SOOTHE webinar: Learning about mental health from people with intellectual disabilities

 

This morning I attended the SOOTHE webinar Learning about mental health & well-being from people with intellectual disabilities. The SOOTHE project is working on mental health in people with intellectual disabilities, with the aim of developing an international community of practice. The webinar was bilingual, with some presenters speaking in Spanish but presenting slides in English. I found this quite refreshing, given usual Anglophone hegemony at events/in science globally.  

A key output of SOOTHE has been its E-quilt: an artistic means for expressing understanding of mental health. The quilt is still accepting submissions at this link. On the broader point of art, Professor Wolter Paans highlighted how artwork by people with ID can be included in an exhibition with an entry fee, underscoring the social value of the artwork.

Research in understanding mental health with people with ID was discussed. Some people with ID had quite biological understandings of mental health, even though they linked challenges to mental health with negative experiences in the past (feelings of rejection was often a theme, as well as not feeling heard/understood). There was a bidirectional effect; it seemed that participants not only gave their own viewpoint, but participation in the project broadened the participants' own understanding of mental health.

Beyond understanding mental health itself, the session went on to discuss innovations and ways of improving mental health. Among ideas discussed were relaxation/mindfulness workshops, musical spaces, use of technology, spaces to reduce stimuli, getting professional support to talk about difficult emotions, and enjoying meaningful activities in company of others. Social interactions as well as faith/religion were highlighted as helping to foster a sense of connectedness. Unsurprisingly, COVID-19 cropped up, with negative emotional impact of lockdown restrictions.

Pablo Alvarez discussed a Learnovate approach: going from ideas to implementable solutions, using storyboards to workshop how ideas might be implemented (e.g. physical activity, social interactions, music activities). The project involved working though how to make music available and accessible online, and how to share it. The team developed a prototype app, then had a Q & A session to feedback on user experience with the app, which can be used to create agenda for daily activities. When I say "team", it should be noted that there was a consistent focus on co-creation with people who will be using app. 

In a final discussion, one panelist sounded an optimistic note of how people are increasingly understanding that we're all on a continuum of mental health. COVID-19 was described as a natural experiment no one asked for, meaning that people in general have no choice but to use technology if they wish to communicate with others. The participation of people with ID in the process was highlighted, so there's an ongoing need for the information generated by the project to be available in an accessible way for people with ID, and that people with ID might be able to recruit others and become mental health advocates.

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The Impact of COVID-19 on People Ageing with an Intellectual Disability in Ireland

 

The Irish Longitudinal Study on Ageing (IDS-TILDA) has been studying ageing in people with intellectual disability (ID) for over a decade. Now in its fourth wave, a number of its research activities had to be paused due to the COVID-19 pandemic and associated lockdown. However, the IDS-TILDA team has taken the opportunity to study the impact of COVID-19 on participants in this longitudinal study. To mark the release of the report of the findings of this research, an online launch was held on 3^rd December 2020, International Day of Disabled Persons.

Attendees were welcomed by Professor Mary McCarron, Principal Investigator of IDS-TILDA. Minister Anne Rabbitte, TD, Minister of State with Responsibility for Disability, gave a speech highlighting the context and main findings of the study, and praising the work of the IDS-TILDA team, those people with ID who have taken part in the study, and those who have supported them during this pandemic. Minister Rabbitte acknowledged that the pandemic and associated lockdown have been difficult for all of us, but it has often been even more challenging for people with ID, who can be more vulnerable, and often have less autonomy than the general population.

Professor McCarron then presented key findings from the COVID-19 survey. The COVID-19 survey had a response rate of 96% from the IDS-TILDA cohort, meaning this survey was representative of the population with ID in Ireland. A majority of participants were tested for COVID-19, with many being tested multiple times. Of those who did test positive or had symptoms, a clear majority had a plan in place to manage self-isolation. Key sources of stress and anxiety were being unable to do one’s usual activities, not seeing friends/family, loneliness and isolation. At the same time, many participants reported there had been some positive aspects to the lockdown, such as trying new activities or using technology to communicate with relatives and friends. Most importantly, there were no reported deaths due to COVID-19 in the IDS-TILDA population.

Following this summary of the results, broadcaster Olivia O’Leary led a panel discussion with a variety of stakeholders, exploring different perspectives on the pandemic and lockdown. Participants on the panel highlighting how best practice was implemented for people with ID in Ireland included Professor Sean Kennelly (Consultant Physician in Geriatric and Stroke Medicine, Tallaght University Hospital), Dr Alison Hartnett (Acting CEO, National Federation of Voluntary Service Providers), Dr Kathleen MacLellan (Assistant Secretary, Social Care Division, Department of Health), and Lisa Lavelle (Director of Nursing, Daughters of Charity Disability Support Service). From an international perspective, Professor Chris Hatton (Manchester Metropolitan University) praised the work of services in Ireland in protecting people with ID, and the research of IDS-TILDA, saying he hoped similar research (conducted at a more localised level) in the UK would be published soon. Professor Philip McCallion, Co-Investigator of IDS-TILDA, highlighted the heterogeneity of experiences across the United States, given the size of the country, but drew particular attention to the deep impact of COVID-19 in the North-East of the USA, where he works at Temple University, Pennsylvania. Mei Lin Yap, a PPI contributor and steering committee member with IDS-TILDA, spoke of her lived experience of the lockdown, and of the importance of social contacts during the lockdown.  

