The Psychologist Annual Conference 2014 Special Edition

psychologistthe

annual conference 2014special edition

AnnualConference 2014An archive collection of some ofthe speakers at this year’s BritishPsychological Society event

‘them and us’ in mental health 2010the anarchic hand 2005Marinus van IJzendoorn 2014for more, see www.thepsychologist.org.uk

£5 or free to members of The British Psychological Society

Child of our Time 2007Chris French 2014

mirror writing 2012time to forget HM? 2013

Incorporating Psychologist Appointments

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extreme sceptic. I had the attitude that all parapsychologists were incompetent,that all self-proclaimed psychics weredeliberate frauds, that no aspects ofparanormal belief were beneficial, and soon and so forth. All of those things I nowthink I was wrong in thinking. I think wehave a natural human tendency to see theworld in black-and-white terms and I wasfalling victim to that. I now think thereare certain paranormal claims that shouldbe taken seriously by the scientific world.I’m not saying that I believe they haveestablished that paranormal forces exist –but the evidence is not as weak as thewider scientific community mightassume. Again I think it’s worth takingsuch claims seriously because, if thewider scientific community is correct to be sceptical and to assume thatparanormal forces don’t exist, then itgives us great insight into the strengthsand weaknesses of the scientific processitself – issues that arise with respect to

appropriate statisticalanalysis, whetherappropriate controls havebeen used, publicationbias and replicationissues. All of those kinds of things arise

with a vengeance inparapsychology. So when I’m

teaching about anomalistic psychology I like to look at the strongest evidenceand give my reasons why I’m still notconvinced by it. Also, at the other end of the spectrum, I like to look at what I would consider to be extremely weakevidence in favour of paranormal claims,because that gives us a great insight intoeveryday reasoning that people use tocome to the conclusion that they havehad a paranormal experience. But maybethere are other much more plausible non-paranormal explanations available.

I’d be interested to know what do youthink about Rupert Sheldrake’s claimsthat he has demonstrated things liketelepathy, given he was a seniorscience academic. I think Rupert is a very articulate andintelligent proponent for the other side ofthe argument. I’m actually a closet fan ofRupert Sheldrake. I don’t think he’s right– but I think the reasons he is wrong arereally interesting. He is one of those rareindividuals who has the golden touchwhen it comes to demonstratingostensibly paranormal effects. I alwaysfind that when I try to replicate his effectswe don’t get the same results – which isinteresting. I think of Rupert as a personalfriend, and I wondered why he gotpositive results and I don’t, so I suggested

You started out in neuropsychology,but over the years you’ve become

well known for anomalistic psychology.Talk me through this transformation.My PhD, which was at LeicesterUniversity, used EEG to look athemisphere differences, so it’s very much a neuropsychological background.Subsequently I’ve worked in a number ofareas. I’ve done quite a lot of work withmy wife Anne Richards on cognition andemotion but then developed this interestin the psychology of, for lack of a betterphrase, ‘weird stuff’. Initially it started offpretty much as a hobby or side interest. I would do occasional lectures on it andthese went down well with the students.Then I’d do occasional student projectslooking at various aspects and it kind ofgrew from there. And now it is the mainfocus of my research. I used to have a bitof a dilemma about what I called myselfbecause when people asked me ‘what isyour research interest’ and I would say ‘it’sthe psychology of paranormal beliefs andostensibly paranormal experiences’, whichis a bit long-winded. So I took to usingthe term ‘anomalistic psychology’ –I didn’t come up with it but I think it bestdescribes what I do. So now I say ‘I studyanomalistic psychology’ and they say‘What the hell is that?’

Was there one key event or person that planted this seed of interest inanomalistic psychology? Absolutely, I used to be a believer in most of these kinds of claims. Then, whenI was doing my PhD, I read a book calledParapsychology – Science or Magic? byJames Alcock, a Canadian socialpsychologist. It dealt with all of the kindsof thing I was very much interested in –but from a sceptical perspective andoffered explanations in non-paranormalterms. It made me realise there was asceptical literature, but at that time it wasquite hidden so it was difficult to trackdown. I started subscribing to scepticalmagazines and got involved in scepticalconferences. It grew from there.

I still occasionally come across theattitude ‘We all know it’s nonsense, sowhy do you study it?’ Well, there arevarious reasons. For example, mostpeople believe in this stuff and a sizeableminority claim to have had directexperience of it. As psychologists, we needto explain this. Also the fact that there’s a multi-billion dollar industry builtaround it and thatpeople base importantdecisions about health,relationships andfinancial investments onit means we can’t justignore this area andpretend it’s not there.

