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The aware mind in the motionless body Martin Monti and Adrian Owen go looking for consciousness
Incorporating Psychologist Appointments ÂŁ5 or free to members of The British Psychological Society
forum 450 news 458 careers 516 looking back 534
our emotional neighbourhoods 474 raising school attendance 482 reimagining our school system 486 talking therapies with David Clark 488
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The British Psychological Society Contact The British Psychological Society St Andrews House 48 Princess Road East Leicester LE1 7DR tel 0116 254 9568 fax 0116 227 1314
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forum giving voice to the voiceless; black women in the UK; politics; and more
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THE ISSUE
news, digest and media social science and family politics; new child development unit; brain waves project; nuggets from the digest; and media coverage from the conference
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conference reports from the Society’s 2010 Annual Conference in Stratford-upon-Avon
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Our emotional neighbourhoods Peter Totterdell, Karen Niven and David Holman look at how social networks can regulate what we feel
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Raising school attendance Anne Sheppard asks whether legal sanctions can really be the answer to problems of truancy
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Reimagining our school system Anthony Montgomery and Ian Kehoe ask why schools get so little attention from organisational psychology
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Talking therapies Tony Roth talks to David Clark about his pivotal role in IAPT, and more
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Earlier this year, when Adrian Owen’s team were all over the news following their apparently successful attempts to communicate with patients who had been classified as in a vegetative state (see p.478), I read an account from a similar case. It was horrendous: the visits from relatives slowly drying up, a fly crawling across the ceiling considered a good day. As psychologist Chris Frith has said, ‘It is difficult to imagine a worse experience than to be a functioning mind trapped in a body over which you have absolutely no control.’ So surely anything that psychologists can do to ‘give a voice to the voiceless’ should be welcomed? Not all psychologists are convinced. On p.450, Celia Kitzinger offers a measured response and calls for psychologists to become more critically engaged in the issues the research raises. Dr Jon Sutton (Managing Editor)
DUNCAN PHILLIPS/REPORTDIGITAL.CO.UK
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book reviews 494 how science works; predicting and changing behaviour; research methods; the psychological contract; living with voices; and communication disorders society President’s column; Doctoral Award; and more
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516 careers the psychology of industrial safety, with Tim Marsh; a route to counselling psychology work in a Greek Family Care Centre, with Stefania Papadaki; featured job; and how to advertise looking back 534 a lifetime of achievement in occupational psychology: Hazel Stevenson meets Sylvia Downs one on one …with David Lavallee
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The aware mind in the motionless body Martin Monti and Adrian Owen go looking for consciousness 478
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‘Giving voice to the voiceless’ – high-tech speculation, or basic respect? basic assumption that increased blood flow to the brain is an accurate surrogate for consciousness (see Poldrack, 2006). There is also often no acknowledgement that for severely brain-damaged MCS patients ‘consciousness’ does not mean an
intact cognition, the capacity to weigh up different clinical options, or to ‘converse’ with caregivers about treatments and to make decisions. The recent jubilance about fMRI scanning feeds into a culture of misunderstanding encouraged by false media reports about patients diagnosed as vegetative being able to type complex sentences (as in the recent case of the much-publicised Belgian ‘coma writer’, Rom Houben) or grossly inaccurate films featuring patients waking up from even prolonged comas with fully intact cognition. In fact, the prognosis after prolonged coma, vegetative and MCS states is bleak; for example, ‘there are no reports of patients in a vegetative state identified as “conscious” by functional neuroimaging making a recovery to functional independence’ See p.478 for Martin Monti and Adrian Owen’s article on (Wilkinson et al., 2009, consciousness and the vegetative state p.509). TIM SANDERS
Our sister is one of the so-called ‘living dead’ referred to in your news report (‘Mind of the living dead’, March 2010). Serious brain injuries sustained over a year ago left her first in a coma and now in a minimally conscious state (MCS) from which she is extremely unlikely to recover. We read your report with dismay, since we do not share your excitement about the ‘amazing’ findings emerging from brain-imaging research and we feel that psychologists should be more critically engaged with the wider issues such research raises. Your report seemed to reflect and reiterate, rather than challenge, some of the uncritical reporting so often evident in mass media coverage of this topic (Racine et al., 2006). Although the New Scientist and Independent– in the two articles you cite – were better than most, their headlines are hardly, as you claim, ‘justified’, but instead typify the overblown claims that often accompany reporting about brain imaging. We challenge the notion that imaging allows scientists to ‘read minds’ (the Independent’s headline) or that it provides ‘A voice for the voiceless’ (New Scientist). Uncritical summaries of this field fail to address the limitations of brainimaging technology or to challenge the
Black women in the UK – the last of the impostors?
contribute
A series of writings in The Psychologist has led me eventually to write this letter that I have been reminding myself to write for about 15 years now. Firstly, it was a recent edition about mothers with a colour photograph of a black woman but making no specific mention of black mothers/infants; then it was Yvonne Walsh’s letter ‘Applied discrimination?’
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These pages are central to The Psychologist’s role as a forum for discussion and debate, and we welcome your contributions.
(May 2010) commenting on the omission of mentions of counselling psychology in a recent special edition of The Psychologist on social inclusion; and finally Christian Jarrett’s article ‘Feeling like a fraud’ (May 2010) about females ‘masquerading’ as males and having a corresponding fear of ‘being found out’ (as not being viable practitioners and scientists). As part of
Send e-mails marked ‘Letter for publication’ to psychologist@bps.org.uk; or write to the Leicester office.
this article, there was a photo of a female named Dr James Barry with her (black male) servant and her dog Psyche. My concern has for many years now been the invisibility of the psychology of black women in Britain and elsewhere in the world in The Psychologist. Do we have a psychology that is distinct and relevant to be commented on in UK psychology
Letters over 500 words are less likely to be published. The editor reserves the right to edit or publish extracts from letters. Letters to the editor are not normally acknowledged, and space does
not permit the publication of every letter received. However, see www.thepsychologist.org.uk to contribute to our discussion forum (members only).
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We believe that ‘giving a voice’ to such patients (to use neurologist Steven Laureys’ phrase in the New Scientist report) should not simply be pursued by expensive fMRI scanning – with whatever remote ‘hope’ that offers. Instead (or as well) it requires more basic listening skills – and psychologists already have a key, albeit often neglected, role to play here. Our sister’s ‘voice’ was, for many months, expressed mainly through grimaces of pain, moaning or frantic kicking, and her opinions before brain injury were clearly articulated in her poetry, letters and conversations with family and friends. Ensuring that her voice is heard means paying attention to these more transparent indications of what she might now want – we do not need brain imaging to understand this. Unfortunately we have found that public enthusiasm for research that ‘listens’ (via fMRI) to patients answering questions about their father’s name by imagining a tennis game [see p.478] is matched by professionals’ total lack of interest in patients’ clearly expressed values and beliefs. For the first 11 months our sister’s clinical team never asked about what our sister might want in this situation, nor did they take seriously the efforts of family and friends to communicate this. The Mental Capacity Act 2005 is supposed to put the person who lacks capacity at the centre of any decision making about them. It builds on a strong disability-rights perspective and on the long experience of organisations of, and for, people with mental incapacities of all types. The Act spells out the fact that ‘best interest’ decisions about medical
treatment, for example, are not purely clinical: they are supposed to take into account the person’s past and present wishes and feelings. There is a crucial place for psychologists here. Psychologists can support families and friends to ‘give a voice’ to incapacitated patients by ensuring that we distinguish between what we might want for ourselves, or for the patient, and what the patient might want for herself. Psychologists can support families and friends to articulate the patient’s views and help decision makers to take these views into account in decisions about the patient’s best interest. The Mental Capacity Act, and the values that underpin it, are not as ‘sexy’ as the supposedly dramatic findings revealed by fMRI. However, ensuring that all psychologists understand the Act and help to implement it, is a key place to start if a patient’s voice is really to be ‘heard’. Only then can we hope to reinstate ‘A voice for the voiceless’. Professor Celia Kitzinger University of York Professor Jenny Kitzinger Cardiff School of Journalism, Media and Cultural Studies, Cardiff University References Poldrack, R.A. (2006). Can cognitive processes be inferred from neuroimaging data? Trends in Cognitive Sciences, 10, 59–63. Racine, E., Bar-Ilan, O. &Illes, J. (2006). Brain imaging: A decade of coverage in the print media. Science Communication, 28(1), 122–143. Wilkinson, D.J., Kahane, G., Horne, M. & Savulescu, J. (2009). Functional neuroimaging and withdrawal of life-sustaining treatment from vegetative patients, Journal of Medical Ethics, 35, 508–511.