Following final comments from Professor McCarron, the launch closed with the original song “We’re in this together” by Sunbeam House Services. The song and its accompanying video, made by the service users, was a great way to finish the launch and underscore the importance of solidarity with each other at this time.    

You can download the report at this link.

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Writing workshop: "Novel Problems" with Niamh Campbell

I recently attended "Novel Problems" at the Irish Writers Centre The course was conducted entirely online, given the pandemic. The course is run by Niamh Campbell, whose debut novel This Happy has been getting very positive reviews. I had previously attended Fundamentals of Fiction, which combined a didactic aspect with workshopping of work, whereas Novel Problems focused more heavily on workshopping throughout. 

The quality of writing at Novel Problems was very high, and some of the participants were progressing quite well in the publishing game; one person in particular had already secured an agent, and their novel was in the process of being sent to publishing houses. Whereas the participants at Fundamentals worked in a mix of genres, the pieces workshopped on this course tended to be  more grounded in realism (in contrast, my current work combines the surreal, hyperreality and magic realism, so I felt like somewhat of a black sheep in this regard). During some of the discussions I realised that I would have benefitted from reading through the circulated extracts a few times; a lot of subtleties of people's work can go over one's head at a first read.

For the last week, we spent some time talking about an interesting article by Zadie Smith which led to much discussion around issues of identity, and authenticity in writing. I think this discussion was very pertinent for many of the writers in the group, whose work had a semi-autobiographical quality. My current work in progress is a totally fictional piece that is not based on anyone I know, but the article by Zadie Smith does make a fair point that the writer's personality will come through in their writing (regardless of how outlandish their story might be). 

This course is geared towards writers who have been working on a novel for some time, but I wouldn't write it off if you're starting on something, as long as you're passionate about it. If the course is running again, it's a great chance to get feedback from other motivated writers. 

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The distracted muse: generating new ideas when performing a separate task

 

There are many distractions on offer when one is undertaking a creative task. I write fiction, but do so on a laptop connected to the internet, and research into some aspect of life I want to include in a novel can quickly lead down a rabbit hole of interesting Wikipedia articles. 

A new paper in Creativity Research Journal looks at the possible effects of distraction on creative thinking. In contrast to the usual story of distraction spoiling the creative person's work, the idea presented here is that, by occupying attentional resources that could otherwise inhibit possible ideas, more creative ideas may emerge.  

The author assessed divergent thinking (generating different ideas/multiple possible solutions to a problem) using an Alternate Uses Task. Participants were provided with the names of everyday items and asked to come up with different ways of using them (so, if you see an iron, you could take the water out of it to water a plant, leave the iron out to make it look like you do more housework than you really do etc. etc.). Participants also had to complete a simple task which involved pressing coloured buttons in response to coloured boxes appearing on a screen. Sometimes (the dual-task condition) they had to complete the two tasks at the same time.

The results indicated that participants' scores on the alternate uses task increased in the dual task condition, compared to when they did the alternate uses task by itself. This was the case for originality (i.e. how unique the ideas were), fluency (i.e. how many ideas were produced), flexibility (i.e. how many broader categories of ideas were produced), and elaboration (i.e. how developed the ideas were). I would have expected originality to increase in the dual task condition, as unusual ideas become less inhibited, but was quite surprised to see overall fluency increase, given that the dual task might have made it more effort to produce a given number of ideas.

There is a history of different explanations offered as to why one can come up with better ideas while working on a different task to the creative endeavour. One possible explanation is opportunistic assimilation, where an idea from a different field can influence another project where you're stuck for ideas. However, I don't think such assimilation could be demonstrated in a short-term study of this nature, where the rather basic dual task would be unlikely to provoke many ideas.       

 This research looked at divergent thinking over a short period of time. Collins himself notes that divergent thinking is not equivalent to creativity.  Longer creative works will often take longer periods of focused concentration. Doing a line edit on a novel is probably best done without distractions (so unplug your internet!). The experimental scenario was set up in such a way that the participant would be encouraged to keep working at the creative task at the same time as the distracting dual task (rather than just disappearing down the Bermuda triangle of Wikipedia and leaving the Word doc with the novel closed). Nonetheless, this article suggests that giving your full and undivided attention to a task when generating new ideas might not be all it's cracked up to be.

Collins, M. J. D. A. (2020). A Distracted Muse: The Positive Effect of Dual-Task Distraction on Creative Potential. Creativity Research Journal, doi: 10.1080/10400419.2020.1816066. 