How can people come to believeastonishing things, like they have beencontacted by aliens or have regressedto a past life? There’s a multitude of reasons for thesebeliefs. One of the good things aboutanomalistic psychology is that we cancherry pick from all of the othersubdisciplines of psychology. So if we look at alien abduction, I think the mainexplanation is the development of falsememories – then the whole psychology of false memories comes into play and lots of cognitive research underlies that.Also there’s lots of work on individualdifferences that shows different kinds ofpersonality factors might be involved.There’s various kinds ofneuropsychological explanations thatmight lead people to believe they mayhave been abducted by aliens. One of the most common explanations is sleepparalysis – they put that experience downto alien abduction as an explanation.

In one of your articles you describeyourself as a ‘relatively moderatesceptic’. Can you unpack that for me?As a teenager I was interested in this kind of thing, and there was no scepticalliterature out there so I pretty muchbelieved it all. When I read Alcock’s book,it was my epiphany, and I became an

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An anomalistic psychologistChris French tells Lance Workman about his journey into weird stuff

“Sceptical voices areheard a lot more than theyused to be”

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let’s do something collaboratively. Butthose collaborative studies have neverproduced replicable statisticallysignificant results. One of the problems of course in general is that researchers are far less inclined to write up failedreplications than they are to write upsignificant ones. Also journals are far less likely to publish failed replications.

Can you give me an example here?Yes, as you may know the well-knownsocial psychologist Daryl Bem published a study in 2011, in a very well respectedjournal, that consisted of nine studies thatdemonstrated precognition, that is, that,in a sense, people can predict the future.He claimed that, whereas we all knowthat if you give people a list of words thatis presented only once and another list ofwords that they are allowed to rehearsethey will remember the rehearsed wordsbetter than the unrehearsed words. Bem’sresults showed that, even if you do therehearsal after they have been tested, theywill still perform better. So the claim herewas that, in some mysterious way, theeffects of the future rehearsal can reachback in time and improve yourperformance. Now we were intrigued bythis – that is myself, Richard Wisemanand Stuart Ritchie – and we agreed thatwe would each carry out an independentstudy [see also tinyurl.com/psycho0512].Bem asked for replication studies andvery kindly made his software available.We didn’t replicate his findings, but whenwe wrote up our results and sent thepaper to the Journal of Personality andSocial Psychology the editor politelyrejected it without sending it out for peer review. We thought this was notacceptable given the original paper hadcaused a huge amount of media coverageand it had made an explicit appeal forpeople to try and replicate the effects. Wethen got the same treatment from ScienceBrevia and from Psychological Science. We then sent it to the British Journal ofPsychology where it was sent out forreview – but it was rejected. One of thereferees was very positive about it, but the second referee had reservations andrejected it. It turned out the secondreferee was Daryl Bem! Fortunately,PLoSOne did decide to publish it whichmeant we were eventually able to makeour point. I think this experience raisesissues…

How can psychology possibly moveforward if many journals won’t publishfailures to replicate studies! It’s almostas if ‘this has been shown therefore wecan tick that box and move on’. Movingon ourselves, one phenomenon you’ve

looked into is near-death experiences.Can we explain this in scientific terms?I think there are two major hypothesesabout near-death experiences. First, isthat near-death experiences are exactlywhat they appear to be – the person ishaving the experience that consciousnesshas left their physical body, that they havehad a glimpse of the afterlife. The secondway to explain it is what is known as the‘dying brain hypothesis’. This is the ideathat it is a hallucinatory experience withall of the experience happening inside theperson’s head. Now each of thosecomponents of that experience doesoccur outside of near-death experiencesand there are plausible provenexplanations in terms of what washappening in the brain at the time.

In terms of trying to support theparanormal angle, if you could prove that people really were able to pick up

information from remote locations thatthey couldn’t possibly have known aboutin any other way that would be a realchallenge to sceptics. I’m a greatsupporter of these studies that are goingon in hospitals around the world wherethere are targets that are at vantage pointshigh up in hospital wards that you canonly see if you are high up. So far thoseexperiments have been going on forseveral years and no one has yet reportedone of these hidden targets. But we’ll see.There is certainly lots of anecdotalevidence – but it does not seem to standup well when studied scientifically.

You’ve appeared a lot on TV and radiolooking into paranormal beliefs. Hasanything ever happened during one of these that really does open the doorto the paranormal?In all of the studies that we have doneand all of the TV and radio programmes I have taken part in there has been very

very little that constituted a real challengeto my scepticism. But then again there areone or two TV programmes I’ve donewhere at the end of it I’ve put somethingin a mental box with a question marknext to it. To give you an example – there was one case of a programme wherea man called David Mandell claimed hehad dreams that could foretell the futureand he would paint pictures about what is going to happen. As he was an artist hecould produce quite good representationsof what was going to happen. Some of theexamples include the Twin Towerscollapsing. He painted this twice, one ofwhich was five years before it happened.He would go down to his local bank andhave his picture taken with that paintingand that day’s newspaper. Spookilyenough the date was 11th September.