journals in general and in The Psychologist in particular? Or are we impostors too (or am I), for trying to make a special case for a feature on psychological research involving black females in the UK, when in fact there are no specific psychological issues for black females in the UK, being no different from white or other ethnic groups of women, indeed no different from any other groups at all? The editor of The Psychologist assures me that a special issue on psychology and black and minority ethnic groups is in the planning stages. However, I would also echo the sentiments of Yvonne Walsh that at the very least the editors should be asking for some reference to wider groups
even if it is to direct readers to more ‘specialist’ reading that cannot be taken fully on board in the limited writing space that is available to contributors. Dr James Barry – said to have practised in the 1800s – would have had to wait until only just over 30 years ago to be considered equal to her male counterparts. Like many others I am very proud to be a British-trained applied psychologist, but I remain concerned that for some areas of research, UK psychology does appear to be rather slow in advancing to the 21st century. Jeune Guishard-Pine Harrow
read discuss contribute at www.thepsychologist.org.uk
Wot, no politics? I was surprised to see that the May edition of The Psychologist was not a little more politically engaged, considering that there was an election on and the inevitable cuts that will affect mental health because of the deficit. I wonder why psychology as a profession is so unwilling to engage in political debate when it can be claimed that ‘politics in psychology is inescapable’ (Fox & Prilleltensky, 1996). By including Jo Silvester’s article the magazine seemed to try to step outside of politics and turn a ‘scientific’ eye on the individual politician instead of confronting the reality that mental health has always been the soft option when it comes to slashing funding in the public service. If The Psychologist really aims to promote the advancement and diffusion of a knowledge of psychology, does that not include the welfare of the individuals we are supposed to be working with as clinical, counselling, educational, forensic and occupational psychologists, all of whom will be affected by public service cuts? Should the welfare of these individuals, and our duty of care, not come first instead of openly admitting in a respectable magazine that all psychology has to show when it comes to politics is how to McDonaldize a selection process? Psychology does not exist outside the social and cultural context of which it operates, and can therefore never be apolitical. When asked why critical psychology always tries to make everything into a political issue, Ian Parker (2007) replied: ‘The problem is not that we make psychology political, but that it already is political, and this is something mainstream psychology does not like to acknowledge’ (p.5). Perhaps there is a need to acknowledge this in an open forum such as The Psychologist and engage with what this entails. Patrick Larsson London N7 References Fox, D.R. & Prilleltensky, I. (1996). The inescapable nature of politics in psychology: A response to O’Donohue and Dyslin. New Ideas in Psychology, 14(1), 21–26. Parker, I. (2007). Critical psychology: What it is and what it is not. Social and Personality Psychology Compass, 1(1), 1–15.
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The happiness goal The football World Cup in South Africa is almost upon us and the clock is ticking down on London 2012. It’s a timely moment to ask: Why, when it costs a country billions of pounds to host a major international sporting event, do they bother? The usual argument is that it’s all about the legacy – the lasting economic benefit. But according to two economists, Georgios Kavetsos and Stefan Szymanski, the evidence for this simply isn’t there. Instead, they have tested an alternative explanation for the political appeal of big sports events: perhaps they make the population happier. Kavetsos and Szymanski also tested an additional claim, often made by governments investing heavily in training athletes: that sports success is good for a country’s well-being and national pride. The researchers mined the Eurobarometer Survey series, involving 12 European nations, including the UK, between the years 1974 to 2004. Twice a year, a random selection of 1000 people per country were interviewed and one of the questions was about their life satisfaction. Kavetsos and Szymanski looked for any changes in average life-satisfaction scores in surveys that took place in the autumn following the Olympics, football World Cup or European Cup. Specifically, they wanted to know if a country doing better than expected in a competition had any beneficial effect on average life satisfaction and/or whether hosting a competition had any benefits (the data available meant the latter question was restricted to the hosting of football events). There was very little evidence that performing better than expected at a sports event had any positive benefit for the average life-satisfaction scores In the April issue of the Journal of a country's citizens. The data of Economic Psychology moved in the right direction, but with one exception the effects were not statistically significant. By contrast, there was strong evidence that hosting a major international football event boosted the life satisfaction of a host nation’s citizens. Just how large was the life-satisfaction increase for a typical citizen in a host nation? Kavetsos and Szymanski said it was pretty big: three times the size of the happiness boost associated with gaining a higher education; one and half times the happiness boost associated with getting married; and nearly large enough to offset the misery triggered by divorce. Is there a catch? Unfortunately, yes. By one year after the event, the benefits had gone, so the effects on people’s happiness were extremely short-lived (the effects of marriage on happiness, by contrast, are long-lasting). There was also no evidence of a host country’s happiness being boosted in anticipation of hosting an event. ‘Most politicians calculate that hosting events can only enhance their political standing,’ Kavetsos and Szymanski said. ‘This makes sense if the benefits of hosting are not derived through economic gains, but through the feel-good factor, specifically associated with being the host.’
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Direct evidence for human mirror neurons? In the April issue of Current Biology V.S. Ramachandran famously wrote that mirror neurons will ‘do for psychology what DNA did for biology’. Yet although recordings from single cells in the brains of monkeys have identified neurons that respond both to the execution of a movement and the observation of another agent performing that same movement, the existence of such cells in humans has been inferred only from indirect evidence (e.g. brain imaging). To address this, Roy Mukamel and colleagues seized the opportunity provided by clinical investigations on patients with intractable epilepsy, who had electrodes implanted into their brains to identify the loci of their seizures. Mukamel’s team had 21 of these patients look at videos of hand gestures or facial expressions on a laptop in one condition, and perform those same gestures and expressions in another. Most of the 1177 cells that were recorded showed a response either to the execution of an action or the sight of that action, not both. However, there was a significant subset of ‘mirror’ neurons in the front of the brain, including the supplementary motor area, and in the temporal lobe, including the hippocampus, that responded to the sight and execution of the same actions. Critics could argue that rather than having mirror properties, a cell that responded (for example) to both the sight and the execution of a smile was actually being activated by the smile concept. Mukamel’s group
reject that argument. They had a control condition in which the words for actions appeared on a screen, rather than those actions being seen or performed. The postulated mirror neurons responded to the sight and execution of an action, but not the word. Another potential criticism is that the execution-related activity of a postulated mirror neuron is triggered by the sight of one’s own action, rather than by motor-output per se. However, this can’t explain the mirror neurons that responded both to the sight of a given facial expression and one’s own execution of that facial expression (although proprioceptive feedback could still be a potential confound). Mirror neurons make functional sense in relation to empathy and imitative learning, but a drawback could be unwanted imitation and confusion regarding ownership over actions. The researchers uncovered another subset of cells that could help reduce these risks – these cells were activated by the execution of a given movement but inhibited by the sight of someone else performing that same movement (or vice versa). ‘Taken together,’ the researchers concluded, ‘these findings suggest the existence of multiple systems in the brain endowed with neural mirroring mechanisms for flexible integration and differentiation of the perceptual and motor aspects of actions performed by self and others.’
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Psychological calm in the eye of a storm
You’ve got lie-mail
In PLoS One (http://bit.ly/dcH9Tk)
In the March issue of the Journal of Applied Psychology
Research conducted in the aftermath of a devastating Chinese earthquake has uncovered a paradoxical psychological phenomenon – survivors living in the most devastated regions appear to be the least concerned by the ongoing risks. Shu Li and colleagues dubbed this the ‘Psychological Typhoon Eye’ in a paper published last year and now they’ve found that the effect was still in evidence a year after the disaster. The 2008 Wenchuan earthquake registered 8 on the Richter scale and killed over 68,000 people. More than four million people were also injured. In their initial paper, Shu Li’s team observed that survivors living in the most devastated regions were the least concerned, as measured by their estimates for: how many relief workers were needed; the likelihood of an epidemic outbreak; the need to take safety measures against aftershocks; and the level of dose needed if a fictitious psychological medication were made available for an earthquake victim. The new study of over 5000 residents finds that this association held after four and eleven months and it also replicates the finding when using a ‘relational distance’ measure of involvement in the quake. That is, people who reported having closer rather than more distant relations who’d been affected by the quake tended to report less ongoing concern with the threat.
One of the explanations for the Psychological Typhoon Eye mooted in Li’s 2009 paper was psychological immunity – the idea that exposure to danger builds psychological resilience. However, the new study undermined this explanation – people living in the most devastated regions still showed the same level of Psychological Typhoon Eye regardless of whether they themselves had suffered physical or economic harm from the quake. Another possible explanation is cognitive dissonance: that continuing to live in a dangerous area is psychologically uncomfortable, and to justify this decision people have to downplay the risks in their own mind. Li’s team said more research was needed to test this explanation. These studies are not the first to find paradoxical psychological responses to danger. Research in the 1970s found that people living nearer to French nuclear power stations perceived the risk to be lower than those living further away.