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Memory clinic for people with intellectual disability

 

It was great to see Trinity College Dublin's news page cover a recent webinar from the National Intellectual Disability Memory Service at Tallaght Hospital. In addition to Professors Mary McCarron and Seán Kennelly, who established the service, the webinar had the special guest speaker Dr Juan Fortea, who spoke of some of the intersectional aspects of health inequities for people ID, as well as highlighting his work with the Down Alzheimer Barcelona Neuroimaging Initiative and international consortia. He mentioned that there appears to be more funding for research on this topic in the United States, although the incidence of Down Syndrome is higher in Europe. He also spoke about the value of research in enhancing quality of life for people with Down Syndrome, and highlighted that barriers to participation in research could well be considered a form of discrimination against people with Down Syndrome.    

The National Intellectual Disability Memory Service will work in assessment, diagnosis, post-diagnostic support, and research. Assessing any patient for dementia is complicated, but this is particularly true in the context of intellectual disability, where physicians cannot assume a typical baseline level of cognitive performance or independence in daily living. The onset of dementia is younger on average in people with ID, so the potential to capture baseline cognitive performance and independence at a younger age (e.g. mid-thirties) will allow for a clearer picture of any decline. Professor Seán Kennelly highlighted the importance of appropriate disclosure of diagnosis, as well as how post-diagnostic support should take into account lifestyle factors such as sleep and physical activity.   

The National Intellectual Disability Memory Service aims to develop satellite clinics across Ireland, so patients from around the country will not necessarily have to travel to Tallaght in Dublin for assessment. Professor Mary McCarron also underlined the value of telemedicine in helping to address equity of access, particularly in this time of the COVID-19 pandemic. A recent guide to memory clinics highlighted that there were no memory clinics for the general population in the Northwest of Ireland, despite this region having the highest prevalence of dementia, and to the best of my knowledge there is no national memory clinic for the general population. Notwithstanding that general memory clinics will see a higher number of patients, the NIDMS is clearly setting a very high standard in this arena.

The webinar is available at the NIMDS webpage: https://www.tcd.ie/tcaid/research/NIDMS.php 

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Irish Research Staff Association: meeting with Minister Simon Harris

I recently became Chair of the Irish Research Staff Association (IrishRSA), which represents research staff across the island of Ireland. My colleague Dr Rosarii Griffin and I had the chance to meet with Minister Simon Harris and his team at the Department of Further & Higher Education, Research, Innovation & Science.

The meeting was very constructive, covering various topics affecting Irish research staff, with the precarity of researcher careers being a key issue underpinning the discussion. We discussed  researcher representation on decision making bodies, and the need for researchers to be consulted on the content of the national Researcher Career Framework.

Another key point was the importance of collating reliable data on researcher numbers & career trajectories, which is required to inform policy with regard to research careers.

We also discussed future research policy, Horizon Europe, impacts of Brexit, UNESCO commitments and full-cost extensions to projects interrupted by COVID-19. We look forward to continued consultation with the Minister on these topics and to supporting the Irish HEI research performing sector.

The IrishRSA consists of members from TCD, UCC, UCD, NUIG, MU and RCSI but actively welcomes research staff from all HEIs across the island of Ireland to contact us and join the association (irishrsa@gmail.com).

Many thanks to Minister’s office for the photograph. Left to right: Dr Rosarii Griffin (UCC, Treasurer of Irish RSA), Minister Simon Harris (Minister for Further and Higher Education, Research, Innovation and Science), Dr Andrew P. Allen (TCD, Chair of Irish RSA)

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Recent letter to "The Psychologist": Psychology as science/psychology and social justice

A recent letter to The Psychologist magazine has attracted considerable controversy, with editor Dr Jon Sutton adding a note below the letter itself, regarding his decision on whether or not to publish it. The author (Dr Kirsty Miller) outlines the reasoning behind her decision to leave the British Psychological Society. (By the by, I let my own membership of the BPS lapse, but only because I moved back to Ireland rather than as an objection to anything). Although the letter is addressed to this British society specifically, the letter touches on a number of broad and timely/timeless issues within psychology. One value of the BPS in its code of ethics is that psychologists should "stay in their lane" or exercise caution in making knowledge claims, so I should say I'm not an expert on the specifics of much of what's discussed in this response, these are just my thoughts/opinions. I quote from the letter in bold italics below, with my thoughts in plain text.

In recent years I’ve become increasingly aware of the politicisation of the British Psychological Society, a shift that I feel is inappropriate for what is ultimately a governing body. When an organisation releases value statements (for example, after the recent BLM furore), it is speaking on behalf of members, and telling us what we should believe. There is no acknowledgement that some members do not subscribe to similar world-views, and it is certainly inconsistent with the BPS’s own statements regarding diversity within the organisation. 

Organisations may make statements on behalf of members. Of course, these can't necessarily represent the views of all members (a task like herding cats). In my mind, it would be somewhat prosaic to preface a statement with the caveat that it doesn't align exactly with every individual member's views, or that individual members are free to disagree with some of the world-views expressed. At the same time, this paragraph does implicitly touch on the point that Western psychology does have a tendency towards a more left/liberal worldview that the general population. One survey of 800 psychologists found that only 6% of respondents described themselves as Conservative overall, though there was a certain degree of viewpoint diversity on economic issues and foreign policy. 