That kind of thing could just becoincidence. The depiction did not

correspond exactly to how ithappened – but it was prettyclose and difficult to explain.

As a (kind of) sceptic do youthink we are moving in theright direction, or do youthink we are more open tobelieve whatever we are toldthese days?There has been a polarisation.There’s no doubt that scepticalvoices are heard a lot more thanthey used to be. On the otherhand there is no evidence ofany fall-off in belief in thingsnew age and paranormal. I think it’s down to a lot of

factors, the internet being themain one. People can now pass

information and ideas on and get togethermore easily. One of the things that I’mmost pleased about is so many cities nowhave a ‘sceptics in the pub’ evening wheresomeone will come along and give a talkand people can question them. Also I’m delighted that the AQA’s psychologysyllabus has anomalistic psychology as an option. So lots of kids are askingquestions about the quality of theevidence they have been given. Personalexperience is generally seen by people as the most reliable form evidence, but as psychologists we are aware that peoplemisremember, misperceive andmisinterpret. We need to get people to question things using the mostappropriate critical thinking tools.

Finally you’ve done a great deal, but is there anything that you still haveburning ambition to do?Burning ambition is the right term – Iwould really love to do a fire walk!

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KANT maintained that ‘freedom ofthe will’ is one of the metaphysicalissues the human intellect is not fit

to tackle. I hope at least to add a tiny tile tothe complex mosaic of ‘will and actions’,through the perspective of cognitiveneuroscience. I will discuss the cases ofpeople whose intentions to act are hinderedby actions they perform apparently againsttheir own will. These people behave as theydo because of lesions in particular regionsof the brain, the frontal lobes.

One evening we took our patient, MrsGP, to dinner with her family. We werediscussing the implication of her medicalcondition for her and her relatives, when,out of the blue and much to her dismay, herleft hand took some leftover fish-bones andput them into her mouth (Della Sala et al.,1994). A little later, while she was beggingit not to embarrass her any more, hermischievous hand grabbed the ice-creamthat her brother was licking. Her right handimmediately intervened to put things inplace and as a result of the fighting thedessert dropped on the floor. Sheapologised profusely for this behaviour thatshe attributed to her hand’s disobedience.Indeed she claimed that her hand had a mind of its own and often did whatever‘pleased it’. This condition is known asanarchic hand: people experience a conflictbetween their declared will and the action

of one of their hands. She is not the onlyperson with this bizarre syndrome. Anothersuch patient had problems in choosing TVchannels, because ‘no sooner had the righthand selected one station the left handwould press another button’ (Parkin, 1996).

Anarchic hand is one of the mostintriguing phenomena in neurology. Thecomplex movements of one hand areapparently directed towards a goal and aresmoothly executed, yet are unintended(according to what the affected people say).The patients are aware of their bizarre andpotentially hazardous behaviour but cannotinhibit it. They often refer to the feelingthat one of their hands behaves as if it has a will of its own, but never deny that thiscapricious hand is part of their own body.The bewilderment comes from thesurprising and unwanted actions, not froma sensation of the hand’s not belonging(Marchetti & Della Sala, 1998). Thiscondition seems to demonstrate that self-ownership of actions can be separated fromawareness of actions. The patients affected

are aware of the ‘actions’ of their anarchichand, which they know to be their handand not a robotic counterfeit, yet theydisown them.

Anarchic hand is a symptom sogrotesque that it verges on the comic.Another patient of ours, Mrs GC, oftencomplained that her hand did what itwanted to do, and tried to control itswayward behaviour by hitting it violentlyor talking to it in anger and frustration(Della Sala et al., 1991). Readers mayappreciate the similarities with DrStrangelove, the irreverent movie thatStanley Kubrick based on the novel RedAlert by Peter George, in which a madGerman-American nuclear scientist, playedby Peter Sellers, constantly had to grab hisright arm to stop it making a Nazi salute.Dr Strangelove syndrome is the term bywhich anarchic hand is now knownthroughout the popular scientific press.

AnatomySome of the literary and movie descriptionsof anarchic hand (see box) neatly overlapwith the anarchic patients’ feelings orreports. However, it was William Boyd, inhis short story ‘Bizarre Situations’ in thecollection On the Yankee Station, whoembraced an anatomical interpretation ofthe syndrome. The main character of thisnovel does not know whether or not his lefthand shot his best friend’s wife dead. Hehad undergone an operation known ascallosotomy, where surgeons sever thebundle of white fibres that join the twocerebral hemispheres. Indeed, in the wakeof the discovery of the specialisation of theleft and right hemispheres, for many yearsa section of the corpus callosum (eithersurgically or due to a pathological process)has been held to be solely responsible foranarchic hand. Feinberg (1997) maintainedthat the key to the anarchic hand is thenotion that you can have twoconsciousnesses in a single individual.