E-mails feel so transient, so disembodied, that we’re more tempted to lie when sending them compared with writing with pen and paper. That’s according to Charles Naquin and colleagues who tested the honesty of students and managers as they played financial games. Forty-eight graduate business students were presented with an imaginary $89 kitty and had to choose how much they’d tell their partner was in the kitty, and how much of the kitty to share with their partner. Crucially, some participants shared this information by e-mail, others by pen and paper. You guessed it – those who shared the info by e-mail were more likely to lie about the kitty size (92 per cent of them did vs. 63 per cent of the pen and paper group), and they were also more unfair in how they shared the money. Participants in the e-mail group also said they felt more justified in misrepresenting the amount of money to their partner.
A follow-up study ramped up the ecological validity. Fulltime managers took part in a group financial game, forming teams of three with each member pretending to be the manager of a science project negotiating for grant money. This game was played with real money, the players all knew each other, and any lies would be revealed afterwards. Once again, players who shared information by e-mail were more likely to lie and cheat than those who used pen and paper. Naquin’s team said their results chime with previous research showing, for example, that peer performance reviews are more negative when conducted online rather than on paper. ‘Moving paper tasks online either within or across organisational boundaries should be undertaken with caution,’ they said. For example: ‘Taxes using the increasingly popular e-filing system could be even more fraught with deception than the traditional paper forms.’
The material in this section is taken from the Society’s Research Digest blog at www.researchdigest.org.uk/blog, and is written by its editor Dr Christian Jarrett. Visit the blog for full coverage including references and links, additional current reports, an archive, comment and more.
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Subscribe by RSS or e-mail at www.researchdigest.org.uk/blog Become a fan at www.facebook.com/researchdigest Follow the Digest editor at www.twitter.com/researchdigest
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Our emotional neighbourhoods
questions
Peter Totterdell, Karen Niven and David Holman look at how social networks can regulate what we feel
e are all embedded within various kinds of social network, such as friendship groups, work-based associates, team-mates at a sports club, and local community contacts. These networks form our personal neighbourhood. But do these networks affect how we feel? Does our happiness depend partly on the happiness of those to whom we are connected? In this article, we argue that the answer is yes. We review evidence for the transfer of feelings between people and for the mechanisms that enable such transfer, and explore some of the complexities involved in this process. But first we start off with some background to social networks, for those unfamiliar with this research tradition.
Does how we feel depend on what other people in our social network are feeling? Recent research suggests that it might; this article examines the evidence and describes some of the mechanisms that may enable this to occur. Also what cognitive or social functions could be served by the transfer of feelings between people, and is there an equivalent transfer of feelings in online social networks? More generally this article aims to illustrate how social network research offers psychologists concepts and methods that they may find useful in their own work.
W
Do emotions permeate through people’s social networks?
Social networks
How can emotions transfer from one person to another?
resources
Analytic Technologies, Ucinet 6 Social Network Analysis Software: www.analytictech.com/ucinet6/ucinet. htm Emotion Regulation of Others and Self (EROS): www.erosresearch.org International Society for Social Network Analysis: www.insna.org
references
Is emotion transfer useful, and who is good at it?
Barsade, S.G. (2002). The ripple effect: Emotional contagion and its influence on group behavior. Administrative Science Quarterly, 47, 644–675. Borgatti, S.P., Everett, M.G. & Freeman, L.C. (2002). UCINET 6 for Windows: Software for social network analysis. Harvard, MA: Analytic Technologies. Borgatti, S.P. & Foster, P.C. (2003). The network paradigm in organizational
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also varies and can be characterised by a number of attributes, including degree centrality (number of ties that emanate from or go to an actor), density (extent to which the people to whom an actor has ties also have ties to one another), and structural similarity (the extent to which an actor has the same set of ties as other actors). The recent growth of online social networking communities (e.g. Facebook, Habbo, LinkedIn) has enhanced popular awareness of social networks. But research on the topic has a century-long tradition (Scott, 2000). Somewhat surprisingly, research on social networks continues
A social network comprises the Group and individual feelings are connected set of relations (also known as ties) among a set of entities (also known as actors or nodes). These entities can be individuals, groups or to attract much stronger interest from organisations. Pairs of actors can be disciplines such as sociology, anthropology joined in a social network by a variety of and epidemiology than from psychology, relationships, including interaction ties, but psychologists – especially those affective ties (e.g. likes or dislikes), roleresearching community and organisational based ties (e.g. manager–employee), and matters (Borgatti & Foster, 2003) – have influence ties. Relations can differ in nevertheless contributed to its intensity (e.g. strong or weak ties) and development. We sketch some of the can be bi-directional (out-ties stem from methods used by social network actors, in-ties are received by actors). An researchers later in this article, but for actor’s position within a social network present purposes the critical message is
research: A review and typology. Journal of Management, 29, 991–1013. Casciaro, T. & Lobo, M.S. (2005). Competent jerks, lovable fools, and the formation of social networks. Harvard Business Review, 83, 92–100. Cohen-Cole, E. & Fletcher, J.M. (2008). Detecting implausible network effects in acne, height, and headaches: Longitudinal analysis. British Medical Journal, 337, a2533.
Côté, S. (2005). A social interaction model of the effects of emotion regulation on work strain. Academy of Management Review, 30, 509–530. Cramton, C.D., Orvis, K.L. & Wilson, J.M. (2007). Situation invisibility and attribution in distributed collaborations. Journal of Management, 33, 525–546. Cross, R., Baker, W. & Parker, A. (2002). Charged up: The creation and
depletion of energy in social networks. Cambridge, MA: IBM Institute for Knowledge-Based Organizations. Decety, J. & Jackson, P.L. (2006). A social-neuroscience perspective on empathy. Current Directions in Psychological Science, 15, 54–58. Fowler, J. & Christakis, N.A. (2008). The dynamic spread of happiness in a large social network: Longitudinal analysis over 20 years in the
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processing includes an individual’s appraisal of the significance of an interaction partner’s emotional display and consequent self-regulation of emotions to produce the appropriate response (Van Kleef, 2009). This account of how feelings are transferred between people fits well with recent findings from social neuroscience concerning the mechanisms of empathy (Decety & Jackson, 2006). The same neural architecture appears to be engaged when individuals produce emotional states in themselves as when they try to understand the emotions of others. This architecture involves automatic bottom-up processes (e.g. mimicry), top-down inferential processes (e.g. perspectivetaking), and self-regulatory processes that enable the person to distinguish between their own and other people’s feelings (e.g. distancing).
Does transfer of feelings serve any function? So if you have a communication tie to your neighbour – at home or work – and if that tie isn’t independent of other ties in the locale (for example, your neighbour has ties to other people), then the social network structure makes it is likely you will be more happy if your neighbourhood contains happy people. This logic can apply to other types of feeling too, for instance anxiety, sadness and excitement. Might this transfer of feelings serve any function? Emotions and moods are known to have a wide range of effects on cognition and behaviour, and a dizzying array of theories have been proposed to account for those effects, but one effect deserving mention in this context is that synchrony of feelings among a group of people seems to enhance cooperation on tasks (Barsade, 2002). It is not yet resolved whether it is the valence of the group’s affect or the synchrony that is the critical factor, but it may be that spreading affect through a network via contagion can help mobilise coordinated action.
Scott, J. (2000). Social network analysis: A handbook (2nd edn). London: Sage. Sy, T., Côté, S. & Saavedra, R. (2005). The contagious leader: Impact of the leader’s mood on the mood of group members, group affective tone, and group processes. Journal of Applied Psychology, 90, 295–305. Totterdell, P. (2000). Catching moods and hitting runs: Mood linkage and subjective performance in
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With respect to inferential processes, research on deliberate social sharing of emotion indicates that the impulse to share emotions is strong but does not seem to reduce the impact of the emotion and can even heighten it by reactivating memory of the associated events. Sharing emotion does, however, appear to strengthen social bonds and distribute knowledge about important events across the neighbourhood (Rimé, 2007). So the benefit of social sharing of emotion may primarily be that it helps maintain the social network itself. The idea that emotions are best understood through their social interpersonal functions, rather than as private personal phenomenon, has gained support in recent years. For example, emotions have been defined as ‘ways of aligning and realigning interpersonal and intergroup relations’ (Parkinson et al., 2005, p.235). Similarly, the recent emotions-as-social-information (EASI) model explains that emotional expressions regulate social interaction by triggering inferences and automatic reactions in observers (Van Kleef, 2009). The reciprocal nature of this social influence process is captured in social interaction theory, which proposes that feedback from the observer impinges on the person expressing the emotion (Côté, 2005).