However, the statement on racial injustice is a poor example to suggest that the BPS has a liberal bias; the underlying message of anti-racism should hardly alienate people across (most of) the political spectrum (I hope). While the statement focuses on racism and anti-racism, the statement more broadly promotes values of inclusion that could be extended to differing political views. However, where such political views themselves become discriminatory, this will frustrate the goal of being inclusive. Furthermore, the BPS can hardly be truly inclusive if it does not at least try to grapple with the fact that different people may find it harder to get into a career in psychology in the first place.

As the cited statement from the BPS with regard to racial injustice and inclusion notes, "The BPS does not exist in a vacuum", and as noted in the about us section of their webpage, the BPS promotes "excellence and ethical practice in the science, education and application of the discipline" (my italics added). 

A further issue is it that the majority, if not all, of these statements are promoting a social justice agenda: an ideology that is ill-defined, subjective, and often far removed from reason or evidence. The concepts tend to be based on the notion that the way to address the historical suffering of certain groups is to give them preferential treatment in the here and now. This is presented as ‘justice’, however many would disagree that there is anything just or fair about giving preferential treatment to some and punishing others on the basis of immutable characteristics. 

However, one of the biggest problems with the BPS subscribing to social justice principles, is that to do so, one largely has to abandon science and facts. This is a particular issue as the BPS is still trying to claim that psychology is in fact, a science. Furthermore, if we were to behave like scientists (i.e. using evidence to support our beliefs, and self-correcting in the face of conflicting evidence), we should have abandoned many of psychology’s pet outputs (such as microaggressions, implicit bias, inaccuracy of stereotypes, the notion that disparity equals discrimination etc.) a long time ago. However, despite evidence challenging these (and similar) notions, they are still presented uncritically and promoted by members, as well as the organisation as a whole. 

I think psychology could be better described as an empirical endeavour rather than just a science. Scientific methods contribute enormously to psychology (e.g. double-blinding, in experiments as well as in peer review, although double-blinding can be difficult to practice in studying talking therapy compared to an active pill versus placebo). At the same time, qualitative research methods used in psychology, while empirical, do not necessarily employ the scientific method, and qualitative researchers have generally pointed to the importance of reflexivity (i.e. acknowledging the role of researchers' subjective appraisal in their empirical work). I think that reflexivity is important across the board in psychological work, not just in employing qualitative methods. 

With regard to dropping ideas with weak empirical support, it is true that, once an idea takes hold, it can indeed be "sticky" in terms of self-correcting if emerging evidence suggests that it was on weak foundations to begin with. However, as Dr Miller points out, research has been done that challenges any perceived social justice "consensus", and besides the research cited here, I would also add that a lot of implicit bias training has come in for some stinging criticism from people with rather diverse political viewpoints. 

Nonetheless, this does touch on an important point. Although psychological research may inform political debates, if political/ethical statements are presented as if they were scientific facts, this can have the negative effect of undermining public trust in science if such value statements are later found to be based on weak evidence. Conversely, do we really need an evidence base to say "racism is bad"? The idea that society needs a better evidence base for racism being a social ill could lead to inertia in addressing racism.    

Finally, and perhaps most concerningly, following a social justice agenda prevents us from achieving the goals that as psychologists, we should be striving towards. First, it actually promotes mental illness – encouraging individuals to look for, and hold on to slights, read in to others’ intentions, and assume the worst from others’ behaviour (all patterns of thinking that CBT practitioners warn against).

Having dismissed social justice as ill-defined, Dr Miller nonetheless opines that it is corrosive to the aims of psychology. This point here appears to make a mistake that is mentioned in an article that she cites earlier in her letter (i.e. conflating social justice with victimhood culture). A lot of thinking that I'm hearing within social justice tends to downplay inter-individual interaction compared to broader systemic issues, and so shouldn't necessarily lead individuals to ruminate on the possible intentions behind another individual's behaviour or obsess over perceived slights. In contrast, there are various mechanisms through which pursuing social justice could be beneficial to mental health. Getting involved in a political organisation that challenges racism, for example, may help someone to overcome feelings of helplessness or alienation (although this research does suggest caution about assuming this will necessarily be the case for everyone).

Second, it prevents education, with professors (particularly those who are categorised as white and/or male) being increasingly unable to respond to, contradict, or ultimately educate those from other demographic groups. 

The article cited here seems an odd choice, referring to an incident on Twitter rather than a classroom (although a number of professors were involved). A lot has been written on this topic, we could talk about anecdotes about someone being fired over a faux pas, but it's beyond the scope of the letter (or this post) to deal with it in depth. It is wrong if academics in psychology (or any other subject area) are disciplined simply on an ad hominem basis. White and/or male and/or cishet etc. etc. professors may feel more defensive in the lecture hall. Applicants who wish to undertake a doctoral in clinical psychology may feel up against it given that they're from an ethnic minority. Nonetheless, I don't think we should be too pessimistic about the possibility of being anti-racist, anti-sexist etc. while still being able to run courses in psychology. As I mentioned in my post on academic freedom, politics and economics it is possible to have academic freedom without having to put up with prejudice towards students/staff.

