, this growth isn’t something reported by the adults with anaphylaxis we interviewed, so whether psychological growth can follow an NDE during an unanticipated first episode of anaphylaxis in adulthood is unclear. It does appear, though, that children and young people can cope better psychologically with traumas compared to adults in the Key sources same situation. For example, our interviews suggested that those Allergy UK. https://www.allergyuk.org/ with adult-onset anaphylaxis might information-and-advice/statistics be more likely to experience the Cohen, M.B., Saunders, S.S., Wise, negative emotions of anger and S.K. et al. (2017). Pitfalls in the use of epinephrine for anaphylaxis. guilt about their condition. Some International Forum of Allergy & appeared angry at the loss of their Rhinology, 7(3), 276-286. good health; for others, the cause Mahoney, B., Walklet, E., Bradley, of their anaphylaxis remained E. & O’Hickey, S. (2019). Improving unknown, promoting a sense of Adrenaline Auto-injector Adherence. uncertainty and insecure physical Immunity, Inflammation and Disease. ISSN Online: 2050-4527 (In Press). health. For those adults with Oland, A.A., Booster, G.D. & Bender, anaphylaxis triggered by venom B.G. (2018). Integrated behavioral (e.g. wasp or bee sting), the source health care for management of stress of the allergy may be known, in allergic diseases. Annals of Allergy, but exposure to it in the general Asthma & Immunology, 121(1), 31-36. environment can remain unknown Taylor, J.Z. & Lewis, C.L. (2018). Counseling adults with food allergies or extremely difficult to control. after an anaphylactic reaction: An These features of anaphylaxis application of emotion-focused therapy. appear to be particularly meaningful Journal of Mental Health Counseling, for adults – we are driven to make 40(1), 14-25. sense of events and experiences, to Walklet, E., Taylor, C., Bradley, E. et derive certainty from unpredictable al. (2018). ‘Because it kind of falls in between, doesn’t it? Like an acute situations and to regain control thing and a chronic’: The psychological through prescribed behaviours or experience of anaphylaxis in adulthood. treatments. For some, this may be Journal of Health Psychology, 23(12), a difficult psychological experience 1579-1589. and it can lead to an ongoing Walklet, E., Mahoney, B., Bradley, E. sensation of vigilance. & O’Hickey, S. (2019). Application of health psychology: Development of a practitioner training intervention in anaphylaxis. Journal of Continuing Education in the Health Professions (in press).

Full list available in online/app version.

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Guilt and anxiety around others Our research also found that some people experience feelings of guilt about their condition. These adults often ruminated about what could

have happened if they had not survived their original anaphylaxis, particularly the consequences for their adult family members and children. One interviewee told us that during her anaphylaxis she remembers thinking ‘I’m gonna die here and I haven’t said goodbye to my kids… what’s happening, if I just go now, am I gonna come back?’ Some adults also became acutely aware of the anxiety experienced by others around them, related to their anaphylaxis. One interviewee spoke about her first anaphylaxis episode, saying: ‘My husband and my daughter were far more traumatised than I was’; another told us that ‘Everybody else was more traumatised than me, I think’. Children and young people with anaphylaxis may appear much less aware of the broader impact of their condition. Independence and risk Many adults we spoke to found it difficult to identify with their anaphylaxis because they associated the condition with children. As one interviewee said, anaphylaxis is ‘the peanut thing and... children really’. Such reasoning made it difficult for adults to accept their condition. Perhaps combined with greater independence, and the lack of ongoing or consistent physical symptoms, adults seemed encouraged to take risks with their self-management. This is to be expected, as children’s transition to adolescence and then into adulthood are known to be high-risk periods for those self-managing long-term conditions. Young people undergo this transition with prior experience of anaphylaxis, having developed psychological and physical strategies over time, often with the support of family. Those diagnosed in adulthood found themselves having to adjust rapidly from a perception of themselves as a previously ‘healthy’ adult, to an adult with physical vulnerability. Psychological challenges for families

‘We’ve sort of done our bit to try and protect him, but if he doesn’t want to do it then that’s up to him, it’s completely up to him’

It is not uncommon for family members to express more anxiety on behalf of their relative with anaphylaxis, than the individual themselves. With adults, there is something of an ‘adherence paradox’: adults are more likely than children to have to selfadminister their AAI, but their family members are likely to believe that there is little they can do to encourage the person to stick to their management plan or use their AAI, precisely because their relative is an adult. As the adult daughter of a parent with anaphylaxis we interviewed said, ‘if he doesn’t want to do it then that’s up to him, it’s completely up to him’. Feeling unable to control the self-care behaviours of their adult relative seemed to distress and frustrate relatives: ‘we know that we’re not going to be there when it happens, the likelihood is we’re not going to be

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the psychologist december 2019 allergy

there… and you don’t like to think of someone having to cope with something like that by themselves’. Individuals also seemed aware that their relative’s years of good health before unexpected anaphylaxis could encourage their relative to be falsely optimistic and not carry their AAI: ‘you’ve been OK yourself even though you’ve had it… I can see how that would just reinforce your attitude that it’s not that big a problem’. Relatives of adults with anaphylaxis also often shared a disbelief that anaphylaxis could be diagnosed for the first time in adulthood: ‘He’s never had anything like this before… So it was just a bit of a shock that he developed it so late in life. I wouldn’t have expected it.’ Challenges for health care professionals

‘They often don’t carry them around, either… you’d think that after having a near-death experience, you would… I don’t know why’

It is common for health care professionals to feel ill-equipped to train individuals with anaphylaxis to use an AAI, and many cannot demonstrate the correct use themselves. However, our research shows that practical support is not the only challenge – many health professionals make erroneous assumptions about the psychological needs of adults following anaphylaxis. Health care professionals may perceive anxiety amongst this group of adults as normative – ‘it’s a trauma, so [patients should] expect to be anxious’ – but not requiring formal support or input. This perhaps led some health care professionals seen by adults with anaphylaxis to be less guarded in their communication style with them than they might be with children. One patient recalled: ‘I think the fear of using the pen – because obviously the doctor mentioned, “Oh, you could do yourself harm with that”, sort of business, before they gave me one originally – means that I’m obviously afraid. I have fears of using it. I just hope I don’t have to use it.’ While paediatric services for young people with anaphylaxis have relatively developed ways of recognising and supporting the psychological aspects of living with anaphylaxis, there is little or no equivalent service support for adults with anaphylaxis. We found that health care professionals supporting adults with anaphylaxis can perceive their role as more medical than psychological, with a focus on the technicalities of using an AAI. Interestingly, adults with anaphylaxis were often assumed to be rational decision makers in relation to the management of their condition. Some health care staff reported disbelief about the self-care behaviours of adults with anaphylaxis they had encountered (see quote above). Psychological interventions

‘I’m clinical, our job is to make sure they know what to do if they have an anaphylaxis. So we teach them

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signs and symptoms and teach them to use EpiPens.’

Dr Béré Mahoney is a Chartered Psychologist and Senior Lecturer in the School of Psychology, University of Worcester. She has diverse applied research interests in addition to how individuals with adult onset anaphylaxis respond to and manage their condition. These include women’s experiences of reconstructive surgery following mastectomy, and the links between sexuality, victimisation and culture.

We need inclusive psychological interventions (health, counselling and clinical psychology) to enable adults who require formal, psychological support to access this as required. There is evidence that CBT can be used to help parents of children with anaphylaxis, so there may be merit in exploring how to transfer good practice from paediatrics to adult-focused work. Eleanor Bradley is a Chartered However, we must also be Psychologist and Professor mindful of the evidence from this of Health Psychology at the group which points to particular University of Worcester. She has challenges, such as pre-existing worked across University and common-sense models of NHS environments, focusing illness and incongruence with research on understanding the the diagnosis of severe allergy experiences of people in receipt in adulthood. Evidence from of and delivering healthcare, counselling and health psychology particularly amongst changing (e.g. Taylor & Lewis, 2018) practice and organisational shows emotion-focused therapy, developments. systemic therapy and patient and practitioner behaviour change interventions could help. Further Elaine Walklet is a Chartered research is needed to identify Psychologist and an HCPC those adults who may find it Registered Health Psychologist particularly difficult to adjust to in the School of Psychology, their anaphylaxis. University of Worcester. Her There is a broader role for research and practice interests psychology in terms of developing include living well with long-term training grounded in health conditions, health behaviour psychology theory, to improve change and psychological awareness about techniques interventions. designed to increase adherent behaviour amongst adults. The Steve O’Hickey is a Consultant development of psychological Physician in Respiratory mindedness amongst health Medicine at Worcestershire professionals more broadly, through Royal Hospital with a particular communication techniques and interest in allergy and asthma, strategies, could address any early and Honorary Professor at the adjustment difficulties for those University of Worcester. recently diagnosed, as well as identifying those in need of further psychological support for more complex adjustment and trauma. Toolkit resources and checklists for professionals, as they gain confidence in discussing psychological issues with patients, could prove particularly helpful. To end with a quote from a clinician attending one of our training workshop: ‘I didn’t realise the assumed knowledge and the assumptions about the way adults deal with emotions and medical experiences, compared to children. When in actual fact, with something like anaphylaxis, adults are as much in need – well, some are – as children.’

