The number of murders committed by people with a mental illness has been falling steadily since the late 1970s according to an analysis of official Home Office figures. Matthew Large and his colleagues who made the observation in the the British Journal of Psychiatry said they believe the trend is likely due to improvements in treatment.

The researchers identified overall homicide rates in the UK between 1946 to 2004 and compared these with rates of homicide with a verdict of diminished responsibility, not guilty by reason of insanity, unfit to plead and infanticide.

Rates of homicide due to mental disorder rose between 1957 and 1979, as did homicides in general. However, since 1979 homicides due to mental disorder have fallen consistently while other homicides have continued to rise.

The fall has occurred despite the fact that there have been no changes to the official definitions of the defences to murder since the mid-1950s. Moreover, one would expect the improved detection of mental illness in more modern times to have inflated the rates of murder attributed to mental illness, not reduced them.

'The introduction and increasing use of antipsychotic medication, the greater awareness of the treatment of psychosis by primary care providers after deinstitutionalisation, and the creation of regional health authorities with responsibility for defined populations, may all have contributed to the observed decline in abnormal homicide since the 1970s,' the researchers wrote.

Dr Large told The Psychologist that he was surprised by how little media coverage his paper had received. 'The British Journal of Psychiatry issued a press release and it was covered in the BMJ, New Scientist and BBC Online - but no print news, ' he said. 'And yet I was in the UK recently for a month and murders by the mentally ill came up quite often. It seems to me this is proof positive that the press are more interested in one murder than the lack of 50-70 per year. I believe the undue attention on very rare events can drive bad treatment and policy and is a serious issue.'

A Society member has been recognised at the recent Healthcare People Management Association awards, for best management practice in tackling workplace stress.
Teresa Jennings, Consultant Clinical Psychologist in Occupational Health, and Margaret Walker, Head of HR at Northumbria Healthcare Foundation Trust, noticed that referrals relating to stress were higher in some wards and departments than others. They developed a system of identifying these 'hotspot areas' by looking at a range of organisational indicators, including stress-related referrals, absence and turnover data, discipline and grievance figures, and areas were there was change, conflict or high rates of violent incidents.
Once hotspot areas were identified, team stress-risk assessments were used to drill down to the specific causes. This involved collaborating with occupational psychologists to use a Health and Safety Executive questionnaire to measure demands, control, role, relationships, support and change. Focus groups were used to verify findings, and action plans were then developed with staff to address specific problem areas.
'Stress is now the biggest cause of sickness absence in the public sector, and psychologists have an increasingly important role to play in helping organisations to tackle this problem,' says Teresa, who also manages the staff support service at her trust. 'Our focus is now on monitoring and evaluating the effectiveness of this process. However, I am delighted that the work has been recognised as a model example of a systematic approach to reducing stress.' js
- For more information contact Teresa.Jennings@northumbria-healthcare.nhs.uk or see www.hpma.org.uk for a copy of the awards compendium


Edited: 12/08/2008 at 08:06 AM by jonsut

Mention brain surgery in the same breath as mental illness and you evoke the shocking spectre of Moniz's lobotomies. And yet a new study suggests a modern day neurosurgical intervention could offer a relatively safe treatment for the 10 to 20 per cent of depressed patients who don't benefit from conventional help.

Writing in the journal Biological Psychiatry, a team of Canadian neurosurgeons report how deep brain stimulation brought clinically significant relief to twenty patients diagnosed with major depression for whom psychotherapy, drugs and electroconvulsive therapy had proven ineffective.

Andres Lozano at the University of Toronto and his colleagues inserted minute electrodes into the subcollosal cingulate gyrus of the patients. This brain region is typically overactive in depression and is known to have connections with many other depression-relevant areas, such as the amygdala, hippocampus and hypothalamus.

With echoes of Penfield, the precise location for deep brain stimulation was chosen by observing the effects of stimulation on patients during an initial operation, in terms of calmness and improved mood. Having identified the appropriate area, stimulation was applied constantly from then on, via an implanted generator, at a rate of 130hz.

A month after the electrodes had been transplanted, 35 per cent of the patients showed improvement , as judged by a 50 per cent reduction in their depression severity according to the Hamilton Depression Rating scale. By six months, 60 per cent of patients showed this level of improvement, a benefit that was largely maintained at 12 months follow up. There were some moderate medical complications in some patients, but no cognitive adverse effects whatever. 'These results, particularly in this treatment resistant patient population, are striking,' the researchers said.

The precise mechanism by which the deep brain stimulation exerts its beneficial effects is unknown but is thought to involve a disruption of the pathological brain activity underlying depression. Brain imaging confirmed that the stimulation led to changes in neural activity downstream of the subcollosal cingulate gyrus.