Finally, the teachings create damaging divisions between groups. As a student, I began a ‘minorities and majorities class’ treating all human beings equally regardless of their demographics, and left it feeling obliged to avoid all interactions with minority groups lest I offend someone – one of the many known problems associated with such programs.

The paper cited mentions potential pitfalls with cultural awareness training (and, implicitly, cross-cultural encounters). These include placing cultural difference at the centre of interactions, and the associated issue of creating/heightening a sense of in-/out-group. Addressing these pitfalls shouldn't necessarily be contrary to efforts at social justice (for example, acknowledging a person's individuality would avoid placing culture at the very centre of the interaction, and could correct the social injustice of seeing members of a given group as "all the same"). The fact that teachings require reform doesn't refute the value of having cross-cultural awareness.

Should the BPS re-evaluate their values and decide to do their job of governing the organisation from an impartial and scientific standpoint, I would gladly pay my membership fees and re-join. Until then, I fear I shall continue to watch the downfall of our discipline – one that is due in large part to the complicity of those who were tasked with protecting it.

The BPS could go in the direction of being more exclusively science-focused, commenting less on the ethical and the political. If it were to do so, no doubt it would gain some members and lose others. However, I think it's alarmist to suggest that the discipline of psychology will suffer some "downfall" as a result of engaging on political or ethical issues (which it has been doing for quite some time). 

The letter as a whole has a sense of having one's cake and eating it, calling for greater objectivity/harder science/evidence-based practice while also making some broad assertions that call for more evidence, such as the idea that a social justice agenda promotes mental illness. This may be coming from a place of wishing to offer a corrective for a left/liberal tendency within psychology, but ultimately the letter vacillates in playing by its own rules. Ultimately, although politics and values will be more/less salient in different sub-disciplines, human psychology isn't really separable from the political or ethical, and I think the BPS overall is "within its lane" in supporting research while also being cognisant of the broader sociocultural context (including the historical context) in which this is happening, and, who knows, maybe even applying psychology to help create a fairer society for the benefit of people's mental health. What's so bad about that?

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Restaurant review: One Pico

                                                       

One Pico is tucked away in an assuming lane of Molesworth Street. I previously had dinner here during a UCD conference on medical humanities. I was perhaps a bit lost in conversation with collaborators to really focus on the food.

When it comes to social distancing, I was previously at another, unnamed restaurant that had us at what seemed like rather close quarters with other patrons (albeit separated by screens). Here though, the tables are suitably distanced from each other. There's a pleasant ambiance, with lively jazz at low volume and friendly waiting staff.

For starter, I had pea velouté-earthy flavour, with dried peas adding nice textural contrast. There was also a Coolea cheese gougere, that seemed to be calling to be eaten in one mouthful, though I spaced it out to two. My wife had seared scallops in a crab bisque-major hit of sea and umami. It had a perhaps unnecessary addition of summer truffle on top - while adding a dash of prestige, this didn't quite integrate with the dish as well as it might. Nonetheless, it didn't impair what was otherwise an excellent dish.

For mains, I had gnocchi-this is in done a lot in veggie fare, although variations on sweetcorn were the real star here, appearing as both seared corn, deep fried in a pastry shell and flavouring a rich sauce. Perhaps it's already making a comeback of which I was unaware, but it's nice to see a vegetable that isn't super hip getting a chance to shine. My wife had turbot, which was decorated with caviar and accompanied by a scene-stealing courgette flower stuffed with langoustine mousse. 

For dessert, my wife had a lemon verbena bavarois with strawberries, elderflower and sorrel ice cream-a beautifully balanced and delicate dessert. I had a chocolate délice with black cherry and cherry ice cream. A classic pairing for anyone who can recall black forest as a childhood treat, this dessert was also well balanced, even though the chocolate was of a richness approaching that of "La bombe" in "Guess who's coming to criticise dinner" territory (as well it should!) Coffee was accompanied by a salted caramel truffle and a white chocolate with a gooey strawberry filling.

We got a bottle of archetypal Soave with a nice citrus feel to accompany dinner. We took most of it home and enjoyed with a leek risotto the following evening. I managed to resist the temptation of the dessert wines. I can definitely recommend if you want to go somewhere nice for an occasion.

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Clinical psychology applications and ethnicity (Review of thesis by Ragavan, 2018)

There's a major bottleneck in clinical psychology training in Ireland and the UK, with many people with a psychology degree hoping to pursue clinical psychology as a career, and much demand for the services clinical psychologists provide, but a limited number of places on training courses. Not only are applicants trying to build up clinical experience, but also research/publication experience and continuous professional development. Psychology graduates often work for years after finishing their primary degree (often taking on voluntary/unpaid work part-time or even full time) in order to pad their CV's enough to compete. Needless to say, this creates a lot of scope for those from less advantaged backgrounds to face an uphill struggle if they want to get into this area of training.  

With regard to ethnicity and clinical psychology, much previous research has focused on people who are already on training courses, but there's a whole cohort of those who may or not make it onto such courses. An interesting thesis by Dr Romila Naiken Ragaven interviewed people from a BAME (Black and minority ethnic) background who were applying for clinical psychology training courses.