The idea that ‘Man is not truly one, buttruly two’ (Stevenson’s Dr Jekyll and Mr

SERGIO DELLA SALA on the bizarre ‘Dr Strangelove

syndrome’ and what it tells us about free will.

‘ANARCHIC HAND’ IN FICTIONThe theme of a hand with a will of its own has captured theimagination of several movie-makers and writers.

The 1935 film Mad Love was based on a Maurice Renard novelabout a pianist whose mutilated hands had been surgicallyreplaced with those of a criminal which then acted on theirown will.A pianist’s severed hands cropped up again in the1946 film The Beast with Five Fingers, and portrayals continuedthrough the 1960s (The Nutty Professor, Dr Strangelove), 1980s(Evil Dead 2) and 1990s (Body Parts, Idle Hands, and Me, Myselfand Irene).

In Hemingway’s The Old Man and the Sea, the cramped handwould not conform to the old man’s fish-catching endeavoureven when he gently entreated it to. Other examples abound.Julio Cortazar, in one of the short novels of Octaedro, Cuello deGatito Negro, portrayed a girl whose hand ‘does not want tolisten and sometimes to her consternation does whatever itlikes’. Maurice Sheridan Le Fanu in The House in the Churchyard,presented a disembodied hand trying to choke the haplessperson it was persecuting.

Peter Lorre in The Beast with FiveFingers

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Hyde), perhaps half good and half bad as in Italo Calvino’s Cloven Viscount, isentwined with the history of humanity, andcertainly is fascinating from the artist’spoint of view. However, scientifically it israther simplistic, and as an interpretationfor anarchic hand it proved wrong. Thecallosal hypothesis of anarchic hand isslippery on more than one ground. Bearwith me for a short anatomical digression.

Anarchic hand interpreted as adisconnection between the two hemisphereswould result from the separation betweenthe right hemisphere motor cortex(governing the left hand) and the lefthemisphere areas devoted to planning andthe correct execution of complex motoractivities. Therefore the hand showing theanarchic behaviour must always be the lefthand in right-handers. This assumption has

been debunked by the observation of right-handed patients with a right anarchic hand(see Goldberg, 1985).

So, if anarchic hand is not caused byinter-hemispheric disconnection, what doescause it? Our patient GC (Della Sala et al.,1991) who had right-sided anarchic hand,suffered a subarachnoid haemorrhage – therupture of an artery within the brain – eightyears before she came to us. Two days afterthe haemorrhage she was operated upon bya neurosurgeon who attempted to clip herbroken aneurysm. As a result she had astroke. She was left with damage in theanterior part of her brain, encroaching uponthe medial area of her left frontal lobe.

We reviewed 39 detailed cases we couldglean from the literature (Della Sala et al.,1994). It appeared that most of the patientsshowing anarchic hand had a lesion

encroaching upon the medial wall of thefrontal lobe contralateral to the waywardhand. In particular, lesions seem to becentred on an area known as thesupplementary motor area (SMA). EachSMA lies in the medial surface of one ofthe frontal lobes (see Figure 1). It plays a role in the execution of movements. It isthought to be responsible for convertingintention into self-initiated actions, or to beinvolved in the selection of what movementto make. Several studies converge indemonstrating that the part of the SMAknown as the SMA-proper stores andorganises motor subroutines related tointernal drives.

Several physiological single-cellexperiments point to the distinction betweena lateral and a medial premotor system. Thepremotor medial systems centred on theSMAs are connected with a lateral motorsystem (centred on a region sometimesreferred to as premotor cortex – PMC). Thislateral system is considered to be responsiblefor the so-called responsive movements,which are generated in response to externalstimuli. I will summarise for you oneexperiment I found particularly enlightening.

Mushiake et al. (1991) trained monkeysto press buttons in a given sequence. In onecondition, the ‘external condition’, lightstold the monkeys which button to press (it was a visually guided sequence). In theother condition the monkeys performed thesequence from memory with no externalcues, this was the ‘internal condition’. The movements made by the monkeyswere identical. Yet the SMA cells weremore active during the internal conditionand the PMC cells were most active during the external, visually guidedcondition.

Neuroimaging studies provide us withfurther compelling examples. A series ofexperiments carried out in London (seeBlakemore et al., 2002) showed that willedactions are associated with a clear activityin the medial walls of the frontal lobes.These and other similar experimentsindicate that the control of movements mayvary as a function of whether the action isinternally or externally guided. The SMA-proper will dominate when the task isinternally guided. In contrast, the lateralregion becomes more relevant when theenvironment triggers the task. A neataccount of anarchic hand could be given asa result from the imbalance of this complexmechanism: a lesion of the SMA leaves thecontralateral hand at the mercy of external

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FIGURE 1 Localisation of the premotor cortex (PMC) and the supplementary motorarea (SMA) in the lateral and medial view of the left hemisphere

Peter Sellers in Dr Strangelove

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stimuli that operate through the PMC,and it therefore behaves anarchically.