As acknowledged by Lozano and his team, future work is now needed to establish the efficacy of this intervention using blind, controlled conditions. However, they point out that it's unlikely a placebo effect is responsible for the results. For example, the benefits were progressive over time (uncharacteristic for placebo). Moreover, in two patients for whom stimulation was, unbeknownst to them, temporarily discontinued (in one case this was planned, for the other it wasn't) depressive symptoms returned until stimulation was resumed.

Five mental health organisations have together published a report 'While we are waiting' that calls on Primary Care Trusts (PCTs) to reveal waiting times for psychological therapies, and to provide a greater choice of therapies and therapists to clients.

Although the report welcomes the government's Improving Access to Psychological Therapies programme, it says that half of PCTs will remain uninvolved, and that the benefits of the new programme won't be clear unless all PCTs publish their waiting times.

A survey of 75 service users conducted for the report last Autumn found that ten per cent had to wait between one and two years just to receive an assessment, with further waits before they subsequently received therapy. One person described her experience: 'When I was told that the wait after assessment was two years it felt like a real let down, offering a life line and [then] snatching it away.'

Other recommendations include the introduction of more flexible appointment times for psychological therapy, including evenings and weekends, and greater contact with people who are on a waiting list, for example to inform them how much longer they have to wait.

Emily Wooster, Policy Officer at Mind, one of the partner organisations behind the report, said: 'People are still struggling to access a choice of treatments, still waiting months and even years for urgently needed support, and still watching their lives deteriorate while they are stuck on waiting lists. The government needs to hold Primary Care Trusts to account on this issue.'

It's rare for a journal article to trigger the intensity of debate as that provoked by psychologist Professor Irving Kirsch's meta-analysis, published earlier this year, which purported to show that for the majority of patients with depression, anti-depressant medication is clinically no more effective than placebo.

For the 36th Maudsley debate, held at the Institute of Psychiatry, Kirsch, with psychiatrist Dr Joannah Moncrief in support, defended the conclusions of his research findings. Arguing against Kirsch and Moncrief's motion - that anti-depressants are no more effective than placebo - were psychiatrist and expert on the psychopharmacology of depression Professor Guy Goodwin and biology Professor Lewis Wolpert, who has written a book about his own experience of depression.

Kirsch's meta-analysis used the freedom of information act in America to access all drug trial data, published and unpublished, submitted to the Food and Drug Administration by pharmacological companies seeking approval for their anti-depressants. Taking all the trials together showed that while drugs are statistically more efficacious than placebo, their advantage, for all but the most extremely ill patients, is not clinically significant (using the National Institute of Health and Clinical Excellence threshold of a three point score difference on the Hamilton Depression Rating Scale).

Commentators have criticised the quality of these trials, Kirsch explained, but they are all the evidence we have for the efficacy of anti-depressants. Either you trust these randomly controlled trials, which show drugs are rarely more effective than placebo, or you reject the validity of these trials, in which case we are still left with zero scientific evidence for the effectiveness of anti-depressant drugs.

Next up, Guy Goodwin took issue with the idea that it is easy for drugs to do well in the kind of clinical trials described by Kirsch. Merck, for example, invested heavily in Aprepitant as a possible anti-depressant only to find over several trials that it was no more effective, statistically and clinically, than placebo, whereas the same trials found the established anti-depressant Paroxetine was more effective. 'These trials have real consequences, they aren't just intellectual games,' he said. 'The idea that you just have to do a study, chuck in anything and you'll get a response is not a myth that you must carry away from this lecture.'

Goodwin said some of the strongest evidence for anti-depressant drug efficacy comes from so-called continuation trials. For example, one study looked at patients who had responded positively to the drug Agomelatine, switching half the sample onto placebo after eight or ten weeks, but ensuring the patients were unaware of whether they had been switched or not. Twelve weeks after the switch, 21 per cent of the patients still on Agomelatine had relapsed compared with 47 per cent of the patients switched to placebo.

None of this persuaded Joannah Moncrief, who argued the idea that we have truly 'anti-depressant' drugs is a myth. What we traditionally think of as anti-depressants are merely psychoactive drugs, with a variety of non-specific effects, including sedation and stimulation. Any such drugs are likely to have an impact in placebo-controlled trials, she said, but they aren't actually treating the disease process. They cut people off from their emotions, they overlay the depression rather than replacing it. Perhaps the most compelling evidence for the ineffectiveness of anti-depressants, she argued, comes from the fact that levels of depression are not decreasing, as you would expect them to if we had an effective drug treatment.

'The last speaker has clearly never suffered from depression herself,' Lewis Wolpert began in characteristically pugnacious fashion. 'When you enter into a depressed state, it's unlike anything ever experienced before.' Wolpert emphasised the biological basis of depression: it's inherited; post-mortem studies show brain abnormalities in the depressed; and treatment with interferon alpha for hepatitis triggers depression, unless the patient is also prescribed an anti-depressant. Also, macaque monkeys and mice with induced depression-like states benefit from anti-depressants, in a way that can't be dismissed as placebo.