Resistance is not futile Lest it should seem from this account that the influence of the social network on people’s feelings is straightforward and inevitable, we should put the record straight and say that this is unlikely. There are many factors at play, and the dynamics are most probably complex. Moreover, the network will influence but
professional sport teams. Journal of Applied Psychology, 85, 848–859. Totterdell, P., Holman, D. & Hukin, A. (2008). Social networkers: Measuring and examining individual differences in propensity to connect with others. Social Networks, 30, 283–296. Totterdell, P., Wall, T., Holman, H. et al. (2004). Affect networks: A structural analysis of the relationship between work ties and job-related affect.
not fully determine what people feel; and in general the sizes of the effects appear to be small to medium. People also develop ways of resisting emotional influence, such as using dark humour to blunt its impact. In our own research, we have identified a wide range of strategies that people use to deliberately improve or worsen other people’s affect (Niven et al., 2009). People often use these strategies to align other people’s feelings with their own, but sometimes they use them to regulate people’s feelings away from their own. By conceptualising these affect regulation strategies as relational (i.e. as something that passes along a tie), we have begun to investigate what effects they have on well-being and relationships within social networks. This forms part of a larger ESRC-funded project examining the neurophysiological and social processes that govern the emotion regulation of others and self (EROS). Another factor that has to be taken
Journal of Applied Psychology, 89, 854–867. Van Kleef, G.A. (2009). How emotions regulate social life: The emotions as social information (EASI) model. Current Directions in Psychological Science, 18, 184–188. Watts, D.J. (2004). The ‘new’ science of networks. Annual Review of Sociology, 30, 243–270.
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that the building block of a social network is a relation between two individuals.
Evidence for transfer of feelings Feelings can include transient affective states, such as emotions (e.g. anger, fear) and moods (e.g. gloomy, calm), as well as more enduring states, such as affective well-being and happiness. If we are to accept that feelings can be transmitted through social networks then, given that the basic unit of a social network is a relation between two individuals, there ought to be evidence that feelings can be transmitted from one person to another. But we don’t need to turn to social network research for that evidence, because there is plenty already available from experimental and field studies of social dyads and groups. The clearest evidence comes from a study showing that moods shift towards that of the most expressive person when people sit facing each other without verbal communication (Friedman & Riggio, 1981). Other support comes from studies showing that depressed persons can induce negative feelings in others (Joiner, 1994), and from studies showing that moods are temporally reciprocated between partners in close relationships (Levenson & Gottman, 1983). The next set of evidence comes from research on teams, which can be conceived as small social networks. Field research on work and sport teams has found that individuals’ moods change in synchrony with the collective mood of their teammates (Totterdell, 2000) and in particular with the mood of a team leader (Sy et al., 2005). Importantly, these effects have been found not to depend on the influence of shared external events. A carefully designed laboratory study has also shown that a trained confederate can manipulate the moods of members of experimental groups without their knowledge simply by expressing specific feelings, causing the moods within the groups to become congruent with the ones transmitted (Barsade, 2002).
Framingham heart study. British Medical Journal, 337: a2338. Friedman, H.S. & Riggio, R.E. (1981). Effect of individual differences in nonverbal expressiveness on transmission of emotion. Journal of Nonverbal Behavior, 6, 96–104. Frost, P. & Robinson, S.L. (1999). The toxic handler: Organizational hero and casualty. Harvard Business Review, 77, 96–106.
Collecting social network data Social network research offers many possibilities for investigating fundamental and applied research questions about social phenomena, such as how psychological characteristics shape and respond to changes in social structure. There are a number of methods that researchers can use for collecting social network data, such as the roster method in which respondents are presented with the names of all people in the relevant network and asked to identify those with whom they have ties. The resulting data is usually coded in matrix format that locates a different actor in each row and the actors with whom they could have ties in each column. The data requires special analysis procedures, such as quadratic assignment procedure (QAP), which is essentially regression for matrix data. Fortunately many of these procedures can be found in UCINET (Borgatti et al., 2002), which is a widely used statistical package for social network analysis (the social network researcher’s equivalent of SPSS). An advantage of social network data is that it includes not only the actor’s view of his or her relationships with others, but also includes the other person’s view of the same relationship. A disadvantage is that it commonly requires people to record judgements about specific others, which can raise privacy concerns.
People’s connections usually extend beyond a single team though, so with our colleagues we conducted a social network study of employees in a large organisation (Totterdell et al., 2004). This study established that: affect is more similar when there is a work tie between two employees; groups of employees who frequently interact with one another have distinctive affect profiles; and an employee’s affect can be predicted from the affect of everyone else in the network if it is weighted by the similarity of their structural position. Further support for the transfer of feelings across social networks emerged from a study of over 4000 people who were followed across a 20-year period (Fowler & Christakis, 2008). A key conclusion was that people’s happiness depends on the happiness of others with whom they are connected. The effect was weaker but still held even when there was only an indirect connection between people (i.e. when they were only linked via their connection with another person). So there are some converging lines of evidence for transfer of feelings within social networks. However, it is possible to find effects that resemble transmission through a social network even where there
Hatfield, E., Cacioppo, J.T. & Rapson, R.L. (1994). Emotional contagion. Cambridge: Cambridge University Press. Joiner, T.E., Jr. (1994). Contagious depression: Existence, specificity to depressed symptoms, and the role of reassurance seeking. Journal of Personality and Social Psychology, 67, 287–296. Levenson, R.W. & Gottman, J.M. (1983).
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are no plausible mechanisms for such transmission (Cohen-Cole & Fletcher, 2008), such as the transfer of acne from person to person. It is therefore important to establish that such mechanisms exist.
Mechanisms for transferring feelings There appear to be two main types of mechanism by which feelings are transferred between people: automatic and inferential. The automatic mechanism, also known as primitive emotional contagion (Hatfield et al., 1994), is activated when individuals involuntarily mimic the expressions and postures of those with whom they interact. Thereafter afferent feedback pertaining to personal emotional state – for example from the facial muscles involved in smiling or frowning – automatically brings the individual’s affect into line with that of their interaction partner. Contagion of this kind has been found to occur even in the absence of face-to-face interaction (Neumann & Strack, 2000). In contrast, transfer by inferential means involves conscious topdown cognitive processing. Such
Marital interaction: Physiological linkage and affective exchange. Journal of Personality and Social Psychology, 45, 587–597. Neumann, R. & Strack, F. (2000). ‘Mood contagion’: The automatic transfer of mood between persons. Journal of Personality & Social Psychology, 79, 211–223. Niven, K., Totterdell, P. & Holman, D. (2009). A classification of controlled
interpersonal affect regulation strategies. Emotion, 9, 498–509. Parkinson, B., Fischer, A. & Manstead, A.S.R. (2005). Emotion in social relations: Cultural, group, and interpersonal processes. Philadelphia, PA: Psychology Press. Rimé, B. (2007). Interpersonal emotion regulation. In J. Gross (Ed.) Handbook of emotion regulation (pp.466–485). New York: Guilford.
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into account is the structure of the social network. How central people are within a network can influence their feelings. We found that employees with many work ties were more enthusiastic but also more anxious, perhaps because of the effort required to sustain those ties (Totterdell et al., 2004). Equally employees with dense networks were less anxious, probably because of the availability of social support. Such findings imply that the formation and breaking of ties will have an influence on affect that reverberates through the social network. Propagation of affect through the network also depends on characteristics of the individual carriers. Extant research indicates that individuals who score high on scales measuring affective communication (also known as charisma) or extraversion or who are perceived by others as displaying positive affect (Totterdell et al., 2008) or energy (Cross et al., 2002) are not only more likely to have a greater influence on how others feel but are also more likely to become more central within their social networks. People even seem to prefer individuals who they like over those who are competent at their job when it comes to
choosing who they seek advice from (Casciaro & Lobo, 2005). Equally, individuals who readily make connections with others – social networkers – will exert greater influence on the affect of their social network (Totterdell et al., 2008). Some individuals have also been identified as fulfilling a role within social networks in which they mitigate the toxic emotions of others (Frost & Robinson, 1999). So the affective dynamics of the social network will depend on the makeup of the individuals within it.
(Cramton et al., 2007). Research has also not yet established whether feelings are compartmentalised into online and offline networks, or whether they transfer from one to the other. In this and related issues concerning affect in social networks, there exists great potential for psychologists to contribute to what has been termed the ‘new’ science of networks (Watts, 2004).
