How does drawing improve children's mood?

Watch a child draw and they can seem so absorbed, their brow furrowed in blissful concentration. It seems an ideal way for them to cope with negative emotion. But what's the best approach - should they draw about what's upsetting them ("venting"), copy illustrations by someone else, or create their own unrelated picture?

Jennifer Drake and Ellen Winner first compared the effects of children venting versus creating their own picture. They recruited 83 kids age 6 to 12 at a museum. They nudged them into a bad mood by having them spend a minute thinking about a time they'd been disappointed. Half the kids then spent 5 minutes drawing about that disappointing occasion; the others drew a house. Using a scale of smiley faces for the kids to indicate their mood, the researchers found that the mood of children who drew a house recovered more than the children who drew about the disappointing experience.

A second study was similar but this time 123 children were split into three groups. After recalling a disappointing experience, some of them drew that experience, others drew a house, and a final group copied pictures of household items. Mood recovery in the "venting" group and the copying group was equivalent, and failed to match the recovery enjoyed by the kids who created their own drawing of a house. In this study, but not the first, the mood benefits of drawing were greater for the younger children, perhaps because they were more absorbed in the task.

Kids found the house task more enjoyable than venting in the first study, but in the second study there was no difference in enjoyment across conditions. Drake and Winner speculated that drawing a house was more beneficial than venting or copying because it was more distracting.

The researchers concluded: "Improved understanding of the mechanisms by which drawing helps children regulate their emotions could have implications for therapeutic interventions for children with poor emotion-regulation skills and for those with depression."

Unfortunately the first of these studies suffered from a serious methodological weakness. The researchers ought to have included a no-draw control condition. It's possible that the children's mood would have bounced back without the benefits of drawing. If so, the results actually show the "venting" task having an adverse effect, rather than the house-drawing having a positive benefit.

The second study rectified this issue somewhat by having a copying task, but still we don't know how the children's mood would have repaired if they'd just been left to their own devices. Another issue, acknowledged by the researchers, is that we don't know if the apparent house-drawing benefits came from the creative aspect of that task or from the subject matter. Perhaps houses have positive connotations for most children and their mood was repaired by house drawing for that reason.
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Drake, J., and Winner, E. (2012). How children use drawing to regulate their emotions Cognition and Emotion, 1-9 DOI: 10.1080/02699931.2012.720567


--Further reading-- Can you tell which of these pictures is the work of a child?
Esther Burkitt on whether those pictures stuck to the fridge are really a window to a child’s mind.


Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

What's it like to have OCD?

Research with people who have obsessive-compulsive disorder (OCD) is often impersonal. Participants' thoughts, feelings and behaviours are reduced to ticked boxes on a questionnaire. There's a risk the real story of what it's like to have OCD doesn't get told. Helen Murphy and Ramesh Perera-Delcourt have taken a different approach. They interviewed 9 people (one woman) with OCD, face-to-face, for about an hour each, to hear how these people felt about their condition and about any treatment they'd received.

The researchers transcribed the interviews and highlighted key themes. Regarding the experience of OCD, the main themes were "wanting to be normal and fit in", "failing at life", and "loving and hating OCD."

Participants found comfort in meeting other OCD support-group members. They also spoke of caring too much about what other people are thinking of them. OCD can interfere with education, relationships and careers and frequently, participants compared their own stalled life trajectories against what they perceived as the societal norm. "I feel like I've got to make up for lost time in a way," one man said. There were in-depth descriptions of the painful situations created by OCD - one man who house-shared had to scrub the entire bathroom with powerful cleaning product for an hour every day before he could use it. But at the same time, there was a fear of losing the crutch that the condition provides. "I wish I could do that [stop checking], I wish I could stop," another man said, adding: "Well, not totally."

In relation to therapy, the main themes were "wanting therapy", "finding the roots", and "a better self". Participants spoke of the relief that came from having their problems recognised and listened to. The importance of rapport between participants and their therapists was mentioned repeatedly, consistent with what's known about the importance of the therapeutic relationship. Although aspects of CBT were found useful by many ("it helped me focus on what is important to me in life," said one), others commented on the lack of interest in the roots of the condition. "There's been a 'stuff the past' sort of thing but it's like cutting a plant above the soil - the roots are still there," said another participant. CBT helped participants with self-esteem issues. "... reanalysing things ... has made me realise that I wasn't to blame for all kinds of things," one person said.

Murphy and Perera-Delcourt concluded that examining people's narratives can help to "understand the lived experience and lessen public and self stigma". Given the way their participants emphasised the value of rapport in therapy, the researchers questioned claims that computerised CBT is a valid substitute. They also highlighted the apparent importance to people with OCD of understanding its origins. "Developmental issues in the maintenance of the disorder have been generally neglected and our findings suggest that understanding and talking through the origins of OCD may lessen treatment resistance," they said.

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Murphy, H. and Perera-Delcourt, R. (2012). ‘Learning to live with OCD is a little mantra I often repeat’: Understanding the lived experience of obsessive-compulsive disorder (OCD) in the contemporary therapeutic context. Psychology and Psychotherapy: Theory, Research and Practice DOI: 10.1111/j.2044-8341.2012.02076.x

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

The advantage of having an anxiously attached person on your team

Psychologists talk about different attachment styles, such as secure, anxious and avoidant. The secure style is usually the one we're supposed to aspire to. They're the calm people who find it easy to get close to others, but not in a clingy way. By contrast, those with an anxious or avoidant attachment style are often seen in a pathological light - being either too needy or too aloof, respectively. They might sound like the kind of people you want to steer clear of, but now Tsachi Ein-Dor and Orgad Tal have published new research showing the upside to having an anxiously attached person on your team.