Wolpert also drew on his own personal experiences. He had switched anti-depressants several times before finding an effective drug, a fact he felt cast doubt on the idea he was only responding to a placebo effect. 'This article of yours has done enormous damage to people with depression,' Wolpert said, addressing Kirsch. 'Such people rarely want medical help as it is. Please vote against this absurd motion,' he asked the audience.

In the minute they were given to round-up their cases, the speakers moved no closer to a consensus. Kirsch pointed to research showing that serotonin depletion in healthy people fails to trigger depression, thus undermining the popular idea that drugs work by correcting such an imbalance. Goodwin said Moncrief reminded him of famed anti-psychiatrist Thomas Szasz, but without the conviction to go all the way. Moncrief simply re-stated her belief that all placebo-controlled trials are invalid because they fail to take account of the psychoactive effects of the drugs. Wolpert agreed good new clinical trials were needed, but he maintained that the efficacy of drugs for severe depression was clearly established. 'If you're taking an anti-depressant, for goodness sake, don't stop now!' he said.

Where people vote could influence how they vote, according to new research conducted in America. Jonah Berger at the University of Pennsylvania and colleagues analysed votes cast in Arizona in 2000 either for or against a tax increase to fund schooling. They found that people who voted in polling stations located in schools were significantly more likely to vote for the tax rise (56.02 vs. 53.99 per cent) than were people who voted elsewhere. This remained true even after controlling for a host of alternative explanations - for example, the possibility that people who vote in schools do so because they have children and therefore live near a school.

The idea that environmental cues might influence people's choice of vote was given further credence in a second study that exposed people to either school-related or office-related images, ostensibly as part of a more general image rating task. Those participants cued with more school-related images were more likely to say they'd vote for a tax rise to fund schools (63.6 vs. 56.3 per cent).

This is one of the first studies to show that environmental primes can have a significant impact on real world decisions. Given the lengths that are taken to ensure political voting is conducted fairly, the researchers said the authorities may also wish to consider the polling environment itself. 'If certain polling locations are clearly related to initiatives or candidates,' they wrote, 'administrators could use more neutral locations (if equally convenient and accessible) to minimize bias.'

The chasm dividing opinion on the role psychologists should play in national security appeared wider than ever in July when two Society members, Professor Karen Carr of Cranfield University's Defence Academy and Dr David Harper of the University of East London, clashed on BBC Radio 4's All in the Mind programme.

The pair's verbal sparring followed a Ministry of Defence (MoD) statement that their psychologists play no part in interrogation and are not in the military chain of command. 'MoD occupational psychologists are committed to enhancing the working lives and effectiveness of our Armed Forces,' the statement reads. 'We are privileged to provide a small contribution to the support of our Service personnel who are protecting our nation.' However, the MoD statement doesn't cover the role played by psychologists in the British security services, which remains unclear.

During the Radio 4 debate, Professor Carr said calls for psychologists to play no part whatever in national defence and security were political.'If we as a society believe that we need military and the police in order to have stability and a safe society, then I believe that professional psychological bodies should be a part of society - all within the constraints of ethics and what's acceptable - they shouldn't hold themselves separate.'

Carr outlined several ways psychologists can make a valuable contribution to national security, including guiding the right way to treat people, helping understand cultural influences on the way people behave, aiding equipment design, and by improving the decision making of our leaders.

Carr also said there was potential value in psychologists acting in a supervisory role during interrogations, so long as they were truly independent and free of peer pressure from the security organisation. 'For psychologists to say "we don't want to get involved, we'll stand back", is abdicating responsibility. The ethical and legal frameworks are in place...The value a psychologist can bring in terms of understanding the sometimes subtle effects that can be happening would be a better way of ensuring that due process was carried out...[and] in terms of looking after the ethical situation,' she said.

However, Dr Harper couldn't have agreed less. Echoing similar calls among psychologists in America, Harper said psychologists (like medical professionals in America) should play no role whatever in interrogations, at least not until 'there are clearer regulations, and until the legal situation abides to international human rights standards.'

Harper explained that whereas the Police and Criminal Evidence Act, in place since the 80s, protects the rights and freedoms of the public, he said such safeguards do not apply in the UK's defence and security sector. He also questioned the ability of psychologists to remain independent and to challenge their colleagues when living and working in high pressure teams.

The pair also disagreed on the appropriateness of the stance taken on these issues by the British Psychological Society. Carr said the ethics code is clear and that a possible route to preventing inappropriate practices could be to ensure that psychologists working with the military are chartered.

By contrast, Harper said that the Society should take a more assertive, pro-active stance. 'It's all very well to make general statements, but to show how in practice you're going to follow up on that, monitor it, how you're going to scrutinise the practice of psychologists involved in those things - all those are unanswered questions.'