The participants were eight females working in typical roles for those applying for clinical psychology roles (e.g.assistant psychologist). No males took part in the study- it would have been interesting to have male interviewees as well, but there does tend to be a higher proportion of female applicants for clinical psychology roles.

The participants reported wanting to be agents of change within their own communities, but also wanting to contribute to change the conversation around Western conceptualisations of mental health (e.g. they mentioned cultural difference as being a brief addendum to educational materials they'd seen). One quote from a Black British participant was used to illustrate how they negotiate multiple identities and narratives. This quote speaks to the value of being a BAME applicant, but also struck me as containing a false dichotomy that worryingly hints at the persistence of stereotypes around ethnicity and competence: 

On the one hand you wanna be seen for like your skill set and the fact that you are an intelligent person that's capable of doing the doctorate, and on the other hand, you wanna show how your own background can benefit the field, and I think it's hard to marry the two without having some sort of, like, controversy (pages 69-70)

Participants referred to having to work harder to achieve the same results as their White counterparts. One person reported feeling that they might not articulate themselves in a manner that comes off as professional as some of her White peers (while pointing out this is a class issue as well), and furthermore that she might not have as much research experience. All this will be filtered through the lens of the intensity of competition for places on training courses. As one person put it:

I’m not going to lie, it freaking annoyed me. This girl had one year’s experience post masters and then she got an interview for two courses and I’m thinking “but I’ve got more years’ experience than you”, but one thing we were talking about was that she has the privilege of not working because she’s middle class, so she was able to go an volunteer and stuff like that. But for me, I needed to work. I don’t come from money like that. (page 87)

The participants referred to experiences of overt racism from clients/service users, but perhaps more concerning was a sense that such experiences were being minimised by some of their supervisors. 

...She was like “oh I don't think he meant it like that”, and I said, "Regardless of how he meant it as a joke, he offended my skin tone." And then she was like, "Well, I've never had anybody say that to me". And I said, "Yeah because you're White like you don't understand." (page 78)

They described a pervasive baseline anxiety about being treated in a negative manner because of their ethnicity, and not mentioning their ethnicity on application forms out of fears that it might negatively affect their chances. This might surprise some readers, as (and the interviewees acknowledge this) there have been increased efforts to make cohorts of clinical psychology trainees more representative. Nonetheless, the participants expressed a certain ambivalence about this, wondering if they might be selected to fill a quota rather than on merit (while simultaneously experiencing hostile discrimination from other quarters). The reported lack of role models alluded to by the participants here may suggest that mentoring could help to overcome concerns about tokenism; external validation from a senior peer with whom candidates can identify with may offer reassurance they can stand over the quality of their application in its own right, rather than seeing themselves as filling a quota.

For a deep dive, do check out the thesis itself:

Ragavan, R. N. (2018). Experiences of Black, Asian and minority ethnic clinical psychology doctorate applicants within the UK. [Doctoral dissertation, University of Hertfordshire]

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Cognitive behavioural therapy for depression

1.     Introduction

Major depressive disorder (referred to as “depression” for the remainder of this essay) is defined by the American Psychiatric Association (APA) as depressed mood or lack of interest or pleasure (for most of the day, nearly every day, for at least two weeks), along with a minimum of other symptoms, for example, altered sleep, difficulty in concentrating or suicidality (APA, 2013), and has been identified as one of the leading causes of disability by the World Health Organisation (WHO, 2020). Depression is associated with poorer performance and presenteeism in the workplace (Cocker et al., 2011). Though there are multiple causal factors in suicide, a substantial minority of people with depression die by suicide; the lifetime risk in people with untreated depression has been estimated at 20% (Gotlib & Hammen, 2002). Given this great personal and economic cost, there has been much enthusiasm for finding means for alleviating depression.

Cognitive Behavioural Therapy (CBT) is a form of psychotherapy that focuses on targeting maladaptive cognitions and behaviours in order to improve psychological well-being. It has been used for a number of psychological disorders, including depression. Although the length of a course of therapy of CBT can vary, given that CBT is generally structured and time-limited (e.g. Hazlett-Stevens & Craske, 2002), it is well-suited for controlled empirical investigation. It is also widely available - the National Health Service in the United Kingdom has led substantial efforts to increase the uptake of CBT via the Improving Access to Psychology Therapies program (see Clark et al., 2009). This is turn has led to a substantial number of potential participants for research studies.

In this essay I will provide a critical overview of existing evidence concerning CBT and depression. I will begin by appraising the evidence base for whether it is a successful therapy for treating depression. I will then briefly discuss evidence for the risks associated with CBT, followed by a discussion of relevant neuropsychological research, although in this latter section, I will emphasise that this area of research is in its early stages, and faces inherent barriers to offering a “fundamental”, reductionist account of depression and CBT.

 

2.     Evidence concerning CBT and depression

CBT: does the evidence suggest that it works for depression?