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22–23 January at voco St John’s, Solihull Conference theme – New adventures in clinical psychology: personal, professional and political partnerships. This year the Faculty for Children, Young People & their Families will be joining the conference, with their own stream. Pre-registration ends 16 January, don’t delay book now. Wine Reception & Conference Dinner at the voco St John’s, Solihull 22 January, book now. Draft programme and Invited speakers are available to view on the website. DCP invited speakers include: Dave Harper, Sara Meddings & Emma Watson, James Hawkins. CYPF invited speakers include: Louise Hayes, Max Davies, Mina Fazel, Sarah Halligan & Rachel Hillier. Also featuring at the 2020 Conference is the ‘Voices for the Missing Choir’ who will not only be presenting a workshop but also performing at the Wine Reception!

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05/11/2019 15:42

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the psychologist december 2019 existential therapy

‘What really matters’ Ernesto Spinelli, a winner of the Society’s Award for Distinguished Contribution to Practice, on what it’s like to be an existential therapist

long, long time ago, in the early the attempt to ‘stay still with what is there’ so that years of modern psychology’s it may be clarified, opened up to its unconsidered existence, Wilhelm Dilthey implications, limitations and possibilities. In short, proposed a distinction between its attempt to understand focuses upon the embodied the natural sciences and the meanings being assigned to an experience. What might human sciences. In brief, such meanings extract as their undesired ‘price’, as well while the former focused on as provide as desirable ‘pay-off’? explanation (broadly, matters of This is not to suggest that existential therapy seeks cause and correspondence), the latter centred upon to prevent ameliorative change from happening. It understanding (broadly, all the issues surrounding remains true to the origins of therapy itself – therapeia the generation and experience of meaning). Dilthey – which expressed the attempt to ‘stand side-by-side argued that as well as both strands being equally with the other’ (in Laing’s words). This is no quasivalid scientific enterprises, it was necessary to clarify medical enterprise, seeking to generate ameliorative that neither strand should be confused with – nor change via directive interventions rooted in an subsumed by – the other. explanatory-centred interpretation of psychotherapy. Understanding and explanation may stand beside It is instead guided by the premise that the act of one another, but their focus describing an experience will, in and and concerns are not one and of itself, change the experience being “…existential therapy the same. Whereas explanation described. seeks to disprove or ‘close down’ Nonetheless, existential therapy embraces its inherent inadequate hypotheses of cause embraces its inherent uncertainty. uncertainty” and correlation, understanding What will provoke change? What perpetually ‘opens up’ and impact will it have on either the illuminates novel, often unforeseen, client or therapist, or both? What possibilities of meaning. Understanding approaches effects will ripple out through them, to any and all within science must remain receptive to the inevitable other beings with whom they interact? uncertainty that accompanies their enterprise. To put it another way: the more adequate the understanding, the more hesitant becomes any explanatory endeavour. An example Existential therapy, as I attempt to understand and Ross comes to see me because he has, in recent practice it, aligns itself with the understanding branch months, begun to suffer from literally paralysing levels of science. It concerns itself with the understanding of of anxiety. He is most often overwhelmed by these lived experience as uniquely embodied by a particular while at work. Increasingly, he feels the pressures of being. And it seeks to understand more adequately demonstrating his ‘know-how’ and superior expertise. in what ways any understanding of the particular These, in turn, wreak havoc on his sense of self-worth also illuminates our understanding of the general, or and self-confidence. universal, experience of being. But it is not only in Ross’s work life that he becomes overwhelmed by these paralytic anxieties; his inability to find his ‘life-mate’ and to relax in the Price and pay-off company of his friends (most of whom, unlike Ross, As a therapeutic approach centred upon are now in permanent relationships) are in some ways understanding, existential therapy is, therefore, even more anxiety-provoking. In turn, Ross’s fear of unlike just about every other model of contemporary the life-threatening consequences of these attacks psychotherapy. It is not primarily concerned with have begun to seriously disturb his sleeping patterns. directively generating change or amelioration from Worst of all, as much as Ross craves social and distress, or in assisting anyone to ‘live a better or intimate contact with others, his sense of failure – and healthier life’. Instead, its enterprise centres upon being seen to be such – pushes him to avoid the very

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contacts he desires. ‘I need help’, Ross says. ‘Help me to get rid of this anxiety’. ‘And what do you suppose would change in your life if this anxiety you speak of were gotten rid of? Alternatively, what might remain the same?’ Ross stares at me as though he is in the presence of some gibbering idiot. He’s not far wrong. Initially, my desire to understand is matched by my current inability to do so. ‘Tell me about this anxiety that you speak of. What is it? How do you experience it? What do you tell yourself about it?’ In asking such questions, existential therapists return the notion of diagnosis to its origins. In its earliest meanings, diagnosis was carried out by the patient or client. As such, every diagnosis had its unique, client-driven qualities (Jaspers, 1963). While often initially confounding, possibly even irritating, to some clients, this form of enquiry serves a number of important functions. Two key ones are that it replaces the abstraction – anxiety – with statements of concrete, embodied experience; and its unique aspects then become more apparent. In this way, the client gains a growing sense of ownership of the experience. While the experience may still be disturbing and disabling, it is also now ‘my experience’. In these moves towards concrete ownership, the seemingly alien, ‘not part of

me’ aspects of the experience are challenged. If it is concretely describable as ‘mine’ then the possibility arises that I can better explore and consider both how I am currently relating to it and what possibilities I may have in reconfiguring that relationship. The existential therapist’s primary skills in adopting this mode of enquiry rely upon assisting clients to better understand their experience from a descriptive focus. While this might often be a primarily verbal enterprise, it need not be so. Drawing, movement, and other forms of non-verbal dialogue can equally serve the client’s descriptive process. In instances of overwhelming distress and disorder, such methods may prove to be initially far more expressive, accessible and safe for clients to be willing to engage with. In Ross’s case, three forms of verbally-focused description dominated our discussion: • embodiment, which focuses on the body – as a whole and in specific areas – and how it expresses the experience under investigation such that how, where, and in what ways it is felt bodily can be opened to description; • metaphor, descriptively exploring the various ‘what is it like’ associations given by the client and what these highlighted associations may add to the client’s understanding of his or her current ‘way of being’ with the experience; and • narrational scene setting, detailing several

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05/11/2019 16:41

the psychologist december 2019 existential therapy

years now, I have yet to experience Key sources anything akin to ‘burn-out’. The curiosity and concern that are part and parcel of an understanding https://www.existentialpsychotherapy. focus reduce any feeling of a ‘here net/definition-of-existentialpsychotherapy/ we go again’ reaction to my clients’ Evans, R.I. (1981). Dialogue with R.D. stated concerns. Laing. New York: Praeger. And what has all this done for Hodges, H.A. (1952). The philosophy of me, personally? I don’t know if it Wilhelm Dilthey. London: Routledge. has made me a better person. But These descriptive explorations led Ross to understand Jaspers, K. (1963). General it has certainly afforded me a lived that his anxiety expressed various desirable, if Psychopathology, vol. 1 (J. Hoening & M. W. Hamilton, Trans.). London: Johns awareness of how inescapably intersignificantly competing and contradictory, ways of Hopkins University Press. related all beings are, and how our being that he sought to live out simultaneously. His Rayner, M. & Vitali, D. (2016). Shortvery uniqueness emerges through inability to fulfil the demands of all of these ways of term existential psychotherapy in that inter-relation rather than in being in any satisfactory way led him to experiences primary care: A quantitative report. spite of it. This view has guided me of ‘splitness’ to the extent that the felt dissociations Journal of Humanistic Psychology, 56(4), over the years and has permitted in mind and body led to a sort of paralysis. While 357-372. Spinelli, E. (2015). Practising existential me sufficient courage (perhaps deeply disturbing and debilitating, this anxiety-fuelled psychotherapy: The relational world (2nd arrogance as well) to respond as paralysis also served to ensure that no one of his ed.). London: Sage. openly as possible to the challenges competing desired ways of being took precedence over Stephenson, L. & Hale, B. (2017). and possibilities that present any other – much less reduced, if not eliminated, the An exploration into effectiveness of themselves. I’ll seek to act on them continuing possibility of any and every possibility. existential-phenomenological therapy regardless of the uncertainty of Ross began to understand that his paralysing as a U.K. NHS psychological treatment intervention. Journal of Humanistic where such will lead. anxiety attacks reflected his demand to ‘want it all’. Psychology. Advance online publication. I firmly believe that whatever And, in doing so, they maintained the whole of the I may have ‘achieved’ in life, be it desire but in a way that ensured that no element of professionally or interpersonally, it could be achieved. As painful and destructive as it was, Ross’s anxiety worked for rather than against him. is an expression of this pivotal existential challenge to be willing to embrace and cherish ‘who/what Further, the ‘price’ required by him to confront that is there, in the way they are there, when they are anxiety was nothing less than an act of choice on his there’. Sometimes joyful, sometimes painful, always part – a choice that, if carried out, would of necessity have condemned him, as he put it, ‘to wave goodbye’ to surprising, this view fuels and enfolds me in every facet of my life. For me, existential therapy ultimately many of his imagined possibilities. emboldens us to look at our own lives and at life in Even if Ross concluded that he was not prepared general from a standpoint that asks to make that choice and, instead, ‘what really matters?’; and then to continued to remain anxious, do the best we can to act on that. the descriptive process and the “For me, existential Nonetheless, I remain all too understanding that accompanied therapy ultimately aware that much of existential it, would still have altered his therapy’s outlook sits uneasily way of being with his anxiety. He emboldens us to look at with the current zeitgeist of could not return to his earlier, less our own lives and at life ‘evidence-based practice’ that adequate, embodied understanding in general from a dominates explanatory-attuned of his experience of being anxious. definitions of psychotherapy. Yet For one thing, now it was his standpoint that asks in recent years, a new generation choice rather than the outcome of ‘what really matters?’; of existential therapists has taken some alien invader. For another, and then to do the best up this challenge. Quantitative it was a meaningful consequence evidence demonstrating at least of Ross’s chosen way to be. In we can to act on that” equal outcomes to those noted owning the experience and its in CBT-based interventions both consequences, the paralysing effects exists and continues to grow disappeared. Even so, Ross now (Rayner & Vitali, 2016; Stephenson & Hale, 2017). found himself being anxious in a decidedly different Many critics of existential therapy claim it’s not way: painful as it still continued to be, he experienced a scientific worldview. In recent years, I’ve taken to it as primarily empowering rather than debilitating. countering that existential therapy’s greatest strength lies in its acknowledgement that every statement it makes ends with a question mark rather than a Curiosity and concern full stop. Such a stance, it seems to me, exemplifies I hope I have managed to convey something of the rather than forsakes the aims of any genuine scientific overall ‘atmosphere’ of being an existential therapist. Although I have been practising as one for well over 30 enquiry. remembered instances of the experience as if re-creating a scenario for each example. Any one reconstructed narrative scene can then be explored both in itself and in relation to all the others so that recurring elements – no matter how seemingly insignificant, even absurd, they might initially appear to be – can be identified and further explored.