New research conducted at London Dungeon's Labyrinth of the Lost shows eye witnesses' memories are even more fallible than laboratory studies have so far led us to believe.

In real life, witnesses to crimes are likely to be in an anxious state when their memories are laid down, yet most lab studies of eye witness memory fail to re-create a stressful context. The London Dungeon setting allowed Tim Valentine and Jan Mesout of Goldsmith's College, University of London, to investigate the effects of anxiety on memory without provoking any ethical objections, and also without participants realising their memories were to be tested. Participants thought their only task was to answer questionnaires at the end of the Dungeon visit.

While in the Labyrinth, 56 participants had their path blocked by an actor wearing a hooded robe and with scars on his face - part of the usual mirror-filled horror experience, which also involves the appearance of a skeleton and a ghostly woman in a rocking chair.

After completing their subterranean visit, the participants were asked to identify the man who had blocked their path from among a series of photographs that also included eight foils all wearing similar costume and make-up.

Anxiety appeared to have had a deleterious effect on some of the participants' memories. Those participants who retrospectively reported feeling more anxious while in the Labyrinth were strikingly less accurate at identifying the actor who'd blocked their path. Only 17 per cent of participants who scored above the median on an anxiety questionnaire correctly identified the actor compared with 75 per cent of participants who scored below the median. (A separate investigation confirmed that people's retrospective reports of their anxiety levels in the Labyrinth correlated with a heart rate measure of their physiological arousal taken while they were underground).

The 29 female participants reported being more anxious in the Labyrinth than the men. Because of the observed association between anxiety and memory, this meant the women's memory performance was significantly worse than the men's - an observation that could have implications for real world witnesses.

'The experience in the Labyrinth of the Lost is much less extreme than the stress a victim of crime may experience,' Valentine said, 'but we still observed a catastrophic failure of identification by visitors who found the experience stressful.'

'The research doesn't suggest there is anything wrong with the identification procedures that the police use, but does demonstrate just how difficult it can be for a victim to identify the offender.'

When it comes to the treatment of chronic fatigue syndrome, the limited evidence available suggests cognitive behavioural therapy (CBT) is more effective than treatment as usual (i.e. seeing a doctor and receiving advice and reassurance) and other psychological therapies, including relaxation and counselling. That's according to a new systematic review by the highly regarded Cochrane Collaboration. Fifteen studies involving over a thousand patients demonstrated the superior benefits CBT can bring, although the researchers, led by Jonathan Price, at the University of Oxford, said more research comparing treatment approaches was needed, especially at follow-up.

An investigation of 38 adults diagnosed with a developmental language disorder in their childhood has found that 12 of them would meet contemporary diagnostic criteria for autism or autism spectrum disorder, based either on their current behaviour or on parental reports of how they behaved in childhood. Dorothy Bishop at the University of Oxford and her colleagues said their findings help explain the increased prevalence of autism in recent decades. Another implication of the research is that studies into developmental language disorders published in the last century would likely have included in their samples children who would today be classified as autistic.

Children who are conceived through artificial insemination should be told the truth about their origins as early as possible, according to new research.

Dr Vasanti Jadva of the Centre for Family Research, at the University of Cambridge, used the US-based Donor Sibling Registry to invite one hundred and sixty five people born through artificial insemination to complete online questionnaires.

Speaking at the 24th annual meeting of the European Society of Human Reproduction and Embryology held in Barcelona, Jadva said she found levels of anger, confusion and shock tended to be higher the later people were told about their conception history. For example, 37 per cent of those told between the ages of 4 to 11 reported feeling confused, compared to 52 per cent told when they were 12 to 18 years, and 69 per cent told in adulthood. Negative feelings towards their mothers were also more common among those people told late.

Jadva said her findings were consistent with research on adoption, 'which also shows that children benefit from early disclosure about the circumstances of their birth.'

A similar message was provided by a second study presented at the same conference that investigated the psychological well-being and attachment of 39 children born to a surrogate mother, 43 by donor insemination and 46 by egg donation, all aged 7 years at data collection.

Polly Casey, also from Cambridge University's Centre for Family Research, found that the children born through assisted reproduction generally had the same quality of relationships with their parents as the 70 naturally conceived children who served as control.

There was a tendency for the mothers who had no genetic link to their children to exhibit a more 'involved' parenting style. Also, parents who had told their children about their conception origins were apparently more emotionally sensitive and warmer.

'The children themselves showed positive psychological adjustment and did not differ as to family type. We were particularly interested to find that, according to teachers, those children who had been told of their origins tended to do slightly better emotionally than those who had not,' Casey said.

A-level psychology is 'easier' than the traditional science subjects of biology, chemistry and physics, according to a report published by the Curriculum, Evaluation and Management Centre at Durham University.