The ‘frontal’ account of anarchic handmakes sense if one considers the basic roleof the frontal lobes in the human brain: toallow interaction with the environment. Thedevelopment of the prefrontal cortex inhumans is, in evolutionary terms, bothrecent and striking. Even in comparisonwith squirrels and rhesus monkeys, therelative proportion of the cortex occupied bythe prefrontal region in humans representsan enormous increase. The comparativerecency of the development of the prefrontalcortex is one of several factors that have ledmany to regard the region as the seat of whatwe believe to be our distinctive qualities ofself-awareness. A lesion in the frontal lobeswill produce a change in the character andhabitual behaviour of the person – they willbe at the mercy of environmental triggers

and will not be able to inhibit inappropriatebehaviour. The person is not himselfanymore. As poignantly described by KenKesey in One Flew over the Cuckoo’s Nest.When McMurphy returned from havingsurgery to his frontal lobes, his matebellowed: ‘Nothing like him.’

What a person does is not what theywould have done before the lesion to theirbrain – they should not be held responsiblefor their actions, yet they are perfectlyaware of what they are doing. The problemis so acute that Pope Pius XII declaredagainst the practice of lobotomy to treat(change) socially unbecoming behaviour,maintaining that a lesion to the frontallobes would strip a person of free will. Thisthorny issue was debated at some length byan ad hoc committee of ecclesiastics andscientists. They came to the conclusion thatthe freedom of will of people affected by

such a lesion would be degraded, andadvised against their becoming priests orreceiving Holy Communion.

Even more bizarre?What would happen if, rather than aunilateral lesion giving rise to contralateralanarchic hand, a person had a bilaterallesion damaging both the SMAs? Theoutcome would be another sign of frontaldisinhibition known as ‘utilisationbehaviour’, whereby patients show acompulsive urge to use objects at sight.

Lhermitte (1983), a French colleague,revamped this symptom. Among theexamples he reported, my favourite is thatof a 52-year-old lady who was sitting in thedoctor’s surgery, when she spotted somemedical instruments. She immediatelypicked up the syringe, Lhermitte was fastenough to take off his jacket and undo histrousers; she bent down to his buttocks togive the injection.

We have recently assessed a patient,with a bilateral lesion centred on theSMAs, showing overt episodes ofutilisation behaviour (Boccardi et al.,2002). For instance, while being tested, hespotted an apple and a knife on a corner ofthe testing desk. He peeled the apple andate it. The examiner asked why he waseating the apple. He replied: ‘Well…it wasthere.’ ‘Are you hungry?’ ‘No. Well, a bit.’‘Have you not just finished eating?’ ‘Yes.’‘Is this apple yours?’ ‘No.’ ‘And whoseapple is it?’ ‘Yours, I think.’ ‘So why areyou eating it?’ ‘Because it is here.’ Onanother occasion the experimenter, whileadjusting the video-camera, put his walleton the table. The patient spotted the wallet,started to take out all the credit cards andother things, such as the national insurancenumber, reading it aloud. The experimenterasked: ‘Whose wallet is it?’ ‘Yours.’ repliedthe patient, a bit baffled by the question,but carrying on ransacking it. Indeed, hisutilisation behaviour was so overt as tobecome a cause of embarrassment to hiswife, and was her major complaint.

It looks as if by damaging one SMA a person ends up with anarchic hand;damage to both will elicit utilisationbehaviour. In both cases the affectedpatients will perform inappropriate actions.The environment triggers the actionsperformed by patients showing utilisationbehaviour exactly as it does those of peoplewith anarchic hand. However, those withutilisation behaviour are not aware thattheir behaviour is inappropriate, and they

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Blakemore, S-J.,Wolpert, D.M. & Frith,C.D. (2002).Abnormalities in theawareness of action. Trends inCognitive Sciences, 6, 237–242.

Boccardi, E., Della Sala, S., Motto, C. &Spinnler, H. (2002). Utilisationbehaviour consequent to bilateralSMA softening. Cortex, 38, 289–308.

Della Sala, S., Marchetti, C. & Spinnler, H.(1991). Right-sided anarchic (alien)hand:A longitudinal study.Neuropsychologia, 29, 1113–1127.

Della Sala, S., Marchetti, C. & Spinnler, H.(1994).The anarchic hand:A fronto-mesial sign. In F. Boller & J.Grafman(Eds.) Handbook of neuropsychology,Vol. 9 (pp.233–255).Amsterdam:Elsevier.

Feinberg,T.E. (1997). Some interestingperturbations of the self in neurology.