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05/11/2019 16:41

‘I strongly believe in broadening one’s therapeutic toolkit’ Ian Florance interviews Paul Grantham, Consultant Clinical Psychologist and Founder/ Director of SDS Seminars

During the last 30 years Paul Grantham’s company, SDS Seminars Ltd, has been involved in training over 150,000 mental health professionals. In Paul’s own words, ‘over that period, everything has changed: the skills that we train, the delivery methodology, the competitive landscape and the number of people who seek this training, both as part of their professional development and as a new direction they want to take’.

SDS Seminars sponsor The Psychologist app, available in the iOS/Android stores. It’s free to download, with complete access for Society members via login.

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‘I suppose I’d call myself a bright working-class child’, Paul begins. ‘My Dad was in the navy and was away a lot on tour so, for most of the time, I was brought up by my Mum. Passing the 11+, I went to a grammar school and was preoccupied – like many adolescents – with “finding myself”. In contrast with my childhood, adolescence was privately unhappy. I experienced a religious conversion experience when I was 14. Several of my peers – many of them the most academically bright – experienced something similar. However, at the same time, another influence had a much more positive impact on my life. I was at school during the Watergate scandal, and, although it wasn’t a part of a curriculum, my history teacher, Keith Baker, started every lesson with a political analysis of the previous day’s developments, pointing out that we were living through a historic time, not just learning about the past. It’s no surprise that I chose Modern History to read at Corpus Christi, Oxford.’ During his first term at Oxford, Paul suddenly realised that he didn’t believe in God anymore. ‘That has left me with a feeling of potential and liberation that has stayed with me ever since. Not coincidentally, it also paralleled an interest in earlier rebellious 60s San Francisco counter culture – reading Kerouac and listening to the Grateful Dead dominated my non-work time. I think those changes had something to do with the fact that Oxford took me out of a working-class background but gave me no group to join.’ Paul thought he would become a history academic, but decided dusty documents weren’t for him. ‘I was interested in the present day and above all in people, their systems of beliefs, their ways of interacting with each other – on both a personal and global scale. The transition from a historian to a psychologist was quite a natural one. I decided to do a conversion Master’s degree in experimental psychology at Sussex. I liked the idea of seeing if I could handle dealing with people with a scientific (rather than a humanities) methodology. The one-year course involved intensive working through vacations, weekends and late into the night. I clearly was a young man in a hurry.’

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the psychologist december 2019 careers

To clinical psychology Paul considered a number of research jobs, but ‘I wasn’t particularly motivated at research relating to the visual perception of the flea, for instance! I quickly became interested in clinical psychology and applied for a number of technician jobs – what psychology assistants used to be called – which seemed to lead on to clinical training courses. I worked in one of the special hospitals before doing my Clinical Psychology training in Liverpool. It was a course that exposed students to behaviour therapy, radical behaviourism and exploratory psychotherapy. Many of the philosophical and clinical issues that were raised on the course still affect what I do now. Interestingly, I again became conscious of how a tutor’s personality impacts training effectiveness, and that awareness later influenced SDS hugely.’ As a Clinical Psychologist Paul worked in primary and secondary care, developing a particular interest in substance misuse. He was part of a team that did pioneering research on benzodiazepine dependency; he led a community mental health team and started presenting research papers and then training courses for mental health professionals. ‘These were really gratifying because you could control the content. I was doing something both my audience and I enjoyed.’ Training in the digital age This is the point where Paul started his company. ‘It was first called The Skills Development Service; it was incorporated in 1990 and now known as SDS Seminars Ltd’ (see www.skillsdevelopment.co.uk/seminars.php). I asked Paul to sketch in the changes training – and his company – have undergone. ‘I was initially a one-man band… no-one else seemed to do psychological skills training and several of my friends were worried… they thought there was no demand for what I offered if no-one else wanted to do it. They were wrong. Anyone starting up their own business shouldn’t necessarily be put off by the lack of competition. If you know your field and believe that you know what people want – go for it. Our first two courses were on anxiety management and skills for running groups. We still periodically run them… hugely modified and regularly updated, of course.’ Paul points to a massive expansion in CPD need and provision. ‘The field of psychological skills training nowadays is crowded, and highly specialised. In order to meet needs, we had to hugely increase the variety of subjects we cover. We invite prominent figures in their fields to train for us on various specialist therapies, and we’re just entering the child psychology field with a new Certificate in CBT for Children and Adolescents.’ At this point Paul became quite animated and I realised that he was approaching one of his favourite subjects. ‘How training is delivered has taken up a lot of our recent work. Ten years ago we established a sister company, PsychotherapyDVDs.com, which produces and distributes training DVDs. Apart from

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our own DVDs we hold exclusive licenses to distribute video materials for a number of US leaders in the field. Visiting one of our American partners I watched with growing excitement how he held an event with 300 people in a room and 200 people watching live online. I haven’t stopped thinking about it since!’ Out of this experience, SDS grew their ‘Interactive Webcasting System’ (IWS). ‘Some of webcasting’s advantages are obvious – not least that it makes fewer financial and time demands on participants. We’ve already used it for broadcasting our training from the British Psychological Society’s London offices, with webcast participants from California, OAE, Hong Kong, Malta, Germany and many other countries. Some advantages are less obvious and were surprising even for us – people interact online considerably more and ask more questions in live webcast training. Of course, to work with IWS, trainers must learn new skills, and structure their training in new ways. But that’s a small price to pay if we can bring our training to people who would not be able to join us otherwise.’ Towards a sharper professional identity What issues do you see your audience grappling with? ‘There are many things that fascinate our participants; they fascinate me as well. For example, CBT has squeezed out other evidence-based psychotherapy modalities – I’m interested in why. I don’t know why Motivational Interviewing, for instance, hasn’t grown as fast as CBT. I personally use different approaches depending on the client I am working with. I strongly believe in broadening one’s therapeutic toolkit, not narrowing it. Evidence-based practice may now be a piece of jargon, but the idea is important, and outcome research must use evidence. Context is important too.’ There’s also, according to Paul, ‘a huge debate about the role of clinical psychologists today, especially since the introduction of IAPT. They need a sharper, more defined professional identity and a greater focus on leadership. They are being financially undercut – it started 20 years ago in the States and it’s happening here. The reaction is often to run to the universities, choosing research and lecturing jobs over clinical practice. We’ve tried to run courses teaching the skills necessary for clinical psychologists and other mental health professionals to set up their own independent practices, but the response hasn’t been what we hoped.’ And what are your future plans? ‘Developing our webcasting system and bringing it to other people; filming more training videos; inviting more worldexperts to train for us; offering more courses as online training; writing books. This last one has been on the backburner for ages! I’ve written two practical handbooks and have three longer books in a draft form, but I find it quite difficult to motivate myself to allocate enough time to them. I prefer to influence thousands of people through our training rather than a few hundred through a book. Maybe this reflects my still rebellious nature!’