Researchers analysed the performance of over half a million A-level students using results obtained in 2006 across 33 subjects. To establish subject difficulty, five methods of analysis were used, including comparing students' general academic ability (as judged by their average attainment in other subjects) with their performance at a given target subject, such as psychology. Among the findings was the claim that a student would typically be expected to perform 0.9 grades higher in psychology than in chemistry.

However, Dr Richard Latto, Chair of the Society's Psychology Education Board, told us he has concerns about the methods used. 'Although the bulk of the conclusions drawn, and the reporting of them in the press, accept this assumption [about how to ascertain subject difficulty] and discuss the results in terms of subjects being 'easier' or 'more difficult', the report also discusses in great detail 10 other factors which may affect performance other than examination difficulty. For example students may do better on subject X because it "is inherently more interesting/relevant/ motivating/needed than Y".'

Issues of interpretation notwithstanding, the good news is that whereas commentators have an annoying habit of grouping psychology together with so-called 'soft' subjects like media studies, the report actually found psychology to be more difficult than 16 other subjects, including English, law, geography, sociology, art and media.
The report was commissioned by SCORE, a partnership of organisations - including the Royal Society, the Institutes of Physics and Biology, and the Royal Society of Chemistry - amidst concerns that students are being put off the traditional science subjects by the perception that they are more difficult. Given that A-level grades are used by admissions tutors at university and employers as a general measure of aptitude, rather than as an indicator of skill in a given subject, the report's authors, led by Robert Coe at the University of Durham, concluded the current system is unfair and likely to entice students to opt for 'easier' subjects.

One idea for correcting subject discrepancies is to apply a correction to awarded grades. However, the report's authors acknowledge there is no way to know whether this would help stem the decline in students taking sciences. 'Perhaps the status that science subjects have depends in part on their difficulty;' they wrote, 'take that away and you remove part of their attractiveness for some.'

Dr Latto said it was important to note that the new findings contrast with those published in February by the Qualifications and Curriculum Authority (QCA) in its Inter-subject Comparability Report (see The Psychologist, April 2008, p.288), which compared psychology papers and candidates' work with those found in biology and sociology.

'The QCA report concluded that psychology was "technically demanding",' Latto said, 'and that in terms of the demands of the examinations and the grading standards set, there was little basis in fact in the perception that psychology was a soft option.'

Edited: 25/07/2008 at 10:01 AM by The Psychologist News Moderator

Those who thought that the new Mental Health Act had either gone away or had little relevance to the discipline as a whole, could be in for a surprise. On 3 November, any suitably competent chartered psychologist will join psychiatrists and some other healthcare professions in being eligible to be 'approved clinicians' for detained patients. In appropriate cases, they will be responsible for their care.

The reforms mean that the profession most competent to lead the key intervention takes overall responsibility for patient care and team leadership. Within the ethos of New Ways of Working and the recent NHS emphasis on person-centred care and treatment choice, this will sometimes mean psychology. This extension of statutory responsibilities to non-medics on the basis of patient need is likely to occur in a step-wise fashion, starting with service areas currently poorly served by psychiatry, like personality disorder and learning disability.

A working party of the British Psychological Society, led by Professor Peter Kinderman (University of Liverpool) and latterly by Professor John Taylor (Northumbria University), has been at the forefront in these developments.

Can psychologists really make a difference? 'Yes', says Peter Kinderman, 'but psychologists must bring and maintain a distinctively psychological viewpoint to services.' John Taylor points out that the approved clinician role is really an extension of the current clinical responsibilities of suitably qualified and experienced professionals. 'It is a function, not a job.' Nonetheless, this is a major cultural shift in professional accountability and influence, and the changes bring both controversy and opposition. As Taylor says, 'That is why psychologists of all stripes need to approach these issues with the astuteness that their training provides.'

One of the 'field test sites' for early implementation of professions other than psychiatry is at Northgate Hospital near Newcastle upon Tyne. Bruce Gillmer, who leads this interdisciplinary group, says, 'There has never been a more auspicious time for applied psychologists to influence mental health care the sharp end.'
The broader definition of mental disorder and its assessment in the new Mental Health Act means that a more holistic formulation can replace stark medical diagnosis. This is what attracts clinicians who, like Bruce Gillmer, work in secure hospitals. He would like to see 'an exploitation of the training of applied psychologists in the integration of theories and models that places them uniquely at the interface of biological and psychosocial influences.' This, says Gillmer, would bring about novel approaches to more dimensional assessment and an emphasis on mental well-being rather than an illness model. Kinderman has long pointed to the centrality of personal meaning as the essential mediator of genetic or environmental influences.

In association with related developments such as Lord Layard's call for psychological therapies to influence the positive economics of mental well-being, Gillmer feels that the Mental Health Act may come to be seen as a 'watershed moment' for psychology and psychologists. 'It may help to provide an opening for non-medical therapies to have greater front-line acceptance in the treatment
of psychosis as well as personality disorder.'