Seminar in Neurology, 17, 129–135.Goldberg, G. (1985). Supplementary

motor area structure and function:Review and hypotheses. Behaviouraland Brain Sciences, 8, 567–616.

Lhermitte, F. (1983).‘Utilisation behaviour’and its relation to lesions of thefrontal lobes. Brain, 106, 237–255.

Lhermitte, F. (1986). Patient behaviour incomplex and social situations:The‘environmental dependencysyndrome’. Annals of Neurology, 19,335–343.

Lhermitte, F., Pillon, B. & Serdaru, M.(1986). Imitation and utilizationbehavior:A neuropsychologicalstudy of 75 patients. Annals ofNeurology, 19, 326–334.

Marchetti, C. & Della Sala, S. (1998).Disentangling the alien and anarchic

hand. Cognitive Neuropsychiatry, 3,191–207.

Mushiake, H., Masahiko I. & Tanji, J. (1991).Neuronal activity in the primatepremotor, supplementary, andprecentral motor cortex duringvisually guided and internallydetermined sequential movements.Journal of Neurophysiology, 66,705–718.

Parkin,A.J. (1996).The alien hand. In P.W.Halligan & J.C. Marshall (Eds.) Methodin madness: Case studies in cognitiveneuropsychiatry (pp.173–183). Hove:Psychology Press.

Sacks, O. (1995). Scotoma: Forgettingand neglect in science. In R.B. Silvers(Ed.) Hidden histories of science(pp.141–187). New York: New YorkReview Books.

ANARCHIC VS. ALIENAnarchic hand is often referred to in the literature as‘alien hand’. However, alien hand is a differentsyndrome altogether.The confusion arose owing to amistranslation from the French and dragged on insubsequent scientific reports (see Marchetti & DellaSala, 1998, for a full account).The term prevailed, andalien hand began to mean different things to differentauthors.

The abuse of the term alien hand is even more evidentin the popular scientific press. For example, in apamphlet Oliver Sacks calls a phantom limb ‘alien’(Sacks, 1995, p.149); and in a TV documentary (TheMind Traveller, BBC2, 31 October 1996) described as‘alien hand’ the typical involuntary movements and ticsshown by a patient with a Parkinson-like disease.

References


don’t show any conflict between wantedand unwanted actions. It may well be thatthe lack of awareness observed in patientswith utilisation behaviour comes from thecomplete impairment of the medial system,while patients with anarchic hand still havesome access to their inner ‘Fat Controller’through the spared half of the system.

Think about a possible scenario thatmay apply to us all. One Saturday morningwhile driving towards a holiday site tospend your weekend you cross the usualroad to your office. Absentmindedly youmay turn and find yourself driving to theoffice for a while before recognising yourerror. The environment provided a triggerstrong enough for you to initiate anautomatic behaviour, which you had toinhibit to go back to your intended plan.This is what often happens to peopleaffected by utilisation behaviour who lackthe capacity to inhibit behaviour triggeredby the environment. When the actionsperformed go beyond the simple toying,manipulation and utilisation of an object,they are often referred to as ‘environmentaldependency syndrome’ (Lhermitte, 1986).

Controlling the anarchist insideSevere forms of environmental dependencysyndrome are observed in patients withlarge lesions in their frontal lobes(Lhermitte et al., 1986). Yet, nobody isreally immune. Jonathan Miller, the Britishphysician turned opera director, revealed avery pertinent autobiographical episode. Hewas standing by a road waiting for QueenElizabeth to pass by, and he was scoffing atall those poor souls hopping about andwaving their hands frantically at thetriumphal black stretch-limousine. Yet,as soon as the mighty car approached hisposition he could not refrain from hailingthe queenmobile. Disgorging nationalisticpride? More probably an automaticperformance triggered by the environmentthat he failed to consciously inhibit.Indeed, according to a recent neat model ofthe motor control system (Blakemore et al.,2002) the deficit responsible for anarchichand and utilisation behaviour would residein the lack of inhibition of theseenvironmental cues which will generateunwanted actions.

From all that we have discussed so far,

it appears that neuroscience provides uswith examples of inability to inhibit actionstriggered by the environment. So canconscious will only veto undesired actions?From this perspective it looks as if ourbrain may have a free ‘won’t’ rather than a free will.

■ Sergio Della Sala is Professor of HumanCognitive Neuroscience and HonoraryConsultant in Neurology at the Universityof Edinburgh. E-mail: [email protected].

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DISCUSS AND DEBATEDoes anarchic hand contribute to our understanding

of consciousness?

Could neuroscience contribute to the discussion onfree will?

Does the brain only allow room for a free won’t?

Has neuroscience got much to say to lawyers aboutpersonal responsibility?

Have your say on these or other issues this article raises.