In the last decade, a number of primary research studies have demonstrated successful use of CBT for treating depression that occurs in the context of other conditions, such as Parkinson’s Disease (Dobkin et al., 2011), chronic obstructive pulmonary disease (Hynninen et al., 2010), and HIV-infected drug users (Safren et al., 2012). This trend in primary research might be interpreted as indicating that the efficacy of CBT for depression per se is a foregone conclusion, although this trend can also be explained by the hypothesis that depression that is co-morbid with other health conditions may respond in a particular way to CBT, and CBT itself may be adapted to accommodate this. However, there is ongoing research interest on the impact of CBT on depression itself.

Indeed, given the quantity of research that has been conducted on CBT, a number of articles in this area are meta-analyses, i.e. quantitative syntheses of the results of multiple previous primary research studies. In appraising existing literature on efficacy, these meta-analyses have tended to focus on randomised control trials, i.e. studies in which patients are randomly assigned to either an experimental group (in this context individual CBT), or one or more comparison/control group(s) – for research of this nature, the term “comparison” is perhaps preferable (Lilienfeld et al., 2015). Following the experimental/comparison intervention, an outcome of interest, in this context depression, is compared between the two groups. By randomly assigning research participants to experimental or comparison conditions, the researcher should avoid systemic bias with regard to the baseline characteristics of the experimental and comparison groups, although inadvertent baseline differences between the groups can still be controlled for statistically. For example, if the experimental group and the comparison group differ in age, this can be entered as a covariate into an analysis of covariance (e.g. Field, 2009).

A review of existing meta-analyses evaluated a range of meta-analyses, appraising them on whether they included only randomised control trials, whether they weighted effect sizes according to sample size, whether moderating variables were included and whether the heterogeneity of effect sizes and outliers was analysed (Butler et al., 2006). Butler et al. found that CBT was somewhat superior to antidepressant medications in treating depression in adults. They also criticised a previous review by Parker et al. (2003) which had suggested that CBT was not as effective as previously suggested in treating depression, on the basis that it had not explicated what criteria they had used to select the primary studies and meta-analyses they reviewed.

More recently, López-López et al. (2019) conducted a systematic review focusing specifically on randomised control trials of CBT in depression. They found that CBT interventions was associated with a greater reduction in depression scores compared to either treatment as usual or waitlist comparison group, and the greatest decrease was observed for face-to-face CBT, compared to multimedia or hybrid CBT. They also examined different components of CBT (e.g. behavioural activation, goal setting, homework), although this analysis was somewhat frustrated by a lack of reporting of the components of CBT interventions in many publications.

The choice of a comparison group is important: it is easier to demonstrate a more substantial effect of CBT when one compares CBT to a waiting list, rather than comparing CBT to an active intervention (e.g. psychoeducation or social support). Even a given term, such as “treatment as usual”, may describe comparison conditions that are actually quite heterogenous across studies; “treatment as usual” can range from an intervention as minimal as being given a link to a website with information about depression (Clarke et al., 2009), up to an intervention involving antidepressant medication, monitoring, and perhaps referral for specialist psychological services (Williams, 2013). Notwithstanding these methodological issues, the meta-analyses of randomised control trials do largely offer support for the efficacy of CBT in treating depression.

Besides this evidence base arising from randomised control trials, a meta-analysis of non-randomised studies on outpatient individual (and group) CBT found that CBT was effective in reducing depression, although the effect sizes were lower than those observed in randomised control trials  (Hans & Hiller, 2013). These findings sound a cautionary note about assuming that the effect size one observes in a randomised control trial will translate to clinical practice. Hans & Hiller also found a reasonably high drop-out rate; this contrasts with a low risk of attrition bias for nearly half of the randomised control trials observed by López-López et al. (2019).

In the past decade there have been increasing calls to enhance the replicability of empirical research results, i.e. to ensure that the same findings of a study can be produced if the study is run again using the same methods (e.g. Munafò et al., 2017). Different measures can be used to assess depression pre- and post-CBT, such as the Beck Depression Inventory (Beck et al., 1996), the Hamilton Depression Rating Scale (Hamilton, 1960) or the CES-D (Radloff, 1977). Furthermore, studies can take more than one measure of depression, and so the measure which shows the strongest effect size can be selected for publication. Alternatively, researchers may conduct sub-group analysis to identify effects where an overall effect is not evident (e.g. males versus females, younger versus older people, suicidal versus non-suicidal clients, etc.). Munafò et al. refer to the practice of taking a post-hoc observation and publishing it as if this had been a pre-existing hypothesis, which they call “hypothesising after results known.” To take one example, Stangier et al. (2013) found that maintenance CBT was more effective than manualised psychoeducation in preventing reoccurrence or relapse of depression in people who were in remission for at least two months, but this effect was only the case for people at higher risk of reoccurrence. This reported sub-group effect may be one of multiple such analyses they could have conducted. Although their research was registered at www.controlled-trials.com, their sub-group analysis is not reported in this registry, suggesting it was a post-hoc comparison, conducted after their data had been collected.

Pre-registration is a particularly useful way to prevent hypothesising after results known. To pre-register a study, researchers make the method of the study, as well as its hypothesised outcomes, available to the research community prior to collecting and analysing their data. Pre-registration is not just for primary research in which novel data is collected from research participants; websites such as PROSPERO (https://www.crd.york.ac.uk/prospero/) provide a forum whereby systematic reviews and meta-analyses can be described in advance (including explicit statements of the outcomes to be assessed).