For information on the field test site at Northgate Hospital, contact bruce.gillmer@ntw.nhs.uk Field test site

Less intelligent children are more likely to develop vascular dementia in old age - a finding that has implications for the design of public health campaigns. Brian McGurn and colleagues at the University of Edinburgh identified 173 people born in 1921 who, since passing the age of 65, have been diagnosed with Alzheimer's disease or vascular dementia, and who also took part in a large-scale survey of childhood intelligence in 1932, when they were 11.

Compared with age-matched controls born in the same region of Scotland, who also completed the 1932 intelligence test, the report in Neurology found those cases with a diagnosis of vascular dementia had a significantly lower childhood IQ report. The same wasn't true for the cases with Alzheimer's, which suggests cognitive vulnerability is unlikely to be the cause of the low IQ - vascular dementia link.

Co-author John Starr explained there are several other ways lower childhood IQ could be linked with vascular dementia in old age. For example, less intelligent people are more likely to indulge in risky behaviours like smoking and drinking (although the IQ - dementia link held even after controlling for smoking). Lower IQ and poorer vascular health could also share a common cause, such as low birth weight. More speculatively, Starr told us that 'IQ could reflect some overall "system integrity" of the brain, or possibly the whole human organism. For example, people with lower IQs might have impaired CNS control of blood pressure.'

Starr said the work could help promote the idea of controlling vascular risk in early life, and that the finding also suggests that 'public health campaigns should consider their methods to engage with people with lower IQs.' cj

Prisoners need access to psychological therapy to help them to overcome the trauma and abuse many of them have experienced, according to a report published by the Sainsbury Centre for Mental Health.
From the Inside is based on interviews with 98 prisoners in five West Midlands prisons. It finds that the 'average' prisoner has a combination of mental health, substance use and other problems. However, few prisoners feel able to admit that they have problems for fear of bullying and harassment.
Many said that prison health services did not provide the safe space they needed to deal with emotional problems, but the report did find that specialist prison mental health teams were beginning to make a difference. Prisoners seeing 'inreach' teams said they felt more confident about their chances of getting their lives back on track outside prison. Unfortunately, most prisoners with less severe mental illnesses are not seen by such teams.
The report's author Graham Durcan (Sainsbury Centre research and development manager), said: 'Prisons will never be mental illness-free zones. Prisoners should be offered mental health services that match the severity of their needs. This not only needs new investment in improved services but efforts to tackle the customs and practices that are wasteful of resources and that make good-quality care hard to achieve.'
Professor Peter Kinderman, Chair of the Society's Standing Committee of Psychologists in Health and Social Care, said: 'There is a deplorable discrepancy between the demand for mental health services in prison and the availability of mental health practitioners to meet that need. We agree with SCMH on the two key issues - the urgent need to address mental health in prisons and that expanding access to psychological therapies is at least part of the answer... indeed, a replication of the Improving Access to Psychological Therapies programme in prison settings could do much to reduce the inadequacy of services.' JS

The Queen's birthday honours list saw a bumper crop of awards for psychology and Society members - particularly clinical psychologists and those in health care. We spoke to them about the importance of their work, and of psychology within it.

Dr Hazel Douglas, Head of Child Psychology in Solihull, was appointed MBE for services to children and families. She told us: 'I am really pleased to see the tangible recognition of the importance of early intervention with children. A practitioner can change the life trajectory of some children within a few sessions of work with the family. Of course, the sooner this happens the better, given that most brain development occurs before the age of three years, so our current challenge is developing an antenatal resource pack and parenting group. The Solihull Approach model has cascaded to many areas of the UK, and psychologists in Russia are looking to take it on to stem the tide of children being given up to orphanages. After that we would like to work with developing countries who have primary care workers, as we think the model may help their work in the community.'

Dr P.O. Svanberg, a consultant clinical psychologist previously with the South of Tyne and Wearside NHS Trust, was appointed OBE for services to infants and their families. 'Many years ago, working as a bog standard adult mental health psychologist, I realised that unless we did some serious preventative work we would always be like little Dutch boys with a finger in the dyke,' he told us. 'This created for me an abiding interest in the applications of attachment theory, particularly in its focus on the highly significant impact of the early parent - infant relationship and how this creates the secure or less secure base for the growing child. Thus, for me, applying perinatal psychology, parent - infant psychotherapy and infant mental health in order to improve infants' futures and enable their families to hopefully develop a more rewarding and fulfilling pathway is an abiding passion. Although it's now very high on the government's agenda, it concerns me that these services are still very piecemeal on the ground.'