Eighty undergrads (28 women) completed attachment style and personality questionnaires. High scorers in anxious attachment agreed with statements like "My desire to be very close sometimes scares people away". Two weeks later they returned for what they thought was a study into artistic preferences. Each participant sat down at a computer and was left to rate a series of paintings that appeared on-screen. After the third piece of art, an error message popped up and the next thing, after the participant clicked OK, the computer started running a virus that wiped the whole hard-drive. The experimenter - a trained actress - came back in the room, feigned horror, and asked the participant to take the flash-drive out of the computer and head to the Dean's assistant manager for help.

Over the next few minutes, four obstacles were thrown in the way of the participants, potentially diverting them from the aim of seeking help. Outside in the corridor a person asked them to complete a short survey; the Dean's assistant manager, when they got there, directed them to the lab manager, but asked them to do some photocopying first; the lab manager's door had a sign on it asking visitors to wait; and finally, after being directed to the lab technicians' room, the participants passed a student who dropped a load of papers on the floor.

The higher that participants scored on anxious attachment, the more likely they were to seek help about the virus with single-minded focus. They more often than others refused to do the survey, shrugged off the photo-copying request, sought help rather than waiting outside the lab manager's office, and left the student to pick up their own papers from the floor. In contrast, the personality variables of extraversion and neuroticism were not related to this single-mindedness.

Ein-Dor and Tal have nicknamed anxiously attached people "sentinels". In past research they've shown that they, like people of a generally anxious disposition, are quicker to detect threats (e.g. smoke in the room). This new result confirms the researchers' further prediction that anxiously attached people are also particularly motivated to seek help from others, to raise the alarm - a tendency that "in many real world situations, might save others from a serious threat". Concluding, Ein-Dor and Tal said their study offered "a new perspective on the strengths of individuals who have long been viewed as deficient and poorly adapted."

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Ein-Dor, T., and Tal, O. (2012). Scared saviors: Evidence that people high in attachment anxiety are more effective in alerting others to threat. European Journal of Social Psychology, 42 (6), 667-671 DOI: 10.1002/ejsp.1895

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

The new psychology of awkward moments

The fascination of socially awkward moments certainly hasn't been missed by comedy writers. Millions of us have cringed our way through series like Curb Your Enthusiasm and The Office. In contrast, psychology before now has largely neglected to study this fundamental part of social life.

In a new exploratory study, Johsua Clegg proposes a model. Social awkwardness, he posits, is what we feel when the situation threatens our goal of being accepted by others. The feeling prompts us to direct our attention inwards, to monitor our behaviour and attempt to behave in a way that will improve our chances of achieving acceptance. There's been a lot of research before on embarrassment, but that's tended to focus on embarrassed individuals, their feelings and dispositions. This new study is less personal, being more about the situations that reliably trigger everyday feelings of social awkwardness in most people.

Clegg invited 30 undergrad participants (13 men) into a carefully prepared room in groups of three. Each trio sat facing each other on chairs arranged in a triangle. They knew they were being filmed through a two-way mirror. There was also a table with a microphone and five cookies on it.

For the first three minutes, the participants were given no instructions. Then another participant (actually a stooge working for Clegg) arrived with a chair and sat down with them. Three more minutes passed, a researcher appeared and instructed the trio to begin an ice-breaker task (the stooge exited at this point). After three minutes discussion he would ask each of them to introduce each other to the group. Once this was done, the participants left the room and moved to another where they watched back the footage of themselves. They used a slider box, like the kind used in audience research, to indicate how awkward they were feeling during the social interactions on a moment by moment basis.

Clegg noted those moments that participants recorded a dramatic increase in social awkwardness and he cross-checked with the videos to see what was happening at the time. Moments of feeling awkward fell into distinct situational categories, which we can probably all relate to. These included times when participants didn't know what was expected of them or what the social rules were (such as when they first sat down in the room without instructions); when a social norm was broken (e.g. one person interrupted another; someone infringed on another's personal space); a social standard wasn't obtained (e.g. a person stumbled with their speech, there was a long silence); norms around eating were broken (e.g. spilling food from mouth while eating); negative social judgements were made by one person towards another, either explicitly or implicitly (e.g. by pulling a face); when names were forgotten or people weren't recognised; and when social processes were made explicit, such as during the ice-breaker task.

There were also five kinds of moment when social awkwardness plunged. This included: when people were sharing common interests, when one person helped another, when one person was positive about another, and humour. It's notable that a lot of the humour was actually about social awkwardness - joking about it seemed to make it go away.

The study is a tentative first step towards cataloguing when and why people feel socially awkward. It has obvious limitations, foremost that the participants were being filmed and the study is US-centric. But as Clegg argues, it raises all sorts of interesting avenues for future investigation. Perhaps most significant is the similarity of participants'  descriptions of social awkwardness to typical accounts of full-blown social anxiety - they talked about feeling "pressured", "anxious", "nervous" and "crazy". In attempting to understand problematic social anxiety, Clegg said psychology has tended to focus on the individual, on traits like shyness and attention to the self. His new psychology of awkward moments focuses attention on the situations that trigger social discomfort in all of us. Understanding more about everyday social awkwardness, and how people deal with it, could provide new insight into why and how socially anxious people come to feel awkward nearly all of the time.