CBT: Are there risks?

Discussion around talking therapies tends to focus more on the effectiveness or efficacy of a therapy in treating depression and less on potential side effects, compared to pharmacological treatments and certainly compared to electro-convulsive therapy (e.g. Ingram et al., 2008). Nonetheless, we should also be mindful that, like any intervention, CBT may have side effects. One study (mostly focused on depression, although some clients were seeking CBT for other issues) estimated that almost half of clients had experienced at least one side effect from CBT, including deterioration of depression, and strains in family relations (Schermuly-Haupt et al., 2018). Schermuly-Haupt et al. note the lack of a generally accepted methodology for assessing the side effects of psychotherapy in general, although a questionnaire for the assessment of potential adverse aspects of psychotherapy has been developed (Parker et al., 2013); again, this was validated with a sample of participants attending a variety of forms of therapy, although CBT was one of the most popular.

Although there is a clear paucity of evidence on this research question, any cost-benefit analysis will be incomplete unless it considers the net benefit of CBT to clients, allowing that there may be negative effects as well as positive. Outcome measures such as the Beck Depression Inventory will likely capture deterioration in overall depression, but side effects such as strain in family relations may be missed by researchers’ primary analyses.

CBT: The search for markers in the central nervous system

Given the fact that some individuals respond better to therapy than others, there has been some interest in the possibility of identifying potential markers/predictors of therapy via functional neuroimaging. However, such efforts should be made with caution, given the heterogeneity of depression, as well as the fact that it is defined and clinically assessed at a cognitive/affective level rather than a neurobiological level. A systematic review found that research on the impact of CBT using brain imaging technologies does not provide convincing evidence that CBT leads to changes in brain function, or at least that such activation is not detectable with existing brain imaging technologies (Franklin et al., 2016). It should be noted that the studies they identified were more likely to use technologies suited to detecting activation (via blood oxygenation) in different brain regions (functional magnetic brain imaging/fMRI) and less likely to use those better suited to identify changes in particular neurochemicals (e.g. positron emission tomography, PET). It may be that more neurochemical-based markers may lead to more interesting results in future. If optogenetics (a technique for targeting specific neural cell types with millisecond accuracy developed in rodent models; Boyden et al., 2005), becomes less invasive and more usable in human trials, this may provide more precise information on this topic in future.

A particularly large and ambitious brain imaging study employed fMRI (including a replication dataset) and appeared to identify different “biotypes” associated with depression (Drysdale et al., 2017). The fact that the authors did not simply conflate all patients into a single biotype suggests an allowance for the heterogeneity of depression. Furthermore, the biotypes were predictive of responsiveness to transcranial magnetic stimulation therapy, suggesting this could perhaps be a promising avenue for predicting responsiveness to CBT. Unfortunately, a subsequent attempt at replication did not find evidence that was as convincing (Dinga et al., 2019).

Of course, “locating” depression at a sub-individual level (e.g. reduced activity in a specific brain region) risks ignoring the social and environmental factors associated with depression; for example, socioeconomic status is a predictor of depression (Lorant et al., 2003). Even for one-on-one therapy sessions with individuals, discussion will often focus on inter-individual factors (e.g. marital relationship, problems with one’s boss) or the impact of broader social/economic/cultural factors (e.g. poverty, systemic racism). Nonetheless, a more nuanced understanding can allow for the aetiological impact of psychosocial adversity to be realised at a neurobiological level (e.g. Gianaros & Manuck, 2017).

 

Conclusions

Research on the impact of CBT on depression has been ongoing for decades. This has generated a substantial evidence base demonstrating the efficacy and effectiveness of CBT for treating depression. However, even within the last decade, the standards by which empirical psychology is appraised have risen, and I would contend this is particularly true with regard to replicability. As much research on CBT and depression turns from the general question of “whether it works or not” per se, and begins to focus on issues such as treatment for co-morbid depression in the context of other conditions, as well as the question of online versions of CBT compared to face-to-face delivery, it is important that researchers harmonise their methodologies to allow for easier comparison between studies, and increase the use of pre-registration, transparency and data-sharing so that researchers can build on one another’s efforts more rapidly.

Despite this success is demonstrating the efficacy and effectiveness of CBT in treating depression, I wish to sound some cautionary notes with regard to this research area. Firstly, one must be cautious about assuming that the effect sizes observed in randomised control trials will generalise to the clinic. Secondly, although there has been some research explicitly addressing potential negative side effects, this has been much more limited in scope, and has often been conducted on a variety of different psychotherapies, rather than focusing on CBT itself. Lastly, although there has been research enthusiasm in searching for neurological correlates of depression and associated “biomarkers” or biological predictors of responsiveness to treatment (including CBT), given the complexity of both depression and the human central nervous system, understanding how they interact is a mammoth task, and research in this area is still in its early stages.

 

Related articles: 

I felt a funeral in my brain

The biology of depression treatment: An understudied factor

If you like this post, follow me on Twitter: @ArchivePsych

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