05/11/2019 16:42

‘We need to support our diverse population’ Susan Cousins works in equality, diversity and inclusion at Cardiff University, and is the author of Overcoming Everyday Racism: Building Resilience and Wellbeing in the Face of Discrimination and Microaggressions (Jessica Kingsley Publishers). Annie Brookman-Byrne asked Susan about her book. Can you start by saying a little about your background and why you decided to write this book? I was born on the other side of the world. I was abandoned by my parents and left on a pavement in the slums of Mumbai and later rescued by the police and taken to an orphanage where I spent the first year of my life. Since then my life has taken many a dramatic turn but eventually, I found a career in counselling both in the NHS and in Higher Education. Another twist in the tale has led me to take up a role at Cardiff University working in

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race-equality. The decision to write this book came about through the realisation that over the past 20 years there was nothing I could give to my black and minority ethnic (BAME) clients; there were few if any BAME self-help books or narratives that addressed our wellbeing and the impact of racism on psychological distress. Where are the books that help us to live well enough, feel good enough, and function well enough? I wanted to write a wellbeing book that addresses this gap. I wanted to support BAME people who experience exclusion and face barriers when accessing support services that are sometimes capable of questioning and denying a BAME person’s reality and lived experience. So, for people who work in the caring professions, the NHS, Student Support Services or counselling and wellbeing services this book is a self-help resource. It allows BAME people to connect with the wellbeing agenda. A book is something tangible and solid, something you can slip into your back pocket, download, or carry in your handbag when you need support.

It may seem strange but by far the most important influence on my life has been my adoption into a multi-racial family of seven brothers and sisters all of whom are adopted and from different racial backgrounds. Watching my family struggle through life gave me a wider view of the world – a broader sense of what is out there beyond my front door. This led to curiosity about where BAME people can go for encouragement and support when managing everyday encounters with racism. We need to support our diverse population and extend the wellbeing and counselling narratives. The book is based around six key factors: self-acceptance and identity, environmental mastery, positive relations with others, autonomy, personal growth, and purpose in life. Do you consider these equally important for building resilience and wellbeing? Firstly, I need to be clear that ‘being resilient’ is not an antidote to racism, we should not need to be resilient towards something so unhealthy and damaging. Finding ways to heal, reflect and explore your experience

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the psychologist december 2019 books of racism is important. I chose Carol Rhyff’s six factor model of psychological wellbeing because it offered a broad framework through which to approach the subject from multiple angles. It takes into account the varying experiences of BAME people and the different approaches required due to the experiences of everyday racism that I witnessed in my clients. People who have read this book have told me that they find comfort and solace within its pages and that is something I’m proud of. I don’t think any of the six key factors hold more importance than the others. Maybe at one stage in life identity might be something you want to explore, and at another time you might wish to explore how race impacts on your work environment and relationships. And as with all books, when we go through the process of reading, we take ownership of the parts of the book that hold personal meaning and importance for us. What message would you like white readers to take from your book? I don’t understand what it is like to be white and I don’t think that white people understand what it’s like to be BAME. I think this book helps white people to gain a nuanced understanding of the complex issues that BAME people face in a majority white culture. White readers have told me they find the book offers new perspectives, increases their knowledge and understanding of the BAME lived experience and the impact of racism on psychological distress. They have told me that the book aids an understanding of the BAME experience, taking the reader on an emotional journey that enlightens and educates. Other people have told me that it helps bring their unconscious bias into the light and is challenging and yet encouraging. I want practitioners in all the caring professions to be able to offer a self-help resource to their BAME clients and to explore the book in order to understand a diverse experience. BAME people have told me that the book has articulated subtleties they knew existed but hadn’t put

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into words. The book provides a place to deal privately with racism. It encourages personal agency, providing useful tools and coping mechanisms. It provides a call to realise one’s potential above the classificatory system of race. In the book you talk about some clearly very painful personal experiences of racism. Were these difficult to put on paper? Was there anything therapeutic in getting it all out? I feel the most powerful experiences in my life have been lived out within my family, friends and through the process of adoption. Growing up in my family remains far more of a painful experience than my experiences of racism. I am in some senses immune to what happens to me in public because racial abuse has been something that has lived with me since the first day of school, and still does. It feels familiar to me and I’ve learned to recover from it many times. I think my world view is very different from most because of my adoption. I have few and low expectations of life being safe in a public sense. So writing about these experiences was not painful, I don’t think I have gained anything therapeutic from the process other than reading the works of other BAME writers. I feel a huge sense of healing and of pride when people talk to me about how the book has helped them and supported them, because some of what I have been through has made some sense and holds some meaning – so that is where the therapy and healing is happening. What next for you? That’s a very interesting question. I feel the book is taking me in all sorts of directions that I couldn’t have imagined. For example, I have been asked to talk about my favourite book, Beloved, by Toni Morrison and its links to my writing – I find it astonishing to be asked to engage in something so thought provoking and creative and I feel humbled and excited to do so. I would like to return to Mumbai and visit the orphanage where I stayed, which is now a school. That is fundamental to me.

Taking ownership Possessed: Why We Want More Than We Need Bruce Hood Allen Lane (Penguin) £20

One day in 1949, the blues musician BB King was playing a gig in Arkansas when a fight broke out between two men over a woman named Lucille. They knocked over a heater, which started a fire, and soon everyone was evacuated. Once outside, however, King realised his $30 guitar was still on the stage and ran back into the dancehall to get it. He subsequently named all his guitars ‘Lucille’ – and even wrote a song about the incident – to remind himself never to act so stupidly again. King’s reaction may seem extreme, but many of us are already risking our lives for our possessions. Fire departments report that hoarding is a serious hazard, with one estimate suggesting that they contribute to a quarter of preventable fire-related deaths. How come? This is the subject of Bruce Hood’s excellent new book, which upends the concept of possession and ownership. In his view, it is we who are ‘possessed’ by material goods, at a great cost to ourselves and the environment – and we need to exorcise their power over us. Following the success of Marie Kondo’s anticlutter TV series early this year, the topic is very much within the zeitgeist. But as you might expect from the author – a professor of psychology at the University of Bristol – Possessed combines philosophy with rigorous experimental research to examine the reasons why we want to own so much more than we need. Some of the themes may feel familiar to readers of The Psychologist – though Hood adds much needed nuance to the most well-known findings. The cliché that money can’t buy happiness, for instance, has been widely debunked with the now famous studies of lottery winners. But as Hood points out, the latest replications show that their judgements of overall life satisfaction are higher; lottery winners are conscious of their comfort, even if

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they are not any more likely to report joyful emotions in any given moment. Or consider the ways that money and possessions contribute to status; like the peacock’s tail, they are a costly display to impress potential mates and establish our superiority over our rivals. Hood points out that this is prevalent even among the poorest members of society, who spend proportionally more money on showy luxuries, which may seem illogical until you recognise the fact that competition and hierarchy are so much more tangible in poorer neighbourhoods. Unfortunately, the possession of one luxury means we feel more dissatisfied with our other, less fancy goods, fuelling a desire to upgrade everything – a phenomenon known as the Diderot effect. Hood’s argument hinges on the fact that our goods are essential for maintenance of our own identities, as part of our ‘extended self’. Research shows that – at least in the West – we tend to rate our possessions as being even more important to our sense of self-identity than our friends and family. And the very act of ownership causes us to inflate our perceived value of something, while the loss of a good can trigger feelings of pain. (Studies have even shown that analgesic drugs can reduce our loss aversion for this reason.) Hence why Kondo’s clients find it so hard to let go, and why someone like BB King risked his life to save his guitar. Possessed is only 165 pages long (excluding footnotes), but Hood’s writing is crisp and he covers an impressive range for such a slim volume – fitting, perhaps, for an argument against waste and excess. Besides provoking questions about our own habits, he shows us how this understanding can inform discussions of inequality, climate change and domestic abuse. For practical strategies to declutter, read Kondo. But for those interested in the psychology and philosophy of materialism, this rich and engaging book will spark hours of joy.

Reviewed by David Robson, science writer and author of The Intelligence Trap and How to Make Wiser Decisions. He is @d_a_robson on Twitter.

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‘Why we butt heads with our parents…’ Five children review Why Your Parents Are Driving You Up the Wall and What To Do About It (Penguin) by neuroscientist and author Dean Burnett. We reached out on Twitter to invite parents to share this book with their teenagers. Joanna Brooks (University of Manchester) shared it with her three children, Ellie (17), Milly (14), and Mal (8), who picked it up herself as the title appealed, even though it’s not intended for her age.