How often do you experience social awkwardness? Are there any specific social situations that trigger the feeling for you?
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  Clegg, J. (2012). Stranger situations: Examining a self-regulatory model of socially awkward encounters. Group Processes and Intergroup Relations, 15 (6), 693-712 DOI: 10.1177/1368430212441637

--Further reading--
The new science of "Phew!"
The new psychology of everyday playing cards

Post written by Christian Jarrett for the BPS Research Digest.

Are eating disorders the manifestation of an "Extreme Female Brain"?

According to an influential and controversial theory, autism is the manifestation of an "Extreme Male Brain". The reasoning goes something like this - the condition is far more prevalent in males than females; people with autism think in a distinctive style that's more commonly observed in men than women (that is, high in systematising and low in empathising); and greater testosterone exposure in the womb appears to go hand in hand with an infant exhibiting more autism-like traits in later childhood.

Simon Baron-Cohen, the psychologist who first proposed the theory, always conjectured that there may also be such a thing as an "Extreme Female Brain". Now in a new paper, a pair of researchers in the USA have made the case that the Extreme Female Brain exists, it's highly empathic, and it comes with its own problematic consequences, in terms of a fear of negative evaluation by others, and related to that, a greater risk of eating disorders (which are known to be far more prevalent in women than men).

Supporting their claims, Jennifer Bremser and Gordon Gallup Jr surveyed hundreds of male and female undergrads and found that men and women with more dysfunctional attitudes towards eating, and more fears of being negatively evaluated by others, also tended to score more highly on self-reported measures of empathising. A fear of being negatively evaluated was also associated with lower scores in systematic thinking.

In other words, people with a thinking style more often observed in women, and opposite to that seen in people with autism (high in empathising, low in systematising), tended to be at greater risk for eating disorders and social anxiety.

The results got a bit messier with objective measures. Among female participants, dysfunctional attitudes towards eating were associated with higher scores on an objective measure of empathising, one that involved interpreting emotions from pictures of people's eyes. But for males, dysfunctional attitudes to eating actually predicted lower scores on the test.

The researchers surmised that perhaps these men were over-interpreting the pictures - "hyper-mentalising" - and seeing emotions that weren't there, which would be consistent with their central thesis about the Extreme Female Brain. Supporting this, further studies found that dysfunctional attitudes towards eating and fear of negative evaluation by others also tended to go hand in hand with higher self-reported scores on schizotypy, including exaggerated suspiciousness, magical thinking and paranoia - arguably all signs of "hyper-mentalising", and the opposite of what's seen in autism.

What about objective measures of systematising? Dysfunctional attitudes toward eating and fear of negative evaluation weren't associated with understanding the laws of physics, but they were associated with poorer mental rotation performance scores.

"Evidence from all four studies converge to show that a combination of disordered eating and negative evaluation anxiety are associated with a cognitive style that Baron-Cohen predicted for the Extreme Female Brain," the researchers concluded.

One last thing - Bremser and Gordon Gallup Jr said their ideas suggested a novel explanation for why vegetarianism is particularly prevalent among people with eating disorders. Previously it's been assumed that vegetarianism is popular for this group as a means of calorie restriction. However, if eating disorders are part of the manifestation of an Extreme Female Brain, one that's associated with exaggerated empathy, then vegetarianism may be a natural consequence of having enhanced empathy for animals.

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Bremser JA, and Gallup GG Jr (2012). From one extreme to the other: Negative evaluation anxiety and disordered eating as candidates for the extreme female brain. Evolutionary psychology : an international journal of evolutionary approaches to psychology and behavior, 10 (3), 457-86 PMID: 22947672

Post written by Christian Jarrett for the BPS Research Digest.

How happiness campaigns could end up making us sadder

Founded in 2010, the Action for Happiness movement states: "What we want for our society is as much happiness as is possible and, above all, as little misery". These aims are well-intentioned, but a new study shows public campaigns like this could have an ironic effect, actually making sad people feel sadder (update: please see the comments below where the Director of Action for Happiness, Mark Williamson, gives his response to this study).

Brock Bastian and his colleagues surveyed hundreds of Australian and Japanese students and found that those people who believed more strongly that society expects us to try to be happy, also tended to evaluate their own negative emotions more negatively. In other words, believing that there's a cultural expectation to strive for happiness is associated with feeling sad about being sad. In turn, people who felt this societal expectation more keenly, also reported experiencing negative emotions more often and having poorer wellbeing (a fall-out that was mediated by these participants being more critical of their own negative emotions). Comparing across cultures, the overall pattern of results was present but weaker in Japan, where negative emotions are generally better tolerated.

These initial findings provided only a snapshot. To get a better sense of the causality of societal expectations, Bastian and his team conducted two further studies in which Australian participants were first primed with carefully prepared newspaper articles, and then prompted to feel negative emotion by reminiscing in writing about a negative event from their lives.

Reading a news article about research that claimed sadness is infectious or that sad people are disliked led participants to experience more negative emotion after they'd reminisced about a bad event in their past. It's as if a reminder of society's intolerance to negative emotion aggravated participants' own negative feelings. By contrast, reading an article that said sad people are accepted and liked, led participants to experience less negative emotion after the reminiscence exercise.