Peter Totterdell is at the University of Sheffield p.totterdell@sheffield.ac.uk
A virtual unknown Earlier we noted the increasing popularity of online social networking communities. It is not yet known, however, whether the phenomena we have spoken of here apply in the same way when the network is online and the communication ties are virtual. Transfer of feelings is not restricted to a face-to-face modality, but research on virtual interaction indicates that differences in online social cues and lack of local understanding can lead to greater disinhibition and misunderstandings and make it harder to establish strong relationships online
I Karen Niven
is at the University of Sheffield k.niven@sheffield.ac.uk I David Holman
is at the University of Sheffield d.holman@sheffield.ac.uk
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subject, we still lack answers to the most fundamental questions. What is consciousness? How and why did we evolve to possess it? How do billions of interacting neurons give rise to it? While much progress has been made in delineating how much (or rather, how little) cognition occurs within the boundaries of consciousness, we still fall Martin M. Monti and Adrian M. Owen go looking for consciousness short of addressing any of these central questions about its nature. Martha’s eyes are now open. Medically ‘The limits of consciousness are What is the neural basis of human speaking, the return of alternating cycles of hard to define satisfactorily and consciousness? This question may sleep and wakefulness mark her quantitatively, and we can only infer seem to be the domain of progression from coma to a vegetative state the self-awareness of others by their philosophy, yet it is at the centre (VS: Jennet & Plum, 1972). However, even appearance and by their acts.’ (Plum of one of the most mysterious and though Martha’s eyes are open, and even & Posner, 1983, The Diagnosis of least understood conditions of the though she gives the impression of ‘seeing’, Stupor and Coma, p.3) human brain: the vegetative state. in fact, she doesn’t. Visual information may The consequences of our limited well reach several centres of her brain understanding of the phenomenon artha is a young woman. Not yet dedicated to processing information from of human consciousness become 30, she was involved in a roadthe eyes, and her brain may even respond apparent when clinicians are called traffic accident in which she differently to different categories of objects. to recognise, on the basis of sustained a very severe brain injury. Martha, however, doesn't ‘see’, inasmuch as behavioural tests, whether a Rushed to the intensive she may not have any patient surviving severe brain care unit, she is now awareness of what she injury is aware or not. Novel stable, but in a state of is gazing at. “40 per cent of minimally functional neuroimaging coma. Her eyes are closed, Consciousness can conscious state patients techniques, however, have the her body incapable of be conceptualised as are misdiagnosed as potential to open a window on to sustaining life encompassing two vegetative state” the mental life of these patients, autonomously, and she cardinal components allowing us to directly assay how doesn’t seem to respond (Laureys, 2005): its level much cognition may remain, to sounds, touch, or any (i.e. wakefulness) and its whether consciousness is other stimulation. Her mother speaks to content (i.e. awareness). A healthy preserved, and maybe even yield her continuously, but Martha gives no individual, when not asleep, is both awake answers concerning their quality response. Within a week, her body and aware. Conversely, at the opposite end of life. recovers its ability to breathe of the spectrum, a comatose patient is autonomously, and her eyes, finally, open. neither awake nor aware. In between these At times she seems to fall asleep and then two extremes, wakefulness and awareness wake up again. She yawns, stretches her typically appear to vary together. They are What mechanisms underlie the arms out, and gently finds another both very low during general anaesthesia, phenomenon of human consciousness, position in her bed. Her eyes, now wide and jointly return as one progresses from its loss after severe brain injury, and its open, appear to be looking away, towards deep sedation, or deep sleep, to recovery? the window. ‘Can she see? Does she wakefulness. In VS, however, these two understand me when I talk to her?’ dimensions seem to dissociate. Hence, enquires her mother. ‘Is she conscious?’ vegetative patients appear to be awake, Jennett, B. (2009). The vegetative state: How do we ever know that someone but are not aware. The reverse dissociation Medical facts, ethical and legal – other than ourselves – is conscious? The occurs naturally during REM sleep, and in dilemmas. Cambridge: Cambridge answer, as things stand, is that we never particular during oneiric experiences, University Press. really know. In fact, despite centuries of where a subjective feeling of awareness www.scholarpedia.org/article/Vegetative _state philosophical inquiry and, more recently, is often present despite the state of nondecades of scientific research into the wakefulness.
The aware mind in the motionless body
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Coleman, M.R., Rodd, J.M., Davis, M.H. et al. (2007). Do vegetative patients retain aspects of language? Evidence from fMRI. Brain, 130, 2494–2507. Davis, M.H., Coleman, M.R., Absalom, A.R. et al. (2007). Dissociating speech perception and comprehension at reduced levels of awareness. Proceedings of the National Academy of Sciences of the United States of America, 104, 16032–16037.
deCharms, R.C. (2007). Reading and controlling human brain activation using real-time functional magnetic resonance imaging. Trends in Cognitive Sciences, 11, 473–481. Giacino, J.T., Ashwal, S., Childs, N. et al. (2002). The minimally conscious state: Definition and diagnostic criteria. Neurology, 58, 349–353. Giacino, J.T., Kalmar, K. & Whyte, J. (2004). The JFK Coma Recovery
Scale-Revised. Archives of Physical Medicine and Rehabilitation, 85, 2020–2029. Gill-Thwaites, R. & Munday, R. (2004). The Sensory Modality Assessment and Rehabilitation Technique (SMART). Brain Injury, 18, 1255–1269. Jastrow J. (1899). The mind’s eye. Popular Science Monthly, 54, 299–312. Jennett, B. & Plum, F. (1972). Persistent vegetative state after brain damage.
RN, 35, ICU1–4. Laureys, S. (2005). The neural correlate of (un)awareness: Lessons from the vegetative state. Trends Cognitive Science, 9, 556–559. Menon, D.K., Owen, A.M., Williams, E.J. et al. (1998). Cortical processing in the persistent vegetative state revealed by functional imaging. Lancet, 352, 200. Monti, M.M., Coleman, M.R. & Owen,
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Chances of recovery from VS are negatively linked to time, and to the nature of the injury. Some patients will never make any significant recovery, and will be diagnosed as in permanent VS (in the UK, a permanent VS diagnosis is made after at least six months, for non-traumatic brain injury, and one year, for traumatic ones; Royal College of Physicians, 1996/2003). Other patients, however, do regain some (transient) level of awareness and thus are said to progress to a minimally conscious state (MCS: Giacino et al., 2002). How do we know that a patient has regained consciousness? With no agreed definition of what consciousness is, and with no means to quantify it, all we can do is to search for signs that may reveal its presence. In the medical setting this translates into careful and repeated (albeit subjective) evaluations of the patient’s spontaneous and elicited behaviour, according to specifically developed scales (e.g. JFK Coma Recovery Scale: Giacino et al., 2004; SMART: Gill-Thwaites & Munday, 2004). In particular, assessing the presence of consciousness, and thereby discriminating MCS from VS patients, requires finding evidence of (i) awareness
ANNA HEATH
of the self or the environment; (ii) sustained, reproducible, purposeful or voluntary response to auditory, visual, tactile or noxious stimuli; or (iii) language comprehension and/or expression (MultiSociety Task Force on PVS, 1994; Royal College of Physicians, 1996/2003). If any evidence of wilful behaviour is apparent, then the patient is diagnosed MCS. Conversely, where there is no evidence of such behaviour, a VS diagnosis is made. This approach, however, suffers from a major flaw. A positive VS diagnosis ultimately relies on a negative result. Lack of evidence of consciousness is, in this situation, equated to evidence of lack of consciousness. What if a patient were conscious, but unable to produce any motor output? What if a patient could comprehend language, but were unable to speak or produce any other kind of response? How could such an individual ever be distinguished from a vegetative patient? In fact, on the basis of current clinical assessments, it is not logically possible to differentiate between the two circumstances. Inasmuch as motor behaviour is required to signal a state of consciousness, an aware patient that cannot produce any behavioural output is undistinguishable from an unconscious one (Monti et al., 2009b). This problem undoubtedly contributes to the high rate of misdiagnosis in this group, according to which 40 per cent of (aware) MCS patients are misdiagnosed as VS (e.g. Schnackers et al., 2009). The issue is all the more important when you consider that a VS diagnosis may result If a patient cannot behaviourally manifest her state of in very different medical, consciousness, what other means are there for assessing legal and ethical decisions whether she is aware? than an MCS diagnosis. In
A.M. (2009a). Executive functions in the absence of behavior: Functional imaging of the minimally conscious state. Progress in Brain Research, 117, 249–260. Monti, M.M., Coleman, M.R. & Owen, A.M. (2009b). Neuroimaging and the vegetative state: Resolving the behavioral assessment dilemma? Annals of the New York Academy of Science, 1157, 81–89.