Ellie

Milly

Mal

Ellie ‘I think understanding more about where your parents are coming from is useful, and thinking about that helps to not get so frustrated as quickly. The points about explaining reasonably being more effective than arguing and not having these discussions with high emotions are practically helpful. It’s good advice and it makes sense.’ Milly ‘Usually I have a really low attention span for books but the way this one had different fonts and images kept me interested and it felt personal. What will change for me as a result of having read it – I think I’ll worry a bit less about some things. I really liked the explanation of the brain losing the connections it doesn’t need and being like a phone that needs upgrading round about age 11, and why that means you forget childhood memories and find stuff that used to be interesting boring now. Understanding more about the reasons for why we butt heads with our parents over things like wet towels and why my emotion levels can be so extreme does help. It means I don’t have to worry about feeling so emotional lots of the time – it’s just because my brain hasn’t worked me out yet.’ Mal ‘I am 99.9 per cent sure the person who wrote this is a parent. Then he shouldn’t be writing books like this. You forget everything about being a kid when you’re a parent, all your feeling goes off and you’re all just guessing.’ Marilyn Sher, Consultant Clinical & Forensic Psychologist, Woodlands Consulting and Therapy, shared it with her son Shai Muniah (11). ‘I now say to my mum, “I’m not stroppy – my brain’s just getting more sophisticated – so be patient” [grin]. I also try to be more patient with my mum and dad now – as long as I am not too tired from school. We also make more deals now so we both get a bit of what we want. For example, I explained to my parents that my brain doesn’t

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the psychologist december 2019 books

let me go to sleep early. Now I can stay up later if I can’t sleep. I just read my book and promise not to go on my iPad.’ Judith Marshall (University of Wales Trinity Saint David) shared it with her son Daniel Bendle (16). ‘When my mother gave me the book, my initial thought was that kids might think their parents had a motive for making them read it; that it was to justify all the nagging and rules. The fact that it has a strong scientific element made me feel it was not biased towards my parents and that it was helping to explain why adults and teenagers can clash over things and parents aren’t always right. I particularly liked the chapters on mental health, smartphones and digital natives. I think these are things that affect even very young people nowadays. I did

Dean also had a new Audible audiobook out on World Mental Health Day – Psycho-Logical. We fired him some of his own ‘Why?’ questions that he considers in the book, along with some of our own. Read the interview via https://thepsychologist.bps.org. uk/spreading-word-about-mentalhealth-accurately-compassionatelythats-priority-mine recognise a number of things that I do myself that can annoy my parents.’ Find longer versions of these reviews on our website.

Exposing the facts of patriarchy The Guilty Feminist: From our Noble Goals to our Worst Hypocrisies Deborah Frances-White Virago Press £14.99

Invisible Women: Exposing Data Bias in a World Created for Men Caroline Criado Perez Penguin Random House £16.99

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Each episode of the hit podcast The Guilty Feminist starts with comedians confessing ‘I’m a feminist but…’, and each chapter of Deborah FrancesWhite’s book starts in the same way. These confessions are the reason Frances-White calls herself a ‘guilty’ feminist, in acknowledgement that there’s no such thing as a perfect feminist. Being raised in and shaped by the patriarchy inevitably leads to some less-than-feminist guilty desires, but Frances-White argues that this doesn’t mean we’re not feminists; this is in fact partly why we need feminism. The Guilty Feminist, as both podcast and book, takes an intersectional approach to feminism, recognising the multiple intersecting aspects of identity that change how we experience the world and are treated within it. Among the many interviews throughout the book is a conversation with transgender and non-binary neuroscientist Reubs Walsh, who shows why inclusion of trans people, who are routinely marginalised, is important in feminism. Comedian Bisha K. Ali talks about the problem with white feminism, which is the equating of all women’s experiences regardless of skin colour, despite this aspect of identity affecting how much privilege we have. The topics sound heavy but Frances-White deftly switches

between serious and funny, helped by those regular confessions, including: ‘I’m a feminist but one time I went on a Women’s March and popped into a department store to use the loo and on the way back, I got distracted trying out face creams and when I came out, the march was gone.’ Invisible Women is a good companion book for The Guilty Feminist, providing the cold hard facts that show how unequal the world really is. In a chapter called ‘The myth of meritocracy’, Caroline Criado Perez tells the story of the New York Philharmonic Orchestra which introduced blind auditions in 1970. The proportion of women in the orchestra immediately began to grow – an orchestra that until 1970 had almost no women soon began hiring women 50 per cent of the time. In a similar story recounted in The Guilty Feminist, the world’s largest short film festival, Tropfest, introduced anonymous judging of film entries in 2017. Following this change, the proportion of women finalists rose from 5 per cent to 50 per cent. Criado Perez points to academia, and STEM in particular, as an area of abundant gender bias. Rightly or wrongly citations are one metric that academics are judged by, yet Invisible Women shows that women are cited

less than men are and they self-cite less than men do – despite papers authored by women being rated higher than those authored by men under double-blind review conditions. Many of us have marked coursework where the student has incorrectly assumed a researcher is a man. But it’s not just students – Criado Perez says that women are cited as if they are male ten times more often than men are cited as if they are women. Invisible Women recounts how students’ teaching evaluations are biased in favour of men. Men receive higher scores than women, even on speed of handing back assessments, despite there being no difference between women and men on this measure. These statistics are all the more concerning in light of those universities using student ratings as a probation or promotion marker. Both books highlight how unconscious and conscious bias leads to real world inequalities. They show the permeation of gender inequality throughout all aspects of our lives, including in medicine, wages, taxes, housework and the media. Feminists still have their work cut out to bring down the patriarchy, and these books show that they really have nothing to feel guilty about. Reviewed by Annie Brookman-Byrne, Deputy Editor

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Scpd

2020 CPD workshops Professional development opportunities from your learned Society We are pleased to launch our popular core programme and some of our workshops for 2020. Supervision skills: Workshop 1 – Essentials of supervision

14 January

Working successfully in private practice

20 January

Supervision skills: Workshop 2 – Enhancing supervision skills

28 January

Clinical skills for working with air crew

17–18 February

Supervision skills: Workshop 3 – Models of supervision

26 February

Supervision skills: Workshop 1 – Essentials of supervision

17 March

Expert witness – Part 1: Roles, responsbilities and business

26 March

Expert witness – Part 2: Writing the expert witness report for court

27 March

Supervision skills: Workshop 2 – Enhancing supervison skills

1 April

Working successfully in private practice

2 April

Expert witness – Part 3:Court room evidence

8 April

Expert witness – Part 4: Choosing, using and presenting psychometrics in court

9 April

Supervision skills: Workshop 3 – Models of supervision

21 April

The application of Rational Emotive Therapy (REBT) in sport (Leicester)

22 April

Expert witness – Part 1: Roles, responsbilities and business

30 April

Expert witness – Part 2: Writing the expert witness report for court

1 May

Supervision skills: Workshop 4: Ongoing development – supervision of supervision

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Expert witness – Part 3:Court room evidence

14 May

Expert wtness – Part 4: Choosing, using and presenting psychometrics in court

15 May

Supervision skills: Workshop 4: Ongoing development – supervision of supervision

2 June

Working successfully in private practice

22 June

Supervision skills: Workshop 1 – Essentials of supervision

30 June

Supervision skills: Workshop 2 – Enhancing supervison skills

21 July

Working successfully in private practice

7 September

Expert witness – Part 1: Roles, responsbilities and business

10 September

For more information on Supervision skills and Expert witness training and dates visit: www.bps.org.uk/find-cpd You can book on all workshops here: www.bps.org.uk/events

www.bps.org.uk/cpd @BPSLearning #BPScpd

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05/11/2019 17:03

The only series to be approved by the BRITISH PSYCHOLOGICAL SOCIETY

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05/11/2019 16:52

How would you feel if you couldn’t play? Hayley Gains visits the new exhibition from the Wellcome Collection

exhibition Play Well Wellcome Collection, London

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hen you walk into the Play Well exhibition at London’s Wellcome Collection, you will hear children’s answer to this question. ‘Bored’, ‘sad’, ‘I’d just watch TV’, ‘It would be unfair’… another child would be ‘a little bit angry’. With this in mind, you are invited to take a journey from the declaration of play as a basic human need (UN convention

on the rights of the child, 1989), to the picture of play in our current urban and digital environments. A big part of this journey is looking at the emergence of playful pedagogies. On display are beautiful examples of teacher training albums from the early 1800s. The albums are carefully crafted and guided by the principles of Friedrich Fröbel. Fröbel was a German educator who established the Kindergarten system and developed a series of play materials known as Fröbel’s gifts. Framed within the nature vs nurture debate, the display shows us that creativity and imagination can be nurtured when teachers are provided with the right tools. The exhibition also highlights that play is a powerful force in environments that are clouded by conflict. For example, in the 1940s war torn region of Reggio Emilia, citizens built a play-based school and developed a pedagogy that is widely followed and highly regarded today. In 2019, there are 800 BRAC Play Labs operating in conflict areas, such as Bangladesh, Tanzania and Uganda. Colourful photography brings this to life in the exhibition, and shows us how play can be used to build resilience, support recovery from physical injury, and be a joyful approach to emotional healing from trauma.