Mary Burd was appointed MBE for her services to health care in East London. She is Head of Psychology and Counselling with Tower Hamlets Primary Care Trust and was, until her retirement from the post, Director of Therapies with East London NHS Foundation Trust. She said: 'My passion has always been about the contribution psychology can make to the whole range of health care, from mental health to long-term conditions, but especially to its role in primary care. I have always believed that psychologists need to be part of the wider management structure. Rewarding as it is to ply one's trade as an expert clinician, we need to be part of decision-making bodies at the highest level. This is not always easy, and we need to be constantly reminding those we work with of the relevance and value of the psychology role. In this respect, the Improving Access to Psychological Therapies programme constitutes a considerable challenge: for well-established primary care services and also for the profession of psychology. We also need to find our way into making the contribution to the Long Term Conditions agenda.'

Dr Michael Paterson, Consultant Clinical Psychologist, was appointed OBE for services to health care in Northern Ireland. Paterson had both arms amputated in 1981, during service in the Royal Ulster Constabulary, when the IRA fired an anti-tank rocket into has patrol vehicle. 'This effectively ended my police career and led to one in psychology,' Paterson told us. 'After dealing with my major physical impairment, and a BSc, PhD and DClinPsych later, I started working with trauma, developing expertise with eye movement desensitization and reprocessing (EMDR). I found this to be a phenomenal psychological therapy which resulted in remarkable changes in people's lives, and I was witnessing this daily! In 2002 a psychiatric colleague and I opened a clinic in Belfast where we specialise in treating post-traumatic disorders. Since then I continued to develop my expertise in EMDR in order to train others in its use. My motivation is to improve the quality of people's lives; from that perspective I have done a bit but have much more yet to do.

Dr Sarah Davidson is Deputy Clinical Director on the University of East London's doctoral degree in clinical psychology and Consultant Clinical Psychologist at the Tavistock and Portman NHS Foundation Trust. She was appointed MBE in recognition of her 30 years' service to the British Red Cross, who she works for as a psychosocial adviser (see News). In recent years, Sarah has guided the delivery of emotional support after the Asian Tsunami of 2004, the London bombings in July 2005, and the capsizing of a dhow in Bahrain in 2006, among many other emergencies. Sarah told us: 'The Red Cross is an amazing organisation which touches so many. Psychology plays a significant role, running through all the services we provide and much of our training too. Only this weekend I was speaking to representatives of 28 nations at the First Aid Convention for Europe in Liverpool about the importance of using psychological principles in first aid. The competition that followed tested teams on 14 different scenarios, each of which incorporated assessments of their psychosocial skills, such as building trust, respecting people's different needs and wishes, treating people with dignity, and empowering them by giving them choices.'

There was also an OBE appointment for a former Society member, Professor Gloria Laycock, for 'services to crime policy'. Professor Laycock told us that her citation suggests she was nominated by someone from the Home Office, where she worked as a psychologist and researcher for over 30 years before becoming Director of the UCL Jill Dando Institute of Crime Science. 'It is deliberately not an Institute of Criminology,' she tells us. 'Not that there is anything wrong with criminology, but in the UK this is heavily influenced by sociology rather than empirical psychology which is my passion. It is alarming just how little real experimentation there is in the crime control area, but we are trying to set that right at UCL. So psychology not only affects my day-to-day work but also the way in which I interpret and think about the many challenges faced by those trying to reduce crime by attending to the situation within which it occurs. Some of the present policies make no sense whatsoever when looked at from a psychological perspective - I have not been slow in saying so! I owe a lot to our subject and am determined to see its greater influence in policy advice.'

In the United States, polygraph testing is used widely in the treatment and supervision of sex offenders. Now a 'hot topic' debate published in Legal and Criminological Psychology has considered the evidence base and the ethics of this post-conviction sex offender testing (PCSOT).

Don Grubin (Newcastle University and the Northumberland, Tyne and Wear NHS Trust) argues that much of the criticism of PCSOT arises because of confusion between it and other applications of polygraphy. He argues that the evidence for accuracy and utility, although not definitive, is sufficient to justify its use. But Gershon Ben-Shakhar (Hebrew University of Jerusalem) counters that the use of polygraphy with sex offenders is even more problematic than its common use as an aid in criminal investigations. He claims that the use of polygraph testing in rehabilitation is misguided, and instead of reducing recidivism in sex offenders is likely to achieve just the opposite.

The debate serves as another example of how, in Grubin's words, 'while some, mostly coming from a practitioner perspective, argue strongly for post-conviction polygraph testing of sex offenders on clinical grounds, others, often from academic backgrounds, remain to be convinced that the gains are real and the risks properly understood.'

Psychologists in America are to publish a partial replication of the infamous Milgram experiments on obedience to authority. The classic 1960s research is often invoked by commentators seeking to explain the latest human atrocities - for example, the abuse of Iraqi prisoners by American guards at Abu Ghraib. But Stanley Milgram's paradigm, which involved participants administering electric shocks to another person, hasn't been replicated in over three decades, due to ethical concerns.

To re-cap, in Milgram's experiments participants were allocated the role of teacher in a fixed draw, and were led to believe they were issuing shocks to another participant, the 'learner', (actually an actor) each time this person made a mistake in a memory test. Participants were told the shocks were painful but not harmful, although labelling on the shock generator carried warnings of harm for the highest voltages.