E-mail Letters on [email protected] or contribute

to our forum via www.thepsychologist.org.uk.

RELAPSE PREVENTION IN BIPOLAR DISORDERA treatment manual and workbook for therapist and clientby Dr John Sorensen

“The manual and the intervention it describes are likely to have a significant impact on the livesof people diagnosed as suffering from bipolar disorder, and to be of considerable value toclinicians working in mental health settings.” Professor David Winter, Head of Clinical Psychology Services (Barnet), Barnet, Enfield andHaringey Mental Health NHS Trust

“The Sorensen Therapy for Instability in Mood will make it possible for the majority of patients,outside of the university clinics, to benefit from effective treatment. To my knowledge there areno other such programmes available.”Dr Jens-Emil Viftrup, Consultant Psychiatrist Adult Mental Health

The Sorensen Therapy for Instability in Mood (STIM) is an important new psycho-educational andcognitive therapy for bipolar disorder. Taking place over only four 60-minute sessions, it can bedelivered by practitioners with little specialist training and is based on the collaborativedevelopment of a relapse-prevention handbook that also provides the client with anindividualised bio-psycho-social formulation of their BPD-related experiences. Impressive resultsinclude significant improvements in patients’ perceived control over mood and significantlyreduced hopelessness.

The author is a Clinical Psychologist at North Manchester General Hospital.

Published October 2005 by the University of Hertfordshire PressThe Manual shrinkwrapped with 5 Workbooks £16.99 ISBN 1-902806-56-5Extra pack of 10 Workbooks £20.00 ISBN 1-902806-57-3

Available from [email protected], tel 01707 284654, or from booksellers.


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attachment here today.It’s quite a short talk, so I decided to talk about some of our recent research on attachment, especially how adultattachment representations are related to responses to infant crying and infantlaughter, and how that might beinfluenced by oxytocin. We are doing a series of studies with oxytocin sniffs.We’re interested in how people with acertain attachment style end up beingharsh to their crying child, or remaincalm and sensitive. Oxytocin might beone of the key issues in the chain fromcognitive representations to behaviour.

The idea being that it’s a kind ofchemical spotlight, it makes socialcues more salient?Oxytocin is a hormone andneurotransmitter that is still not reallydetermined in terms of its function. It’sbeing considered the ‘love hormone’, orthe ‘cuddle chemical’, but again that’s a one-sided view. What we are finding isthat it lowers the activity of fear centres,such as the amygdala, and elevates theactivity of reward centres, such as theorbito-frontal cortex and the anteriorcingulate cortex. But it is not effective in all people – we find that those withnegative attachment experiences are lessopen to the effects of oxytocin. How thatcomes about, that’s one of the big puzzleswe are working on now.

A researcher once did the adult attachmentinterview on me, and said I was the mostdismissively attachedperson they had met!

What would you predict formy reaction to oxytocin, and to my poorcrying children?Amazingly unscientific! The interview is not meant to conduct individualdiagnoses, errors of measurement simplyforbid it. Well, what I’m going to presentis that without oxytocin, insecurelyattached adults feel firstly more irritatedby infant crying behaviour. Secondly wehave a hand-grip measure, we teach theparticipants to exert full force and thenwe teach them to go for half-strength.They manage to do that. And then wehave them listen to cry sounds. Insecurelyattached individuals exert excessive forcemore often than the securely attachedparents, when listening to this aversivecrying.

So that’s not necessarily expressinganger, it could be discomfort, that theyfind that more aversive.Yes, and what in practice the response

We’re here in Stockholm, where I think the popular idea of

dandelion children – those with‘resilient’ genes who will do well inmost conditions – actually originated.The idea of dandelions and orchidsoriginates from Tom Boyce, he used themetaphor. He might be a little distressedbecause it’s taken too literally. I agree –these may not be two classes, but acontinuum of more or less openness tothe environment.

Tell me how you came to it scientifically.We were the first to do genetic researchon the idea of differential susceptibility.The idea was already around on atheoretical level, for quite some time, andin fact was most active in the mid-1990s.The first studies were by Boyce and thenJay Belsky, but then it seemed to slowdown a lot. We were entering into thefield of genetics from the perspective ofattachment theory, which is I think quitelogical because attachment theory is basedon evolutionary theory – it’s the firstevolutionary theory applied to humandevelopment besides Charles Darwinhimself. John Bowlby was the firstevolutionary psychologist you might say,it’s now a very popular concept but hewas the first to apply evolutionarythinking in a systematic way to humandevelopment.

So my colleague Marian Bakermans-Kranenburg and I went into this area ofgenetic research after having done twinstudies, and we found – by accident, in a way – this interaction between DRD4, a dopamine-related gene, and sensitivityto environmental influences on children,developing differentially positively ornegatively. That got us on the way in a series of studies on differentialsusceptibility.