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the psychologist december 2019 culture A particularly touching video in the exhibition, closer to home, comes from project Wild Thing. A young boy from central London shows us a patch of grass by the road, where he takes his dog to play. The patch of grass is tiny, and you can see the shock on the presenters’ face that this is where he comes to play. In the centre of his block, the presenter asks, ‘why don’t you play here?’, and the boy explains that he will get an ASBO (antisocial behaviour order) if he plays ball games there. Something that is evident throughout the exhibition is that societal values (and periodic shifts in these values) are reflected in the time and space we give to play and the toys that we produce. In early LEGO advertisements, you can see boys and girls being equally rewarded for their ingenuity. Conversely the Barbie Liberation Dolls lead an impassioned crusade against the deeply gender stereotyped utterances of Barbie and Ken. A recent campaign, ToyLikeMe, is making further calls for the toy industry to reflect values of diversity and inclusivity, by producing toys with disabilities and realistic, healthy body proportions. If any more evidence is needed for the importance of play, the exhibition informs visitors of world leading research being carried out by academics at the University of Cambridge and University College London. Project HOPSCOTCH (Hi-tech Observation of Play and Social Communication Trajectories in Children) used tracking devices to show that the introduction of simple play materials increased the social interactions of children and tended to make groups more diverse and inclusive. The Play Well exhibition reminds us to be grateful for play. When nurtured, children and adults alike learn to communicate, express emotions, use imagination and experience joy. Despite the natural propensity to play, we must not forget the need to dedicate time, space and thoughtfulness to this powerful expression of self. Reviewed by Hayley Gains, a postgraduate student at the University of Exeter, and one of our Voices In Psychology programme winners. ‘Play Well’ is on until 20 March 2020. Admission is free. Find out more at https://wellcomecollection.org/ exhibitions

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Why so serious? that Joker is stigmatising in terms Being an aspiring clinical of mental health, yet in my eyes it is psychologist and a fan of superhero actually quite progressive. We see films, I was excited for the release how Joker’s mother was of Joker, which follows beaten by her abusive the story of Arthur film partner and developed Fleck, a man living in Joker traits of psychosis as a a dystopian Gotham Todd Phillips (Director) reaction to the trauma. around the 1980s. We Mrs Fleck creates a see how society’s most grandiose delusion vulnerable groups are in which she was in love with her living in dilapidated housing projects, boss, who fathered her son Arthur. and how funding cuts for social To her, this was a way of escaping services impact those vulnerable to her reality of chronic abuse and a isolation. A revolution is in the air as the tension between the rich and poor lack of control. We also discover that she was given the label of grows, catalysed by a Trump-like ‘Narcissistic Personality Disorder’ figure blaming the poor for their own in wake of her abuse, which really poverty and calling them ‘clowns’. provokes feelings of sympathy for her What I like most about this film plight. There is another particularly is actually the cause of most of the poignant scene in which a woman on controversy surrounding it. Joker a bus becomes irritated by Arthur’s is a tale of how adverse childhood experiences (ACEs), social isolation and marginalisation can lead to bleak life trajectories, including criminality. The criticisms claim that ‘incels’ – the ‘involuntarily celibate’ online subculture characterised by their resentment towards females, and males they perceive as more sexually successful as themselves – will see Joker as a rallying cry. I believe that there are two logical involuntary laughing, caused by his pseudobulbar affect (a type of explanations for these negative emotional disturbance which occurs reviews. The first is that it is easier secondary to a neurological disorder to blame movies and video games or brain injury: it is suggested that for mass shootings than poor gun Arthur suffered a brain injury as a control policies, despite the lack of result of the beatings he received evidence supporting this. The second from his mother’s partner). This is that accepting that environmental scene expertly illustrates the and societal factors can, in extreme frustration and helplessness that cases, lead to such outrageous involuntary mental health conditions acts as homicide, is a bitter pill to can cause the sufferer. swallow. In other iterations, including Of course, so many superhero cartoons aimed at children, the films have been based on the Joker has been depicted as being a premise that childhood suffering mentally unstable clown who was has been the motivation for heroes ‘created’ when he fell into a vat of to take charge of their destiny and boiling chemicals. Whilst it may better themselves. Whilst this be more uncomfortable to accept is a lovely concept which does that societal failures create mental on occasion play out in real life health problems, it is surely less – consider the research on poststigmatising for those who have to traumatic growth – we know from live with them on a day-to-day basis? studies on ACEs that childhood adversity is more likely to take you on Reviewed by Aaron Howard, Assistant a negative life trajectory. Psychologist Some critics have suggested

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Based on a hundred true stories ﬁlm The Day Shall Come Chris Morris (director)

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Shining a spotlight on the FBI’s bizarre entrapment and incrimination processes, the latest film from director Chris Morris (The Day Today, Four Lions) and writer Jesse Armstrong (Peep Show, Succession) is a comedic but uncomfortable look into the intersection between terrorism, race, mental health and vulnerability in modern America. It’s easy to dismiss the title sequence assertion ‘based on a hundred true stories’ as a device – a flippant response to the plethora of true crime inspired programming that has exploded onto our screens in the last few years. This is particularly easy to assume with a film from the pen of the famously glib Morris. But The Day Shall Come is, in fact, based on a hundred true stories. Morris was inspired to research the film after stumbling upon BBC coverage of the ‘Liberty City Seven’ back in 2006. This was a group of black, mainly Haitian catholics, who planned to ride into Chicago on horseback and collapse the Sears Tower, drowning the city in its ensuing tidal wave. Then attorney general Alberto Gonzalez called the plot ‘a full ground war on the United States’, but the reality was these men didn’t have any explosives. Or even horses. They did, however, have money that was offered to them by FBI informants posing as ‘Al-Qaeda operatives.’ Speaking to Adam Buxton on his podcast, Morris described the film as an exploration of the ‘elaborate mechanism for incriminating people who are not terrorists’ – those living eccentric lives on the fringes of mainstream society who show enough of a dislike for the government to place them on the FBI’s radar. In the film, Moses (Marchánt Davis) runs the ‘Star of Six’ farm commune in Miami, speaking of ‘black jihad’ and worshipping, amongst others, ‘black Santa’ – who we see fully realised when Venus (Danielle Brooks) colours a statuette with acrylic paint. Moses is obviously struggling with his mental health and throughout the film we see both explicit references (his medication) and more surreal indications (several conversations with talking animals). His declining mental wellbeing makes him perhaps an obvious target for entrapment, but any factors which increase vulnerability and therefore

Reviews online: Find more reviews at www.thepsychologist.org.uk/reviews, including: Tell Me Who I Am, Scarefest at Alton Towers, Who Are You Calling Fat, and a series of ‘monomyth’ themed EPs from electronic artist Russian Linesman…

gullibility are exploited by the FBI in real cases: mental health, substance abuse, youth, and being easily led are amongst the many characteristics that make individuals susceptible to these controversial operations. The FBI’s confected terrorism agenda relies on informants, portrayed in the film as equally vulnerable, if not quite as likeable, characters who have in this case committed crimes and face extradition from the USA. These informants offer money and weapons to smallscale operations like Star of Six in order to further their agendas, often in directions they didn’t intend to take them. This increases their ‘threat’ level and enables the FBI to run elaborate sting operations and make victories in the ‘war on terror’ launched after the events of 9/11. Morris and Armstrong’s skill here is that they enable the audience to really get on board with Moses and feel angry about what’s happening to him in the face of his obvious struggles with his mental health. His ‘army’ is made up of four people who have a crossbow and a dilapidated building they can’t make the rent for as HQ. Juxtaposed with the ‘personality disorder’ of an office block housing the FBI (this is the real FBI field office in Miami) with their Nerf gun warfare and outdated machismo, it’s difficult to see which of the two is supposed to be the professional operation. It’s all too apparent which holds the power. The way the FBI is represented here might be over the top, but Morris spent time with the FBI to understand their team dynamics. Kendra (Anna Kendrick) is a representation of those who join the FBI and struggle with its contradictory stance on human rights but perhaps succumb to the numbing inevitability of working for a powerful institution of its size. Groupthink might now be a questionable theory but there’s something displayed here about the camaraderie induced by working in such a high stakes job that carries people along… values and morals trailing behind as a sticky afterthought. One criticism Morris has faced at promotional Q&A’s across the UK is that all of the black characters are eccentric. Morris argues that this isn’t a film about representation in the way that Hamilton or Black Panther are; it is barely even a parody of the truth it seeks to expose. The characters are eccentric because that’s the reality of those who are targeted: those who are ‘othered within others’. Black audience members laugh ironically from the start as their lived experience is writ large on screen, something that their white counterparts try but fail to grasp until the sobering impact of the final showdown. The difference in the perception of threat is palpable throughout the film, until the tension in this masterful final section builds to a universal experience of the outcome all too apparent to everyone but Moses. Parody? Pastiche? Perhaps the most difficult outcome of all is that Morris has so cleverly blindsided audiences with the truth. Reviewed by Beth McManus, a freelancer and one of our Voices In Psychology winners.