Like many social psychologists, Jerry Burger at Santa Clara University, California and his colleagues knew that Milgram's original data showed the 150 volt shock level was a pivotal point in the experiment. 'But as I was looking over these tables,' Burger tells The Psychologist, 'I was struck by the fact that 150 was more than a common stopping point. It was actually something of a point of no return.'

In Milgram's best known 'Experiment 5', the 150v level was the first moment at which the actor being shocked said they wanted the experiment to stop. If a participant continued to administer shocks beyond this level it was extremely likely they would go all the way to administering the highest 450v shock (79 per cent of such participants did).

The new study replicated Milgram's methodology with great attention to detail, including the use of a replica shock generator and with a script that stayed faithful to the original. Crucially, however, the new version was stopped immediately after participants made their decision as to whether or not to continue issuing shocks beyond 150v. Potential participants were also subjected to extensive screening, with the psychologically vulnerable or anyone aware of Milgram's research being excluded.

The new study, in press at American Psychologist, found 70 per cent of 40 participants were willing to proceed beyond the 150v shock level - a proportion only slightly lower than Milgram's figure of 82.5 per cent. Burger's team said their finding provided compelling evidence that people's obedience to authority today, under lab conditions, is comparable to that which was observed in the 1960s.

To the researchers' surprise, disobedience was no higher in another condition in which participants witnessed what they thought was another participant (actually an actor) refusing to continue with the experiment. Further analysis also showed participants' empathy levels had no bearing on their obedience, although a greater desire for control was linked with more disobedience.

Burger says he hopes this new approach to replicating Milgram's work will allow psychologists to further investigate the situational factors that impact on obedience levels. 'Understanding how and why people respond to these situational factors could provide valuable information for policy makers,' he says. 'We have to be careful when making the leap from a laboratory study to something as complex as the Holocaust. But understanding the social psychology operating in the kinds of situations that interested Milgram - atrocities, massacres, genocide - is an important step in the process.'

By coincidence, a new meta-analysis of data combined from eight of Milgram's obedience experiments has also just been published in Perspectives on Psychological Science. Dominic Packer, a researcher at Ohio State University, also identifies the 150v shock level as a critical moment in Milgram studies. He found that of those participants who were ultimately disobedient, 36.8 per cent chose to stop at the 150v level (with 29 possible shock levels, a random distribution would have seen just 3.5 per cent disobey at 150v).

Milgram observed that at the heart of his experiments lay a conflict, between the desires of the experimenter and of the electrocuted 'learner'. According to Packer, the 150v level, when the learner of the experiment first said he wanted to stop, was the moment that participants saw this conflict in stark relief - when they had to choose between the authority of the experimenter or the rights of the suffering learner. By contrast, expressions of pain from the learner, which began from the earliest shocks and grew in intensity with higher voltage, did not have a significant impact on the participants' decision making.

Packer says these observations have important implications for the treatment of prisoners in interrogation scenarios. Post 9-11 there has been a tendency for authorities to ignore legal rights, for example, as laid down in the Geneva Convention, claiming instead that prisoners will not be subjected to undue pain. However, as Packer concluded, 'pain did not tend to be sufficient for disobedience in these studies; thus, when prisoners' rights are curtailed or ambiguous, expressions of pain may provide little protection from inhumane treatment.' Packer says this means 'harmful treatment of prisoners may be more likely when standards for their appropriate treatment are ambiguous ... and, in particular, when authority figures appear to imply that the harsh techniques (e.g., waterboarding) are necessary and relatively innocuous.'

Edited: 08/07/2008 at 09:36 AM by christian

The trend in healthcare towards greater patient empowerment includes the idea that patients should be involved in their treatment decisions, as opposed to having them imposed by a doctor. To date, this ambition has been driven more by principle than evidence, but now a systematic review has confirmed that, at least when it comes to chronic illnesses, patients do benefit from being involved in treatment decision making.

The researchers led by Evelien Joosten and including Tom Sensky, Professor of Psychological Medicine at Imperial College London, identified eleven high-quality randomly controlled trials that compared outcomes for patients involved in treatment decisions with outcomes for patients not involved.

The six studies that showed a positive effect of shared decision making, in terms of satisfaction, adherence, depression, and well-being, had in common that they concerned long-term treatment programmes for chronic conditions. This included two studies looking at depression and schizophrenia. The absence of a positive effect of shared decision making for acute conditions was no surprise to the researchers who said that such cases, by definition, often involve urgent decisions for which a collaborative approach is impracticable.

Writing in the journal Psychotherapy and Psychosomatics, the researchers concluded there is an urgent need for more research: 'Considering the growing clinical interest in shared decision making,' they said, 'it is surprising and disappointing how little randomised controlled studies have been published regarding its efficacy.'