Results from the control condition in this study were particularly revealing. In this case participants were primed with a mundane article about fertiliser. They experienced just as much negative emotion after the reminiscence exercise as participants who'd read the article about sad people being disliked. This suggests the reminder about society's intolerance of negative emotions was unnecessary for aggravating the experience of sadness. "Social pressures appear to be highly normative and particularly so within Western cultures," the researchers said.

Bastian and his colleagues said their findings show how our beliefs about society's intolerance of negative emotions has downstream effects, changing how we experience our own emotions, "ironically aggravating those same emotions that are deemed to be socially undesirable or unacceptable."

"Attempts to promote the value of feeling good over the value of feeling bad by emphasising social norms for these emotions may therefore have the effect of making people feel bad more often," the researchers concluded.

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Bastian B, Kuppens P, Hornsey MJ, Park J, Koval P, and Uchida Y (2012). Feeling bad about being sad: the role of social expectancies in amplifying negative mood. Emotion (Washington, D.C.), 12 (1), 69-80 PMID: 21787076

-Further reading- Other people may experience more misery than you realise.

Post written by Christian Jarrett for the BPS Research Digest.

Introducing "therapy genetics" - genes can predict whether therapy will help

Psychotherapy, like other forms of treatment, doesn't work for everyone and there would be huge advantages to knowing in advance who's likely to benefit. In the case of drugs, there's a thriving research field - pharmacogenetics - looking at whether a person's genetic profile can predict their chances of responding to treatment. Can the same approach be applied to therapy? A team of researchers at the Institute of Psychiatry in London believes so.

In one of the first papers published on "therapy genetics", Kathryn Lester and her colleagues, including Thalia Eley, took swabs from hundreds of white children with anxiety, aged 6 to 13. The researchers were specifically interested in the genes the children had that code for Nerve Growth Factor (NGF) and Brain Derived-Neurotrophic Factor (BDNF) - proteins involved in the survival and development of neurons. The children, some based in the UK and some in Australia, then underwent a CBT programme designed for helping anxious children. The key question was whether the children's genetic profile would be associated with how well they responded to the treatment.

There were no genetic associations with the children's immediate response to the treatment. However, at follow up (assessed at 3, 6 or 12 months), the children's particular NGF genotype was related to their therapeutic responsiveness. We each have two copies of the NGF gene, rs6330, which can come in two versions, known as the T allele or the C allele. Lester and her team found that among children with two copies of the T allele version, 76.7 per cent were free of their primary anxiety diagnosis at follow up, compared with 63.5 per cent of children with one C version and one T version, and just 53.2 per cent of children with two copies of the C allele. These associations held, even after controlling for other clinically relevant factors such as age, gender and geographical location.

Why should the children's particular form of NGF gene affect the way they respond to CBT? Definite answers will only come from more research, but Lester and her colleagues argued that the finding makes sense based on what we already know about NGF being involved in the growth of new neurons and in changing connections between existing neurones - known as "neuroplastic changes" in the scientific jargon. "Significant learning experiences of the kind undertaken during CBT may very well be underpinned by neuroplastic modifications in brain activity and function," they said.

This new result complements another recent paper published by the same research group, in which anxious children responded more successfully to CBT if they had a particular version of a gene involved in the activity of the neurotransmitter serotonin. Again, the association was found at follow-up rather than immediately after therapy.

Lester and her team said they believed the association they documented in this new research is "clinically meaningful", but that "clinically significant prediction by genetic markers is likely to be best achieved by combining multiple genetic markers (perhaps in combination with clinical predictors) into predictive indices or algorithms."

The research has some shortcomings. For example, without a no-treatment control group of anxious children, it's not possible to say for sure that NGF genotype is specifically associated with therapeutic responsiveness rather than an advantageous tendency to recover regardless of treatment. "These findings should be considered preliminary," the researchers said.

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Lester, K., Hudson, J., Tropeano, M., Creswell, C., Collier, D., Farmer, A., Lyneham, H., Rapee, R., and Eley, T. (2012). Neurotrophic gene polymorphisms and response to psychological therapy. Translational Psychiatry, 2 (5) DOI: 10.1038/tp.2012.33

Post written by Christian Jarrett for the BPS Research Digest.

ADHD Summer Camp

For harassed doctors and stressed-out parents, it can be tempting to treat a challenging child with ADHD (attention deficit hyperactivity disorder) with pills and leave it at that. After all, early results from the one of the largest trials of its kind in the United States - the Multimodal Treatment Study of Children with ADHD (MTA) - showed that behavioural outcomes were better for children given the psychostimulant Ritalin, than for those given psychological treatment. However, follow-up data over several years has shown that the advantages of drug treatment aren't sustained over the longer term. The position of the UK's independent health advisory body, NICE, is that drug treatments for ADHD should only ever be part of a broader treatment package, including psycho-educational sessions for parents (pdf). The hunt continues for the most effective treatment or mix of treatments.

It's in this context that a team of German psychologists, led by Wolf-Dieter Gerber at the University of Kiel, has published a new report looking at the benefits of combining drug treatment for ADHD with an intensive Summer Camp.

Eighteen children with an ADHD diagnosis (aged 9 to 17 years), all on medication, spent 12 days at one such camp, which included social skills training conducted in a playful manner, attention training and sports. Crucially, the camp also incorporated "response cost token-based behaviour training" - that is, the children earned or lost tokens according to whether they followed or broke the camp rules. They were encouraged to compare their token totals each evening and a winner was declared for each day following an "Olympics style" format. At the end of the camp, the tokens could be exchanged for prizes.