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the psychologist december 2019 culture

With support, there is life after addiction This is a one-off programme by addiction specialist Sally Marlow (and – full disclosure – my coAssociate Editor for this section of The Psychologist). Sally is also a Public Engagement Fellow at King’s College London, and this pithy half hour demonstrates why she is well suited to that role. Explaining the psychology and neuroscience behind addiction is not easy, but the programme squeezes in the salient points: namely, the complex interplay between genetics, social support and environment which can make one person addicted, but the next person not. The programme is woven through with interviews with people recovering from addiction. Whilst there’s

variation in the drugs used, the themes of neglect, poverty or abuse are consistent. Different response to different types of drugs may have a root in genetics, but if that drug is not available, or too expensive, then an individual is much less likely to become addicted. The explosion of cheap heroin and benzodiazepines in places such as Liverpool and Glasgow in the 1980s, for example, created a whole addicted generation. Availability and price are also both signiﬁcant factors when it comes to legal drugs such as tobacco and alcohol. The programme also considers the efﬁcacy of addiction treatment, and why it’s not a cure. Although the

drug may leave your brain and body, long-lasting automatic behaviours are not completely reversible. And drug and alcohol addiction rates are still sky high, despite all we know about addiction and the treatments which are available. But this is against a background of up to 80 per cent cuts in treatment services, which are also fragmented, and challenging for individuals to access. Fundamentally, those with strong social support systems are much less likely to relapse than those who do not have them. But with that support, there is life after addiction.

radio The Science of Addiction BBC Radio 4

Reviewed by Kate Johnstone, Associate Editor for ‘Culture’

A gentle upwards spiral For any newcomers to the series, it is worth pointing out and striving to make the world a better place from her that BoJack Horseman is actually a comedy. Whilst it can own uniquely cynical viewpoint. Beginning the season be incredibly bleak at times and deals with some hardtravelling to make videos for blog Girl Croosh, Diane ends hitting themes, it can also at times have a very up navigating a new relationship in a new city light touch and be extremely charming. You and finally determines to write her book. should also be aware that the leading character Princess Carolyn, a pink cat who is tv of this animated series is literally a horse-man. BoJack Horseman: BoJack’s former agent, has successfully In BoJack’s world, humans co-exist with achieved her dream of becoming a mother but Season 6 – Part 1 a variety of anthropomorphised animals. finds that it is more difficult to balance work Netflix Picking up from where the last season left off and parenthood than she had expected. The as BoJack checks into rehab, determined to episode depicting Princess Carolyn’s frantic confront some of the more questionable choices in his efforts to juggle the numerous competing demands on life, Season 6 delves deeper into the lives, relationships her time will ring a bell for many working parents. and (often fairly dark) pasts of BoJack, Diane, Princess Season 6 continues the show’s engaging exploration Carolyn, and the rest of the ensemble cast. of the dysfunctional relationships between the main Clinging to his fame from being in a TV show in the characters, with the final episode beginning to bring 90s, BoJack is now a washed-up actor. He lives a lifestyle together elements from earlier seasons. Things at last steeped in drugs and alcohol. The depiction of BoJack, seem to be going reasonably well for BoJack, but can this as he comes to terms with his substance abuse, follows last? him from his initial feelings of dejection through a gentle upwards spiral towards recovery. The show explores Reviewed by Laura Oxley, PhD student with the Psychology BoJack’s relationship with drugs and alcohol, revealing in Education Research Centre at the University of York and how he has used substances to help him cope with one of our Voices In Psychology winners. stressful situations. Alongside the substance abuse problems, BoJack has some serious attachment issues, judging from the glimpses we get into his childhood home life. His father was a distant workaholic and his mother was neglectful, bitter, and constantly putting BoJack down. Both of his parents were heavy drinkers, and BoJack has adopted many of the same addictions and sense of bitterness as BoJack Horseman was a his parents. suggestion in response Meanwhile, BoJack’s human friend and one-time to this poll we ran on ghost writer, Diane, continues her search for happiness Twitter

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Shining a light on ‘what asylums were’ Jonathon Rutherford on the atrocity of mental health care in the early 19th century

psychiatric reformer, Dr William Alexander Francis Browne was a superb asylum superintendent, later to become the Commissioner for Lunacy in Scotland (1857) and president for what today is named the Royal College of Psychiatrists (1866). The early- to mid-19th century was an epoch for psychiatry in Britain, as superintendents like Browne introduced pioneering art and occupational therapy programmes to once barren asylum life. At the Crichton Royal Hospital in Dumfries, Browne was a radical alienist who provided language classes, dances, public readings and a literary magazine contributed to by his patients. An early adopter, Browne introduced gaslights to the asylum building during the dark winter evenings; this was uncommon as most people during the early 19th century were distrusting of gas lighting because of its potential to explode. Ultimately Browne’s attempts to change the treatment of his patients did not result in an efficacious cure for the mentally ill, but his visionary mindset and inspiring optimism did pave the way to a gentler form of treatment. But what were the conditions of asylums that inspired Browne to seek change for his clients?

In May 1837, Dr William Alexander Francis Browne presented five lectures to the managers of the Montrose Royal Lunatic Asylum in Angus. The third, entitled ‘what Asylums were’, gives us an understanding of why philanthropists saw the need for change. Their ‘glass half-full’ mindset on psychiatric reform is still useful today. 74

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Outcasts and Tom o’ Bedlams Before the ‘insane’ and ‘imbecilic’ were confined to asylums, ‘madmen’ on the continent of Europe were expelled from society as outcasts. They were seen as unworthy of care or compassion, until a catholic priest, St. Vincent de Paul (1581-1660), sought to return the sympathies of our nature towards the poor and outcast, unofficially obtaining the title ‘father of the poor’. His philanthropic exertion ultimately spread the practise of lunatics confiding in the church. Parishioners took responsibility for the care of imbeciles and insane persons. However, a larger proportion of the insane were taken care of by their immediate family, or left to roam local towns and the surrounding areas.

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the psychologist december 2019 looking back

Prior to 1828, only 12 of England’s 52 counties possessed public establishments for the insane and until 1808 there was only one asylum in Ireland. To relieve the few institutions that did exist, patients were customarily discharged. London’s Bethlem Hospital discharged patients long known as Tom o’ Bedlams to survive as glorified paupers, ‘living no one cared how, and dying no one cared where’. Those deemed ‘docile’ or ‘inoffensive’ were confined to workhouses, gaols or vagrancy. The noisy or frenzied madmen were condemned to the darkest dungeon the gaol or workhouse could afford. Many of these people became enclosed in wooden boxes or cages placed into cellars. In the French city of Lille, patients were confined to subterranean holes. At Saumur they lived in cells with no windows. In 1834, on visiting a gaol in England, Solicitor general

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A.E. Menteith found one ‘maniac’ to have lived in a subterranean dungeon for half a lifetime. A select committee for the Lunatic Poor in Ireland (1817) describes, ‘For the accommodation of the insane… in the Limerick Asylum, appears to be such, as we should not appropriate for our dogs-kennels’. Muffling and forcing Sedative medication introduced in the mid 20th century, such as lithium in 1948, stabilised mood; the antipsychotic chlorpromazine, introduced in 1952, was a revolutionary treatment for schizophrenia. However, before tranquilising medication, the infallible remedy for soothing the ‘witless maniac’ was intimidation. To obtain tranquility keepers resorted to ‘muffling’ through binding a cloth tightly around the mouth

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Exhibiting the insane and nostrils. Less creative methods included lashings George Wombwell in 1810 founded ‘Wombwell’s and beatings. A surgeon stated in evidence before a committee for the House of Commons, that on visiting traveling menagerie’. Touring across Britain, Wombwell exhibited rare animals, often from the warmer climate an asylum he witnessed a keeper ‘beating in the most of Africa. His shows included elephants, tigers, ocelots brutal manner a captain in the navy… confined by a and bears, drawing great curiosity from the general means of chains on his legs and hand-cuffs, so that public. In Bedlam, the insane were displayed to the he could neither escape nor defend himself… he same public for one shilling. Their guardians spared died shortly afterwards’. Corporal punishment was ‘neither menaces nor sarcasms in order to rouse the a method of controlling the ‘insane person’ or was sadistic enjoyment for deranged keepers. In either case passions of the patients for the amusement of the visitors’. ‘Imbeciles’ were deprived of food in order to it was not uncommon to subject the mentally ill to astonish spectators by the patient’s voracity when it physical cruelty. was finally given to them. One ‘miserable creature’ who Often patients refused to eat. They suspected food habitually ate his own excrement was fed weeds, grass, was poisoned, or imagined it to be human flesh. They dirt and filth for the curiosity of resisted because of ‘obstinacy’ spectators. Exhibiting the insane or their ‘perversity of character’. to the public was a practise well ‘Forcing’ became the treatment “It was stated, when the established throughout Britain and for these difficulties as patients keepers were asked the France. How debauched humanity were bedbound. Food was pushed or poured down the throat. At reason for putting them in can be to the most vulnerable. and keepers used times teeth were broken or the irons, that it would require the Governors ‘excitement of terror’ as remedy, handle of the spoon used as the a larger expense than frightening the patient ‘into his instrument for the operation was forced through the palate. The head they could afford to keep senses’. This treatment was thought to redirect the patient’s attention was bent backwards to facilitate servants to take away from delusions and fantasy, the food’s descent and this meant care of them if they grounding the patient back in sudden or powerful movement the ‘real world’. For example, at could lead to dislocation of the were not ironed” the Senavretta in Milan, keepers neck’s vertebrae. Should the patient constructed an apartment where die, no coroner’s inquest took place patients could be placed in light to reveal the story. or plunged into darkness; rain Many patients, particularly the could descend from the roof and thunder frightened furious or unstable, were clasped in iron. For example, confined patients. Neglect was ubiquitous in establishments in Rome fixed two iron rings to the asylums… ‘idiots and imbeciles’ are described to have wall of a cell; one of these served as a collar for the lost limbs to gangrene caused by cold. In Bedlam Sir A. neck, the other closed around the ankle. This method Halliday describes how ‘he saw… a rat devouring the forced the patient to stand tied upright, and should extremities of a maniac, who was lying naked on some they give in to exhaustion, the patient would hang straw, in the agonies of death’. suspended. This practise was reserved for the poor, In France during the rule of the revolutionary and the reasoning was not curative, but economical. government, food allowances to lunatics in asylums ‘It was stated, when the keepers were asked the reason were reduced to the smallest amount necessary to for putting them in irons, that it would require a larger sustain life. This caused patients in remission to expense than they could afford to relapse and ‘become frantic with hunger’; mortality keep servants to take care of them if increased greatly. In the Salpêtrière, 56 patients died in they were not ironed.’ Key sources one month. In some asylums patients were ‘confined in out-houses which were formally pigsties, sleeping Browne, W.A.F. (1837). What asylums in cribs so small, as to cause permanent contraction of were, are, and ought to be, being the the limbs’. Another example details ‘three miserable, substance of five lectures delivered before emaciated beings, huddled together in a bed intended the managers of the Montrose Royal for one person, without any straw or covering’; and Lunatic Asylum. Edinburgh: Black. still ‘a number of weak and diseased men should be Donelly, M. (1983). Managing the mind: compelled to sleep in a damp cellar containing a well’. A study of medical psychology in early nineteenth-century Britain. London: Tavistock Publications. Scull, A. (2015). Madness in civilisation: A cultural history of insanity, from the Bible to Freud, from madhouse to modern medicine. New Jersey: Princeton University Press.