Multi-Society Task Force on PVS (1994). Medical aspects of the persistent vegetative state. New England Journal of Medicine, 330, 1499–508. Owen, A.M. & Coleman, M.R. (2008). Functional neuroimaging of the vegetative state. Nature Reviews Neuroscience, 9, 235–243. Owen, A.M., Coleman, M.R., Boly, M. et al. (2006). Detecting awareness in the vegetative state. Science, 313, 1402.
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the United Kingdom, for example, it is possible, under specific circumstances, for the legal guardian of a permanent VS (but not an MCS) patient to file a request for discontinuation of life-supporting therapies (e.g. hydration and nutrition). If a patient cannot behaviourally manifest her state of consciousness, what other means are there for assessing whether she is aware? In the past 10 years, an increasing number of research studies have highlighted the possibility that functional neuroimaging technology, such as positron emission tomography (PET) and functional magnetic resonance imaging (fMRI), can be used to look directly into the brain for markers of consciousness. Between the late 1990s and the early 2000s, a series of such studies showed that functional neuroimaging could detect cognitive processing in VS patients, well beyond that which is observable in (behavioural) clinical assessments. In two reports, patients that were entirely unresponsive at the bedside, exhibited brain activations similar to healthy volunteers in response to speech sounds (Owen et al., 2002), and to pictures of faces (Menon et al., 1998). These findings, quite surprising at the time, highlighted the fact that, despite severe brain injury, it is possible to retain relatively high-level cognitive processing. The extent to which brain activity can be used to uncover the integrity of cognitive processes invisible at the bedside has been recently explored more fully in the domain of audition and language comprehension, by Coleman and colleagues (2007). Using a hierarchical approach, two VS patients were found to retain many aspects of linguistic comprehension, from simple discrimination of speech sounds to detecting the presence of semantically ambiguous words. In these two patients, sentences containing ambiguous words (e.g. ‘The shell was fired towards the tank’) elicited strong activation, in left prefrontalcortex, as compared to sentences containing low ambiguity words (e.g. ‘She wrote her secrets in her diary’). This very
Owen, A.M., Coleman, M.R., Boly, M. et al. (2007). Response to comments on ‘Detecting awareness in the vegetative state’. Science, 315, 1221c. Owen, A.M., Menon, D.K., Johnsrude, I.S. et al. (2002). Detecting residual cognitive function in persistent vegetative state (PVS). Neurocase, 8(5), 394–403. Rodd, J.M., Davis, M.H. & Johnsrude, I.S. (2005). The neural mechanisms of
speech comprehension: fMRI studies of semantic ambiguity. Cerebral Cortex, 15, 1261–1269. Royal College of Physicians (1996, updated 2003). The vegetative state. London: Author. Schnakers, C., Vanhaudenhuyse, A., Giacino, J. et al. (2009). Diagnostic accuracy of the vegetative and minimally conscious state. BMC Neurology, 9, 35.
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same ambiguity effect had been previously documented to occur in healthy volunteers (Rodd et al., 2005). Intriguingly, in anaesthetic studies, this effect appears to vanish as healthy individuals lose consciousness, even at relatively light levels of sedation, suggesting that awareness may be necessary for such response to occur (Davis et al., 2007). With respect to patients, the crucial question is whether we can use brain activity to infer the presence of consciousness. Can brain activity be employed as a substitute for wilful motor behaviour in revealing the presence of consciousness? Does brain activity in response to pictures of faces imply that a patient is aware of them, that she can ‘see’ the faces? If a patient exhibits the same brain response to speech as healthy individuals, does it imply that she understands language? The answer to these questions depends on what type of stimuli are used, and what type of brain
activity is elicited. Indeed, much sensory processing is rapid and automatic, and can happen in the absence of any conscious perception. Furthermore, perceiving a set of lines and contours as a coherent face, or a string of utterances as speech (in the case of a familiar language), is not subject to volition. A healthy individual has no choice but to perceive a face as such (excluding sophisticated cases of ambiguity or other ‘artificial’ circumstances). Hence, while very revealing about the level of residual cognitive processing that is present, a simple brain response to stimulation cannot be taken as an The possibility of using fMRI for the detection of awareness in unequivocal index of the vegetative state raises a number of issues for legal decision consciousness. making relating to the prolongation, or otherwise, of life after Is it possible, then, severe brain injury. According to the Royal College of Physicians, to distinguish the brain’s ‘one cannot ever be certain that a patient in the vegetative state automatic response to is wholly unaware… in view of this small but undeniable element sensory stimulation from of uncertainty, it is reasonable to administer sedation when wilful processes? Recent hydration and nutrition are withdrawn to eliminate the possibility research suggests that, of suffering, however remote’. under specific At present, decisions concerning life-sustaining intervention experimental (nutrition and hydration) are made only once a diagnosis of circumstances, it is permanent vegetative state has been made. In cases in which possible to disentangle the critical threshold for a diagnosis of permanent vegetative the two and thus state has passed, the medical team formally review the evidence recognise ‘wilful brain and discuss the patient’s premorbid wishes with those closest to processing’. Imagine, for the patient. In England and Wales, the courts require that a example, being shown decision to withdraw nutrition and hydration should be referred an ambiguous figure that to them before any action is taken; this is not the case in the can be interpreted as United States or in many other countries, where such decisions representing a duck, are often made between doctors and the patient’s family. facing left, or a rabbit, Whether fMRI will ever be used in this context remains to be facing right (Jastrow, seen. Certainly, if evidence for awareness were to be found in a 1899). While subjective patient who had progressed beyond the threshold for a diagnosis factors may encourage of permanent vegetative state, this fact would surely have us to spontaneously profound implications for this decision-making process. On the converge on one of the other hand, neuroimaging data would need to be treated two interpretations, cautiously where negative findings were found. False-negative top-down attentional findings in functional neuroimaging studies are common, even in processes allow us to healthy volunteers, and they present particular difficulties in this voluntarily adopt one patient population. For example, a patient might fall asleep or the other. Despite the during the scan or might not have properly heard or understood fact that the very same the task instructions. Accordingly, negative fMRI results in pattern of light is falling vegetative patients do not necessarily imply impaired cognitive on the retina, at some function or lack of awareness, and such findings should be level, the two interpreted with caution. interpretations of the
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figure must entail different brain responses. If it were possible to demonstrate that a patient’s brain response to an unchanging pattern of sensory stimulation can change at will, this would necessarily imply the mediation of awareness. In short, in an experimental design in which two tasks are identical in terms of sensory stimulation and only differ according to the ‘mind-set’ required, differential brain responses can demonstrate the ability to voluntarily adopt such ‘mind-sets’, something that requires a state of awareness. Under these circumstances, then, voluntary brain activity can be viewed as a form of nonmuscle-dependent behaviour that, like voluntary motor behaviour, signals the presence of awareness (Owen & Coleman, 2008). In one striking application of this idea, a patient who failed to exhibit any voluntary behaviour when tested at the bedside, and was therefore diagnosed VS, was shown to be able to voluntarily modulate brain activity by producing different kinds of mental imagery (Owen et al., 2006). When tested with fMRI, the patient was asked to imagine playing tennis and, at a different time, to imagine walking around the rooms of her home. Importantly, while the patient was instructed to sustain the imagery for periods of 30 seconds, the only sensory stimulation in the experiment was a onesecond long aural cue instructing the patient to focus on one of the imagery tasks or the other. Strikingly, despite being unable to produce any type of wilful motor behaviour to demonstrate that she was conscious, the patient could produce wilful ‘brain behaviour’ by up- and downmodulation of her brain activity, in a manner that confirmed that she was engaging in the two imagery tasks (see figure above). Testing in healthy volunteers revealed that unless a participant has
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understood the task instructions and has decided to comply with them, no brain activity is observed (Owen et al., 2007). This latter finding entirely discounts the possibility that the patient’s brain activity may have reflected an automatic response. In a similar vein, we have recently described a novel paradigm in which a listener is presented with a series of neutral (i.e. not emotionally salient) words, and alternatively instructed to either listen passively to the words, or to count the number of times a given target word is repeated. Importantly, the perceptual stimulation in the ‘passive listening’ and the ‘counting’ tasks are matched in terms of types of words used, their number and repetition. Yet, when a patient with severe brain injury underwent the procedure, the counting task revealed activation in fronto-parietal regions typically associated with detecting targets and working memory (Monti et al., 2009a). Unless the patient had understood the instructions, had decided to cooperate, and retained a level of cognitive processing sufficient to perform the task, how could the same stimuli have
led to systematically different activations? Until we develop quantitative tools that can directly measure consciousness, we are likely to remain bound by having to inductively infer others’ self-awareness ‘by their appearance and by their acts’. Noninvasive neuroimaging methods, however, are now beginning to allow us to redefine the meaning of ‘appearance’ and ‘acts’ to include non-muscle-dependent ‘brain acts’. Indeed, functional neuroimaging can be used to allow aware, but non-responsive, patients to convey their state of consciousness without relying on muscledependent behaviour. Furthermore, functional MRI techniques are now being used to access thoughts and intentions
Martin M. Monti is with the Medical Research Council, Cognition & Brain Sciences Unit, Cambridge martin.monti@mrccbu.cam.ac.uk
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Adrian M. Owen is with the Medical Research Council, Cognition & Brain Sciences Unit, Cambridge
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(e.g. deCharms, 2007). For example, several recent studies have shown that what someone is viewing, recalling, and even intending to do, can be ascertained solely by observing patterns of brain activity. These advances suggest that very soon it may be possible to directly explore the inner thoughts of behaviourally nonresponsive patients. Perhaps, these techniques could even be used to create a simple ‘language’ in which discrete patterns of brain activation are used, like single words, to convey definite content (e.g. ‘yes’, ‘no’, ‘I am in pain’) thereby allowing non-responsive patients to interact with their environment, and express their thoughts and wishes.