A control group of 19 age-matched children with ADHD, also on medication, didn't go to camp, but their parents received a one-and-a-half hour-long psycho-educational session in which they were taught, amongst other things, about using a token strategy in the home.

Six months later, the children from both groups were tested on a range of neuropsychological measures and their outcomes compared with their pre-intervention test performance.

The key finding is that only the Summer Camp kids showed a reduction in the variability of their reaction times. This is significant because highly sporadic reaction times are a hallmark of ADHD, indicative of reduced self control. Moreover, only the Summer Camp group showed significant improvements in selective and sustained attention and the capacity to integrate information. It's likely these cognitive changes were clinically significant. Only those children who received higher ratings from their teachers (in terms of improved impulsivity, hyperactivity and inattention) showed positive changes in the variability of their reaction time scores on the neuropsych tests.

"We believe this study has merit" the researchers said, "as the ADHD Summer Camp can be regarded as a novelty in ADHD treatment. We could find no comparable intervention programmes that included stringent ... [token reward and punishment] techniques."

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Gerber, W., Gerber-von Müller, G., Andrasik, F., Niederberger, U., Siniatchkin, M., Kowalski, J., Petermann, U., and Petermann, F. (2012). The impact of a multimodal Summer Camp Training on neuropsychological functioning in children and adolescents with ADHD: An exploratory study. Child Neuropsychology, 18 (3), 242-255 DOI: 10.1080/09297049.2011.599115

Post written by Christian Jarrett for the BPS Research Digest.

Blogging for mental health

To coincide with the Mental Health Month Blog Party organised by the APA, I've collated some highlights from our coverage of mental health issues here at the BPS Research Digest.

What is mental illness? In 2010 I reported on a Psychological Medicine editorial that dissected the definition used by the fourth edition of US psychiatry's diagnostic manual. Another post from 2006 explored differences in the way the public and experts view mental disorders.  How we conceive of mental illness isn't only of theoretical interest, it can have an impact on people's lives. For example, this post showed that biological accounts of mental illness may dent patients’ hope and increase stigma.

Mental illness is normal. Several studies I've covered have illustrated just how common mental health problems are. One paper suggested that one in two of us will experience mental difficulties in our life-times. Another asked Who doesn't suffer from paranoia? Other research has shown that psychotic symptoms aren't always pathological and tried to find out how non-problematic symptoms differ from those experienced by patients. Another paper had a similar aim: The same voices, heard differently?

Drug-free treatment is often helpful. Despite widespread beliefs to the contrary, there are drug-free ways to help people with schizophrenia, including using CBT. In fact, psychotherapy has a drug-like effect on the brain. In a guest post, Richard Bentall described the treatment of schizophrenia with maximum kindness and minimum medication. Elsewhere, I covered new research showing that fears could be unlearned without the use of drugs. I reported on a computer game that holds promise in helping prevent traumatic flashbacks. I've also uncovered some novel and straightforward approaches to improving mental health, including floral arrangement as a cognitive training tool for schizophrenia and Grab it, bag it, bin it - a new approach to psychological problem solving.

Self-help strategies sometimes backfire. But we shouldn't assume that all interventions, however well-intentioned, will be beneficial. Popular strategies or tools for being happier or more successful can sometimes be harmful, as these posts demonstrate: CBT-based self-help books can do more harm than good. Positive psychology exercises can be harmful for some Why positive fantasies make your dreams less likely to come true. A related feature article in The Psychologist magazine delved into the world of unscrupulous therapies: When therapy causes harm.

Research into the therapeutic process. Lots of research in psychology tries to get to the bottom of the factors that make therapy effective. For example, this paper put cognitive therapy on the couch. Another found that therapy is more effective when psychologists focus on their clients' strengths (yet another showed that successful therapists focus on their clients' strengths). This paper examined those times when clients in therapy show sudden, dramatic improvements. Other papers I've covered have asked some awkward and tricky questions about therapy - for example, is it really true that therapists don't improve with experience? Can therapists tell when their clients have deteriorated? What happens when therapists have the hots for their clients? And what should a therapist do if a client confesses to murder? Other studies looked at therapy from the clients' perspective, for example What do clients think CBT will be like and how is it really?

Mental health research isn't easy. Because mental health problems are so widespread, it's not always easy to conduct properly controlled experiments, as these posts show: Just how non-clinical are so-called non-clinical community samples? and Beware the "super well" - why the controls in psychology research are often too healthy.

Intriguing case studies. I've covered a few of these, such as the boy who thought 9/11 was his fault and the time that a spontaneous panic attack was caught during a brain imaging scan.

Be happy. There's reason for hope. Sometimes mental health problems can have an upside, for example this post suggested that anxiety has benefits. Remember too that most people with a mental disorder are happy If you want to be happier than you are, this study suggested that frequent, mundane positive activities will make you happier, rather than rare, profound events.
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Post compiled by Christian Jarrett for the BPS Research Digest.

Need a Wii? Games console found to reduce loneliness in the elderly

The marketing people would have us believe that the Nintendo Wii is unlike traditional video games. It has an intuitive controller, they say, that allows you to simulate in-game movements, thus making it an ideal platform for active, social game playing - "fun for all the family". A new study puts this idea to the test in relation to well-being among 35 older residents (average age 82; 4 men) at an independent living apartment block in Connecticut. Patricia Kahlbaugh and her team said that a psychological challenge for older people is to deal with the restrictions that old age places on their way of life. Playing the Wii could be a way for them to socialise and be more active.