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The removed These atrocities depict the nature of care for the insane prior to 1837. No curative attempt was made; patients were considered wild beasts to be tamed and so received no ‘gentle’ form of support.

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the psychologist december 2019 looking back

In many cases cruelty and neglect was so extreme it resulted Jonathon in patient deaths. The cause Rutherford taking place. This shows the callous could be varied: starvation due is a Northumbria indifference superintendents had for to deficient rationing, infection University MSc the wellbeing of their patients. and disease including syphilis, Health Psychology For Browne and other alienists typhoid, and gangrene. Insufficient student and a of his generation, the care for heating, clothing and furnishings Bangor University insane persons was spurred by their meant insane persons died from graduate. philosophy, the moral treatment, pneumonia. Keepers who lost summed up in two words, ‘kindness their temper could beat patients and occupation’. Browne idealised Twitter @JonnyRutherford to death with no repercussions. In a vision of purified water, sufficient Email jonnyrutherford@live.co.uk a report presented to the public food, separating the catatonic and by superintendents of the York melancholic from the furious, and institution, it appeared in one instance that 221 an ample supply of hot baths. Those deemed suitable patients had died in their facility. When investigated can freely egress to the open air; allotments and this was proven to be 365 deaths – 144 unaccounted gardens are to be enjoyed by the patient. Clothing is for. The institution was accused of being directly to be regularly washed and attended, patients play on involved in a cover-up. One person stated: ‘A patient bowling greens, and they even take language classes; disappears, and is nevermore heard of; he is said to all this in an attempt to create an atmosphere where be removed. A patient is killed, the body is hurried tranquillity reins. The asylum should conjure images away, to prevent the coroner’s inquest.’ A York county of serenity in the mind akin to happiness. All these magistrate made the argument that patients were killed therapeutic measures are idealised in the ‘perfect by the fury of the keepers, and then were reported to asylum’. have died. In response superintendents attempted to Today, asylums have been deinstitutionalised ‘bury these and other malpractices into oblivion’ by for care in the community. Asylum history remains burning the registers. The building was then set on fire profound; it allows us to appreciate humanistic and was almost completely consumed in flames. The development and guides us away from the mistakes of fire put all patients in danger with at least four deaths the past.

Looking back Since 2008 we have featured articles on the history of psychology and the psychology of history. These are all collected at https://thepsychologist. bps.org.uk/lookback

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We dip into the Society member database and pick… Asweeni Jansdin Raj who is an Assistant Psychologist at The Brain Injury Rehabilitation Trust One moment that changed the course of your career When I was in my second year of university, I started volunteering at Headway Nottingham. I am grateful that I was able to work with some incredible service users and staff who enabled me to complete two research projects and inspired me to further explore clinical psychology and neuropsychology. One regret Failure to anticipate the difficulties that my surname Jansdin Raj would cause. It’s not hyphenated. I don’t have a middle name, but many people assume Jansdin is my middle name and Raj is my surname. One TV show recommendation Anyone who is a fan of the 1960s film Psycho should watch Bates Motel on Netflix. The writers, Vera Farmiga and Freddie Highmore, did an amazing job showing the audience how mental health problems such as Schizophrenia and Dissociative Identity Disorder develop as well as other disorders. I personally found Norman’s outcome very sad and tragic. If social services were involved at an early age, it may have prevented his breakdown later in life. The example of this fictional character is very realistic to those with a past history of abuse or trauma and it highlights the importance of seeking the right support service. One article from The Psychologist or Digest I really like the Research Digest. Matthew Warren’s article entitled ‘When people close to us behave immorally, we are inclined to protect them – even if their crimes are particularly heinous’ is a great read. It’s difficult to say what you would do in that situation but it’s fascinating to consider what others would do, for example, Norma Bates in Bates Motel protecting her son despite knowing what he’s capable of.

One alternative career path Working with animals. Since watching Blue Planet 2, like many, my awareness of plastic pollution has increased, and I would love to

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one on one

help animals who are helpless due to human errors.

One tool Leaving work at work can be tough when you’re working with people with brain injuries and mental health problems. The Calm app has been my go-to tool when I need to destress or even practice mindfulness. The Calm app consists of guided meditations, narrated Sleep Stories and videos. It has led me to incorporate mindfulness meditation every day and I finally have the opportunity to listen to bedtime stories!

One thing you are proud of Practice what you preach comes to mind. Applying mindfulness techniques into everyday life and activities helped me become a better facilitator of a Mindfulness Group that I designed and implemented for individuals with brain injuries and mental health problems. One thing that you would change about psychology Promoting other pathways and careers to students during their time at university. One nugget of advice for aspiring psychologists Help each other along the way. At times it may seem that there is so much competition in this field. Competition to get Assistant Psychologist posts. Competition to get on to the Clinical Psychology Doctorate course. I have been fortunate enough to know some great psychologists who are at different stages in life but always happy to help. We are all on the same journey, but we may take different paths.

coming soon… what makes a psychologist? Our ‘Voices In Psychology’ winners. Plus all our usual news, views, reviews, interviews, and much more... contribute… reach 50,000 colleagues, with something to suit all. See www.thepsychologist.org.uk/ contribute or talk to the editor, Dr Jon Sutton, jon.sutton@bps.org.uk, +44 116 252 9573 comment… email the editor, the Leicester office, or tweet @psychmag to advertise… reach a large and professional audience at bargain rates: see details on inside front cover maybe you missed… …December 2014,’women scientists in psychology: time for action’ …Search it and so much more via www.bps.org.uk/thepsychologist psy 12_14 pOFC_Layout 1 17/11/2014 12:00 Page 1

the

psychologist vol 27 no 12

One quote ‘Don’t take yourself too seriously. Know when to laugh at yourself and find a way to laugh at obstacles that inevitably present themselves.’ Halle Berry. One interesting thing about my job You quickly learn to be more than just an Assistant Psychologist.

december 2014

Women scientists in psychology – time for action Fionnuala Murphy, Dorothy Bishop and Natasha Sigala

Incorporating Psychologist Appointments £5 or free to members of The British Psychological Society

letters 896 news 904 careers 968 looking back 982

educating Europe 928 psychological literacy 932 the rise of student consumerism 940 interview with Walter Mischel 942

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Society Trustees www.bps.org.uk/about-us/ who-we-are President David Murphy The British Psychological Society was founded in 1901, and incorporated by Royal Charter in 1965. Its object is ‘to promote the advancement and diffusion of a knowledge of psychology pure and applied and especially to promote the efficiency and usefulness of Members of the Society by setting up a high standard of professional education and knowledge’.

President Elect Dr Hazel McLaughlin Vice President Vacant Honorary General Secretary Dr Carole Allan Honorary Treasurer Dr Roxane Gervais Chair, Education and Training Board Dr Juliet Foster Chair, Practice Board Alison Clarke Chair, Public Policy Board Vacant Chair, Research Board Professor Daryl O’Connor Co-opted Trustees Dr Chris Lynch Professor Clifford Stott Dr Ester Cohen-Tovee Christina Buxton Dr Adam Jowett

society notices BPS Practice Board application deadline 6 Jan 2020 See p.16 DCP Annual Conference Solihull 22-23 Jan 2020 See p.22 Presidential Taskforce on Diversity and Inclusion See p.33 BPS conferences and events See p.41 Cyberpsychology Conference Nottingham 7-8 Jul 2020 See p.47 Poverty to Flourishing Expert Reference Group See p.47 DFP Annual Conference Solihull 16-18 Jun 2020 See p.66 CPD workshops 2020 See p.79

Find out more online at www.bps.org.uk psy 1219 p80 motm.indd 81

Chief Executive Sarb Bajwa Change Programme Director Diane Ashby Director of Communications and Engagement Rachel Dufton Director of Finance and Resources Harnish Hadani Director of IT Mike Laffan Director of Membership and Professional Development Karen Beamish Director of Policy Kathryn Scott Head of Legal and Governance Christine Attfield

The Society has offices in Belfast, Cardiff, Glasgow and London, as well as the main office in Leicester (St Andrews House, 48 Princess Road East, Leicester, LE1 7DR).

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