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Talking therapies Tony Roth talks to David Clark about his pivotal role in developing and promoting the Improving Access to Psychological Therapies programme, and more
What led you to clinical psychology? It was probably my mother, who was profoundly deaf and had to raise me on her own from the age of two because my dad died of leukaemia. We were quite poor and it was a difficult situation, but she always seemed to be the person that other people came to with their problems. That got me interested in trying to help people. At school I really enjoyed chemistry and I thought drug treatments were probably going to be the big advance so I went up to Oxford to study chemistry, but by the time I got to Oxford I was much more interested in psychology as a more precise type of intervention for people with mental health problems. Who were the main influences on you at Oxford? My tutor, Alan Cowey, was a physiological psychologist who worked on perception; he was a great experimentalist and had an enormous influence on me. As did Dick Passingham – who later became a very well-known imaging person in mental health – and Anne Treisman and Pat Rabbitt. The course was very experimental, but it was also good at conveying the idea that the way we perceive things can be quite different from what appears to be objective reality and that beliefs influence perceptions. That is such a central idea of cognitive therapy; the fact that that could be analysed so systematically was really fascinating to me. What are the origins of your interest in cognitive therapy? I was lucky to come to the Institute of Psychiatry and had Jack Rachman as one of my main tutors, along with Dave Hemsley. My training was a behavioural one, but Jack always encouraged us to look at those people who weren’t responding to current treatments, and it became clear to me that some of the limitations of our behavioural approaches seemed to do with our not tackling beliefs. There was a patient on the unit who
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important; the first step has to be to get into the patient’s head and see the world from their perspective. It’s only when you’ve done that that you have a chance of working out a way to help them move to a more fulfilling perspective. Other people’s heads are just always the most fascinating place to be. Everyone is different, and he taught always to start with the patient’s own perceptions and move from there – but do it systematically and scientifically.
CBT is sometimes caricatured as the rote application of technique, whereas your emphasis seems very clientwasn’t responding to a behavioural focused. programme for her severe phobias. I It’s partly because there is a strong reviewed her treatment and thought that emphasis on writing manuals in order to the exposure therapy hadn’t been done ensure that therapies are well delivered optimally and that we should try a more and widely disseminated, and these intensive flooding experience, so Dave sometimes read like cookbooks. Over the Hemsley and I spent all day with her in years there has been an unfortunate trend the hope that she would habituate in a for people to be a bit lazy in the way they long session – but she didn’t! It was publish them – publishing extraordinary for manuals developed for a me to see someone clinical trial without being anxious for thinking about how the so long without any “I see cognitive therapy as a approach needs to be habituation and I bit of a magpie looking adapted to fit with the full started to think around at other therapies” range of people that one ‘how could this be?’ sees in normal practice. It’s I noticed that she also because people haven’t had was breathing very the chance to observe the masters of these quickly during her panic attacks and so therapies. I was lucky to be able to watch in a break I asked one of the psychiatrists Beck, and it was very noticeable that he ‘What impact would that have?’ He said would drop a technique very quickly if he ‘That’s hyperventilation – why don’t you felt it wasn’t having any impact – even if try it?’ I thought it was quite pleasant but it seemed to be the obvious thing to do it had big physiological effects. I got the given the model and the manual. When idea that maybe the hyperventilation was you asked him about it he’d say, ‘Well maintaining the anxiety, but it couldn’t be what’s the point in persisting with just that because while I thought it was something that doesn’t work?’ He has quite pleasant she thought it was dreadful, a mental road map of the problematic so it must be something about the way we beliefs that are linked to affect and he’s were thinking about these sensations. using that to drive his selection of what That was what led me to the panic model, he does in the session. So what he does and the panic model got me involved with might seem a bit surprising to someone Tim Beck. I met him at a conference and who has just read the manual, but it’s went out to Philadelphia to learn about because he is following a clear map – cognitive therapy. and the thing is that it’s an affective map. When the Royal Institution held a One dangerously seductive aspect of debate in 2007 you promoted Beck as CBT is that it looks like an assembly the greatest mind who has changed of clever techniques; what you’re other minds. Why do you rank him as emphasising is the importance of highly as you obviously do? He has enormous strengths. He lives holding on to a model of the mind out cognitive therapy in his life in the way of which techniques emerge. Almost anyone who is severely depressed, that he does with his patients, and so after and many people who are anxious, will even only a short conversation with him have a lot of negative thoughts. The you get a clear idea of cognitive therapy. temptation of a novice is to jump in on What I found so fascinating about his a thought because they think ‘I know how approach was a combination of scientific to challenge that’ without really checking rigour – you have to test out your ideas out ‘is that thought driving the affect?’ with experiments and trials – and the What you see Beck doing is standing back notion that your own views aren’t so
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for a while; it looks as though he is asking a series of random questions, moving around the houses. But he’s not just looking for negative thoughts; he’s looking for those where the affect is. So you don’t quite know where he’s going and then you suddenly see the person’s facial expression change. They mention a belief, he says it back to them and suddenly there’s a tear in their eye or their face goes very tense. And then you can start the stopwatch – the whole apparatus of cognitive therapy can come out at that point.