Once a week for ten weeks, 16 of the participants each received a personal visit from a female, undergrad research assistant who played on the Wii console with them for one hour. All participants in this condition chose to play the bowling game. A further 12 participants acted as controls and also received weekly visits from a research assistant for ten weeks, but during these visits the assistant and participant simply watched TV together for one hour. The assistants in both conditions were instructed to be "socially responsive". There was also a second control group of 7 participants who received no visits.

The headline finding is that after the ten week period the participants in the Wii condition reported experiencing less loneliness than they had at the study start. By contrast, participants in the TV condition and no-visit condition experienced an increase in loneliness (perhaps because they'd heard about the Wii playing and felt left out). Also, for nine out the ten weeks, the participants in the Wii condition reported more positive mood than participants in the TV condition (the no-visit condition wasn't part of this analysis). On a disappointing note, the Wii group reported no more physical activity than the TV group during the study and their life satisfaction was no different.

Whilst acknowledging the small scale of their study, Kahlbaugh's team saw the findings as a promising thumbs up for the Wii: "Although students were instructed to be socially responsive in both groups, bowling with a partner may have facilitated the creation of relationships between the elderly person and the younger student in a way that passively watching television did not," they said.

This is the first experimental demonstration of the benefits of Wii playing for older individuals, adding to existing case studies showing benefits for older people with specific impairments. "Based on this study of the Wii," the researchers concluded, "programmes aimed at seniors may want to seriously consider ways to incorporate this type of technology."

But before you rush out to buy the Wii for your older friends or relatives, it's worth bearing in mind that this study hasn't really shown that the Wii per se is the critical ingredient for the observed benefits. It's possible that the extra benefits over TV could have come from playing any kind of video game; in fact, they could have come from playing any kind of game at all, such as cards, which would also have been more social than merely watching TV. Another potential problem is that it's possible that the students in the Wii group were more fun to be with than the students who took part in the TV group. It's hard to say because the study doesn't provide any detail about the students or how they behaved, other than that they were all instructed to be socially responsive.
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Kahlbaugh, P., Sperandio, A., Carlson, A., and Hauselt, J. (2011). Effects of Playing Wii on Well-Being in the Elderly: Physical Activity, Loneliness, and Mood. Activities, Adaptation and Aging, 35 (4), 331-344 DOI: 10.1080/01924788.2011.625218

Post written by Christian Jarrett for the BPS Research Digest.

Mental health problems worsen after cosmetic surgery

Are people who opt for medically unnecessary, cosmetic surgery psychologically vulnerable? Does having such surgery bring them psychological relief?

These are tricky questions. There's actually evidence of increased mental health problems among people who've undergone cosmetic surgery. But whether that's a harmful side-effect of the surgery, or a hangover from pre-operative problems, it's difficult to say.

Randomly controlled trials would help, but of course that's not possible in this situation for ethical reasons. What's needed is a large-scale prospective study that follows thousands of people up over many years. Hopefully a sub-set will opt for cosmetic surgery during that time and then it should be possible to look for any psychological vulnerabilities preceding the surgery and any changes post-surgery.

That's exactly what a team of Norwegian researchers have done. Tilmann von Soest and his colleagues began in 1992 with a sample of over 12,000 school students aged 12 to 19 years, and then surveyed them periodically for several years. Attrition of the sample left 2,890 participants at the final survey in 2005 (many participants were lost early in the study, in 1994, because they changed schools). By 2005, 106 of the participants had had at least one cosmetic surgery procedure. This included 78 women - that's 4.9 per cent of women in the sample; and 28 men - 2.2 per cent of the men in the sample.

Because of the lack of men, the researchers focused only on the women. The majority of their operations were for breast augmentation (26.8 per cent) or reduction (19.5 per cent), with other procedures including liposuctions, ear and nose modifications.

There was strong evidence that women with psychological problems were more likely to opt for surgery. The female participants who went on to have cosmetic surgery were more likely to have a history of poorer mental health, including more depression and anxiety, more illicit drug use, self-harm and suicide attempts. Unsurprisingly, the women who had breast surgery more often had a history of less satisfaction with that part of their body (although general appearance satisfaction wasn't related to undertaking surgery). By contrast, sociodemographic factors were not related to who had surgery and who didn't.

Did the surgeon's scalpel benefit the psychological health of these women? With one specific exception, it seems the answer is a categorical "no". Breast surgery was associated with increased satisfaction with that part of the body, but having cosmetic surgery of any kind was associated with increases in anxiety and depression, eating disorders, more alcohol use and more suicide attempts. Surgery didn't boost general appearance satisfaction.

The study isn't without its shortcomings, as the authors acknowledge. For instance, the apparent adverse effects of cosmetic surgery may not be specific to cosmetic procedures but could apply to having surgery of any kind. The study also relied on participants reporting their own mental health.

This study provides "no evidence that cosmetic surgery should be used to alleviate mental health problems in women dissatisfied with their appearance," the researchers concluded. "Nor do the results support the notion that cosmetic operations in exceptional cases should be covered by the public health-care system due to a potential psychotherapeutic effect for the patient."
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  von Soest, T., Kvalem, I., and Wichstrøm, L. (2012). Predictors of cosmetic surgery and its effects on psychological factors and mental health: a population-based follow-up study among Norwegian females. Psychological Medicine, 42 (03), 617-626 DOI: 10.1017/S0033291711001267

Post written by Christian Jarrett for the BPS Research Digest.

Psychology ignored and depression neglected in the media's coverage of mental health research

Research into some mental disorders receives disproportionate media coverage at the expense of other disorders. That's according to the first systematic study of the way the UK mass media covers mental illness. And in a wake-up call to psychology and its advocates, the analysis found that mental health research stories were biased towards neurobiological aspects of mental illness. They tended to be accompanied by commentary from medical charities, and to neglect psychosocial angles and opinion.

George Szmukler at the Institute of Psychiatry and his colleagues focused on coverage of mental disorders research on the BBC news website from 1999 to 2008, and in New Scientist magazine news and features from Aug 2008 to April 2010. This led to the identification of 1015 relevant stories on the BBC (102 per year) and 133 stories from New Scientist (76 per year).

The approach of Szmukler and co was to compare rates of coverage for various mental disorders against the disease burden of those disorders as measured by the World Health Organisation (WHO). Disease burden is calculated based on years of life lost due to dying early, and years of life affected by disability and loss of full health.

Providing some background context, the researchers said the UK disease burden of mental disorders is 60 per cent greater than cancer, yet in the period studied the BBC had half as many news stories on mental disorder research as compared with cancer research (in defence of the BBC, cancer is the subject of more research than mental disorders). By contrast, New Scientist had 2.5 times as many mental disorder research stories as cancer research stories.

Comparing coverage of research into various mental disorders, both the BBC and New Scientist tended to neglect depression, which is the mental disorder with the greatest disease burden by far. The BBC also tended to neglect alcoholism, whilst focusing more on drug addiction. It also focused disproportionately more than other conditions on Alzheimer's Disease and sleep disorders.

There was also a bias in the type of research that received BBC and New Scientist attention. Seventy-five per cent of the BBC's coverage was on biological research; New Scientist showed a similar trend. "Both sources rarely reported on psychological interventions," the researchers said: on the BBC it was one per cent of stories; for New Scientist it was 1.5 per cent. The dominant approach of both outlets was to present mental disorders as neurobiological in origin. The researchers don't know what proportion of research into mental health disorders is actually psychological, but they said "it is unlikely that talking treatments, in particular, would be so poorly represented."

Most stories on the BBC were accompanied by quotes from commentators intended to provide some context, including from 973 named individuals. There was a bias towards medical commentary. The six most frequently quoted commentators included three from the Alzheimer's Society, two from the Alzheimer's Research Trust and one from SANE. Szmukler and his team said that there was a need for organisations like the Mental Health Research Network to examine ways "in which commentators can be made more readily available across the whole spectrum of mental health research."

The researchers concluded that it was important to study the way the mass media covers mental health research because the media can influence the public's perception of disorders and their perception of the value of different types of research. In turn, this can affect funding decisions by government. In this respect, it is worrying that psychological research into mental disorders was found to have received so little coverage. On a positive note, the overall quality of the analysed news stories was found to be high and to have a neutral or sympathetic tone.

"Studies of media reporting of research, such as this one, can provide ideas as to how the research community, together with its funders and other supporters, can enhance the range and quality of media coverage," the researchers said.

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Lewison, G., Roe, P., Wentworth, A., and Szmukler, G. (2011). The reporting of mental disorders research in British media. Psychological Medicine, 42 (02), 435-441 DOI: 10.1017/S0033291711001012

Post written by Christian Jarrett for the BPS Research Digest.

Is it time to resurrect post-trauma psychological debriefing for emergency responders and aid workers?

You've probably seen on the news, after a disaster, the announcement that trained counsellors will be on hand as a matter of routine. Or you used to. In fact, the practice of offering routine post-trauma psychological debriefing (Critical Incident Stress Debriefing - CISD - to give it its original, formal title) is all but dead and buried. It's hard to say who exactly executed the fatal blow.

NICE - the trusted, independent UK body that provides health advice - is a chief culprit. Based on seven randomly controlled trials (RCTs) comparing psychological debriefing against control groups, NICE recommended in 2005 that brief, single-session interventions not be routinely offered to individuals who have experienced a traumatic event. In 2006, another likely culprit, the Cochrane Collaboration, (widely respected for its meta-analyses of published studies) identified 15 relevant RCTs and made a similar recommendation.

Psychiatrist Simon Wesseley, based at the Institute of Psychiatry in London, went further and must also be a chief suspect. In a debate held at the Royal Institution in 2006, he proposed psychological debriefing after trauma as the "worst ever idea on the mind", based on the fact that it's ineffectual and possibly harmful. "It's a bad idea and a bad intervention," he said.

I must confess that I too may have played a part, however minor, in the demise of post-trauma counselling. In my Psychologist magazine article When Therapy Causes Harm, I highlighted Critical Incident Stress Debriefing as among the therapies identified by Emory University psychology professor Scott Lilienfeld as potentially harmful and that should be avoided. In my book The Rough Guide to Psychology, I used the possible harm caused by post-trauma psychological debriefing as an example of a counter-intuitive finding in psychology.