are central to cognitive therapy. I see cognitive therapy as a bit like a magpie looking around at other therapies and when it spots some of their shining jewels it hops over and borrows them! Therapists of other persuasions often characterise CBT as neglecting the therapeutic relationship, in contrast to the emphasis they place on this as a mutative factor. Maybe CBT researchers themselves are partly to blame for that perception because they talk more about the particular techniques that are being developed rather than the core of CBT, which is collaborative empiricism and Socratic questioning. Those are actually the inalienable core of the therapy and those are the things which tend to produce a good therapeutic alliance. One of the things that I emphasise when teaching people how to treat anxiety disorders is that you do need to change your own interpersonal behaviour in therapy sessions as a function of the
CBT practitioners are sometimes seen as engaging in a sort of triumphalism which puts to one side the accumulated clinical wisdom of other approaches. Do you have any thoughts about that? Within the CBT movement there has always been a feeling of dissatisfaction; what drives it is not the idea that CBT is effective for everyone, but the absolute fact that it’s not. We don’t have a single disorder in which it works for everyone, and so it’s a fascinating area for people to work in because they feel there are still challenges and there is a method which helps them pursue them. One of the criticisms of the Improving Access to Psychological Therapies (IAPT) programme is to say ‘CBT is not a panacea’, as though CBT researchers have been saying it is. Most of the people who are really involved in treatment development obsess about those patients who didn’t get well – that’s what you’re interested in because that’s the next advance. One thing which isn’t highlighted enough is that quite a lot of the innovation in Professor David Clark, King’s College London cognitive therapy actually comes david.clark@kcl.ac.uk from observing the enormous advances made in other therapies different anxiety problems you are and then incorporating the most treating. An obvious contrast is social appealing aspects into the cognitive phobia with PTSD. In PTSD when people therapy intervention. People often say go over their traumas they are reactivating that our work in anxiety disorders has all of their beliefs and experiences from a lot of gestalt influence on it, or that it the traumatic event, and so they are very takes quite a lot from hypnosis, and they prone to see themselves as being are right – there are techniques in both victimised again. So the therapist has to areas which have proved very helpful and be very explicit in being warm, empathic so become incorporated in the and non-judgemental and creating a safe programme. But in doing so they are all environment for the person. That has to deployed in order to hit the target of the be done very explicitly because when you cognitive model. Beck is very explicit activate the trauma memory it produces a about this when you talk to him. He completely different schema, which has to trained as an analyst and many of the be counteracted in therapy. But if you are things he learned about the therapeutic talking to a social phobic and you are relationship from within that perspective
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very warm and empathic and have lots of eye contact, it’s the exact opposite of what they want; it will make them feel much more self-conscious and the therapy doesn’t progress well. So therapists need to be a little bit more distant in order to get the therapy progressing well, whereas in PTSD it’s the absolute opposite. I also think that there are challenges to our ideas about the alliance that come from novel ways of delivering therapies. If you look at the success of computerised CBT it makes you wonder, because computer programs are not very strong on warmth and empathy. What they are strong on is that they are very unlikely to be misperceived. When people come into therapy with their own traumatic history they are very vulnerable to interpreting what we do in a way which makes them feel demeaned, or victimised or humiliated. It’s very easy for something that the therapist does to be misinterpreted in a way which is seen by the patient as critical or demeaning – it’s very difficult for patients to see a computer program as being that. Maybe the defining feature of a good therapist is the ability to behave in a way which isn’t open to misinterpretation, especially by individuals whose history makes them prone to do just that. People sometimes react to research evidence by saying ‘well that’s very impressive but the patients in these trials are highly selected; they’re not like the clients that most people see in the NHS’. Do you have any thoughts about that? These are issues which have to be addressed in a scientific way. It is true that, historically, randomised trials have selected the patients they see to produce a homogeneous group. But whether the results in those trials then generalise to less selected populations is an empirical question; that’s the important thing to recognise, rather than say ‘Oh, because this isn’t necessarily an identical population to the people I see in my clinic then it’s bound not to work’. In the outside world people think you are excluding the more severe cases, but the most common exclusion in the trials I know about is the milder ones. For me, the most important opportunity to look at generalisation was the work we did in Northern Ireland following the Omagh bomb. We were asked to train up clinicians, who weren’t originally CBT therapists, to offer cognitive therapy to everyone who had PTSD and wanted treatment. So a completely unrestricted sample, and the
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really wonderful therapists in Northern Ireland got as good results as we did in our randomised trials with more restricted populations. We didn’t know that’s what would happen, but it did. While there’s been a lot of progress in relation to anxiety disorders, current approaches to depression show more modest efficacy. Do you have a sense of where the field is heading? Beckian cognitive therapy for depression has not changed much, and that’s a problem because only 50–60 per cent of people will recover. After the NIMH trial in 1985 (where CBT didn’t fare as well David Clark (middle) with Richard Layard (left) and Anke Ehlers (right) in the House of Lords as many people expected it to, around the launch of the IAPT programme especially for people who were more seriously depressed) a lot of time and effort was devoted to checking But I would guess focusing on out whether its results were a quirk, an exciting development is a one-week treatment failure in the field can be because the outcomes were somewhat treatment which concentrates the problematic, if therapists experience discrepant from other trials for cognitive intervention. That’s quite radical because this as a threat? therapy. From Steve Hollon and Rob people thought you couldn’t deal with Yes, there is a danger that in an NHS with DeRubeis’ work we now know that such severe and disabling traumas in such targets outcome monitoring will be seen cognitive therapy does pretty well in a short period of time, but our latest trials as something critical rather than a severe depression, but the distraction suggest that one-week treatment does as treasure house for new ideas. It’s up to held up the field for a long time. But well as treatment spread over three people involved in managing services to we’re over that now, and there are lots of months. cherish their workforce and use the data talented people doing new things which Another study is looking at a version in an inquisitive way to get people to will take things forward. For example, of cognitive therapy where people work reflect and improve their practice. Ed Watkins’ work on rumination focused on self-study modules between sessions. cognitive therapy; Adrian Wells’ We were able to get twice as much Why is IAPT such an important metacognitive work; Chris Brewin’s focus improvement per hour of therapy than we programme from your point of view? on intrusive memories from the past. And had previously done, so we could get 80 In the last 20 years there have been of course behavioural work has come per cent of people recovered with seven enormous advances in developing back in a much more systematic way, and sessions rather than fourteen. But some effective psychological treatments for with a new slant, through behavioural people didn’t improve, and we have a anxiety disorders and depression but it activation. So we have at least four rather ‘post mortem’, trying to work out if there has been a persistent sadness that the promising ways forward. What they are is some phenomenon that we didn’t get majority of people don’t get these doing now is similar to work on anxiety good traction on and what can we treatments. IAPT tries to change that by disorders in the last 15 years: it’s focusing develop to improve that. vastly increasing access to the treatments on particular features which we aren’t That is an aspect of the work that and so it’s something that I passionately good at changing in the existing people don’t always spot – a focus on support. treatment and asking what we can do to failure rather than success. I also think that we are at a crucial develop something which has a better That’s why the monitoring system in moment in history where several traction on that phenomenon. IAPT is so important, because it allows important themes are coming together. Where is your own research heading us to compare traditional monitoring Society is increasingly valuing subjective over the next five years? systems (where you only collect data reality. Political leaders throughout the One thing we are trying to do is make before therapy starts and after it finishes) Western world are making speeches to treatments more broadly available. We with session-by-session monitoring. What the effect that they are no longer judged are working on an internet version of our you find is that the people who have simply on financial success, but also in social phobia treatment, which we hope missing data using the traditional system terms of whether the population feels will be as effective as the therapisttend to be those who have done less well. that it’s having a satisfying and happy delivered treatment. If that is the case we That’s a problem for two reasons: it means life. That creates a great opportunity will be aiming to make it available free – you overestimate how good your service for psychology; it means that good computerised CBT can greatly increase is, but also the people who do less well experimental work and good science availability of treatments, but if it’s linked are the people you want to focus on in by psychologists can influence policy to very restrictive licences then it rather order to improve things for the future. in a way that hasn’t been possible before. undermines its point. If you don’t get to spot them, then the The investment that the government Our work on PTSD has been aimed at field dies; there is no possibility of is making in IAPT is so substantial – it’s making treatments more appealing, and advance. very important that we make the best of
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it. If we don’t, people might be carries a longer-term message. But there disillusioned about the value of are good reasons for this emphasis. psychological therapies and reluctant Although other evidence-based treatments to do anything further in the future to are recommended for depression by improve public access to it. So it’s very NICE, they are not for anxiety disorders. important that we do it well and we do As CBT is a treatment that covers the full it in a way that is responsive to what the range of cases, there’s clearly a need to public wants. start there. But When he announced IAPT as IAPT goes Alan Johnson said that it forward it needs “this is a sharp sword to be would be judged by how many to bring in other people recover, not just what sorts of therapist, judged by and we need to the waitlists are; it’s a welcome and there are step up to the plate” change for the NHS to be plans to do that – talking about people getting for example IPT, better rather than how long which is as strongly they wait for something. But obviously advocated by NICE in depression as CBT this is a sharp sword to be judged by and is. And it’s good that it’s going that way. we need to step up to the plate. When you develop new services and new training programmes there are And as you know, some people are important questions about how they very opposed to IAPT and see it as intersect with existing systems, and these a potentially destructive programme. need to be worked through carefully. How you understand that? There aren’t straightforward answers and Some criticism of IAPT has been very the psychological community has to come understandable, because in order to make together to try to solve the problems. We progress much of the initial emphasis has need coherent care pathways that not been on developing training in CBT; only deal with people who are going into because it’s not focusing on other IAPT but also with those people who are approaches, people can feel that this not – and we need a seamless system. We
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don’t want to create IAPT as a sort of ghetto, separate from the rest of the mental health services. There is also a tension between commissioners on the one side and clinicians on the other, and commissioners for understandable reasons often want to try and do things more cheaply. As clinicians we are rightly concerned that this might degrade quality and there needs to be an ongoing debate to try and get to good value without reducing this. I think all the discussions IAPT is producing should result in a more level playing field for psychotherapy in general. Its emphasis means that for those therapies that haven’t enjoyed the opportunity to be systematically examined in controlled trials, routine monitoring will automatically constitute pilot work and create a strong argument for approaching funders and getting support for randomised trials. The creation of this monitoring system will inevitably mean that the range of therapies recommended by NICE in five, ten years’ time on the basis of good evidence will be much wider than now and much less CBT dominated – and that’s a really positive thing.
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