Now a team of therapists and trauma consultants, Debbie Hawker, John Durkin and David Hawker, who've worked extensively with NGOs, aid workers and emergency responders, have called for post-trauma debriefing to be resurrected for these specific client groups. In a scholarly plea, they've argued that the damning conclusions formed by NICE, Cochrane, Wesseley and others were premature and too narrowly interpreted (NICE acknowledges that their guidance may not apply to debriefing of emergency workers or group debriefing). Hawker and co claim that there are many who would welcome the return of post-trauma debriefing: "As mental health professionals active in the military, emergency service and humanitarian fields, we are aware that the personnel we work with often request debriefing, and speak of its benefit for them". Yet the debriefing is usually not available: "Professionals ... are afraid of being accused of professional misconduct if they offer psychological debriefing ...".

Hawker and co point out that of the 15 RCTs identified by the NICE and Cochrane reviews, three found a positive effect of debriefing, nine found no effect and only two found a harmful effect. These two studies, they explain, were seriously flawed. The patients who received debriefing were more severely injured than the controls; they received debriefing too soon, before they were ready; the debriefing was too brief (it averaged 44 minutes, whereas experts say it should last at least two hours, with at least one follow up); and the debriefers were inadequately trained (a research assistant delivered the debriefing in one study; the other negative outcome study said the debriefers had received half a day's training).

In effect, Hawker et al say, these trials were more like "inefficacy trials" - exploring what happens when an intervention is delivered badly to the wrong people. As it was originally conceived, they explain, post-trauma psychological debriefing was meant to be part of:

"a package for emergency workers who'd experienced critical incident stress as part of their work. It was specifically designed for selected psychologically resilient personnel who are trained to cope with expected pressure during their routine work in stressful situations. These are teams of people who have trained together and been briefed together before working together."

Post-incident debriefing was also meant to be delivered by a mental health worker and a peer debriefer, both of whom should have experience of the emergency services they're working with, thus lending the debriefers all-important credibility.

Debriefing is popular with emergency workers and aid workers, Hawker and co say, because many of them see it as their only chance to talk about their experiences. It allows them to do so as a matter of routine, without the stigma of therapy, which they sometimes fear could be detrimental to their careers. Given this need, perhaps it's no surprise that post-trauma psychological debriefing is surfacing under new names like "powerful event group support" and "trauma risk management".

"We have been told that the case against debriefing is proven and the debate is closed," Hawker, Durkin and Hawker conclude. "We disagree ... We predict that appropriate psychological debriefing will be shown to have benefits for secondary victims of trauma who have been briefed together and who have worked together through traumatic events. Research into these uses of debriefing should be encouraged and supported."

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Hawker, D., Durkin, J., and Hawker, D. (2011). To debrief or not to debrief our heroes: that is the question. Clinical Psychology and Psychotherapy, 18 (6), 453-463 DOI: 10.1002/cpp.730



Post written by Christian Jarrett for the BPS Research Digest.

Trainees in Cognitive Behavioural Therapy underestimate their therapeutic skills

For psychotherapists, the research literature can sometimes make for uncomfortable reading. Yes, most people benefit from therapy, but other findings are less welcome, such as that therapeutic outcomes are unrelated to therapist experience, and that therapists tend to overestimate their skills.

A new study of trainee cognitive behavioural therapists bucks this trend. Freda McManus and a her team have found that several dozen trainee CBT therapists tended to underestimate, not overestimate, how good they were at conducting CBT therapy.

Finding out how accurate therapists are at judging their own skills is important because quality control in therapy often relies on therapists seeking out extra help and supervision when they think they need it.

The new data come from 26 trainees enrolled on the Diploma in Cognitive Behavioural Therapy and 38 trainees enrolled on the MSc in Advanced Cognitive Behavioural Therapy - both courses are at the University of Oxford and the Oxford Cognitive Therapy Centre. The Diploma and MSc students submitted two to six video recordings of therapy sessions they'd conducted. They watched these tapes themselves and rated their own performances. These self ratings were then compared against ratings provided by expert supervisors on the training courses.

Overall the trainees tended to underestimate their skills as compared with ratings provided by their supervisors. Splitting the trainees into two groups - more and less competent - it was the more competent trainees who tended to underestimate themselves. The less competent trainees' self ratings didn't differ from the ratings they received from supervisors.

"These results are encouraging in suggesting that CBT therapists may be less susceptible to over-estimation of their competence than has been previously reported," the researchers said, "which is likely to have benefits for the delivery of CBT interventions in routine clinical practice."

Why would trainees be underestimating their skills? One explanation lies in a concept known as "defensive pessimism" - a way for high performers to ensure they still receive support and remain motivated to improve their standards. Potentially this is a good thing for clients, but the trainees could suffer in terms of job satisfaction and morale.

There are some question marks over the new findings. For example, the rating scale that was used to assess CBT performance (the Cognitive Therapy Scale) is known to be rather unreliable. Also, it's possible that the supervisors' ratings were lenient so as not to demoralise their students. A strength of the study is that the participants were not self-selected - they were all obliged to submit their therapy recordings. By contrast, an earlier study that reported over-confidence in CBT therapists was a highly selective sample obtained by inviting participation. It's possible that sample may have been biased towards particularly over-confident therapists.
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McManus, F., Rakovshik, S., Kennerley, H., Fennell, M., & Westbrook, D. (2011). An investigation of the accuracy of therapists’ self-assessment of cognitive-behaviour therapy skills. British Journal of Clinical Psychology DOI: 10.1111/j.2044-8260.2011.02028.x

Post written by Christian Jarrett for the BPS Research Digest.