Am I right in thinking that twopsychologists at King’s College London,Caspi and Moffit, had raw data andgraphs in their 2002 and 2003 papers

pointing to this idea, but it didn’t reallyget a foothold?Well, their wonderful research preparedthe way for gene by environmentinteraction research more broadly. Buttheir study is really firmly grounded inthe tradition of diathesis-stress andcumulative risk.

So in people who did not face severe or repeated stress, the risk alleles inquestion actually heightened resistanceto stress and depression.Carriers of risk alleles were more prone todevelop, for example, anti-socialbehaviour or depression having grown upin a bad environment with lots ofmaltreatment experience. But the otherside of the equation, the bright side, Caspiand Moffit didn’t touch on. So absolutelygroundbreakingstudies, because forthe first time in thehuman developmentarea they opened upthe way of thinkingin terms of measuredgene by observedenvironment interaction, but differentialsusceptibility is a two-sidedphenomenon – the same risk alleleswould also create more options to learnfrom a positive environment. That’s quiteunique to the idea of differentialsusceptibility and to the research that wedid in Leiden.

And it was about that time that positivepsychology was coming to the fore, soyou were surfing the zeitgeist oflooking on the bright side!It might be that it’s not by accident –about that time more people started to do research on the positive side ofdevelopment, but again one-sided studies,of positive development in positiveenvironments. But it is the power of theidea of differential susceptibility, that itcovers both streams of research.

So tell me how you’re linking it with

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‘Children suffer… that’swhat drives me’ Marinus van IJzendoornmet Jon Sutton at the European Congress of Psychologyand talked about his research on differential susceptibility in child development

“there is a gap betweenbrain and behaviour, whichis very intriguing”

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would be. It could be an alarm signal thatis more pronounced, it might also triggerharsh parenting. Crying behaviour isprimordial attachment behaviour, it’s oneof the first behaviours that an infant canshow to display discomfort, distress,stress… it’s a proximity seekingbehaviour, which JohnBowlby wrote about quiteextensively. But it’s also atrigger for harsh parentingand child abuse, anepidemiological study showedthat aversion to crying in thefirst half year is the stimulusfor about 6 per cent of youngmothers to slap the child, tosmother the child, to really gointo the direction of childabuse. You might imagine that it’s a powerful trigger,because persistent crying isreally a nuisance, that’s forsure, for any person, but somepeople might have a lowerthreshold to react in a harshway. What we see in thescanner is that listening to crysounds compared to controlsounds elevates the level ofamygdala activation, becauseit’s aversive, and oxytocinlowers that level of activation.What we hoped to find wasthat it’s a mediatingmechanism betweenattachment representation to those feelings of irritationand excessive force on thehand grip. We didn’t find that,so there is a gap betweenbrain and behaviour, which isvery intriguing.

So it’s not as simple as intervening onthat pathway with a sniff of oxytocinwhen your baby starts crying.Exactly. We can’t really connect the threeparts of the equation to each other…that’s not unique to our lab, in the fMRIarea the dominant paradigm is looking atthe brain as a dependent variable, so whathappens in the brain is the end product ofa series of stimuli. For me this is totallyunimportant, because what happensbetween your ears, no child or infant willever see. What’s important is how specificbrain activity is expressed in behaviour.I’m interested in parenting, in childbehaviour, I would like to know howbrain activation affects parenting style andhow it’s made visible to the child, shapingthe course of development. That’s really a big puzzle still, and not even addressedin a lot of the neuroscientific studies onparenting.

A lot of your research is still veryhands on with children and parentsand behaviour, it’s important not totake it that level of abstraction too far.These are absolutely fantastic times tostudy parenting, with big advances ingenetics, in brain research, in hormonal

research. It all creates lots of opportunitiesto look at the mechanisms, the processesof how exactly parents are influencingchildren in their development, but weshould refrain from using those types ofdevices for their own sake, because it’sfancy, because it’s creating these nicepictures. It’s always a means to a goal andthat goal is to understand better whathappens between parents and childrenand to know more about how to intervenein families with an environment that isnot so great for the child to grow up in.

In terms of creating positiveenvironments, what do you think wecan learn from the Scandinavians,given that we’re here in Sweden? Inthe UK I think people look to here foran example of how it should be done;whereas in the UK some people say‘we go out to work and get paid badlyso that we can pay other people badly

to look after our children badly’.In Scandinavia the parents really seem to have the choice to be at home, bothparents, to care for their infant in the firstyear of life. In the UK and othercountries, maternity and particularlypaternity leave is very brief, so people areobliged to have other forms of care.

From the perspective of attachmenttheory there’s a misunderstandingaround the concept of monotropy.There’s lots of evidence that childrenare able to grow up in a network ofattachment relationships. Sarah Hrdyhas written about the survival value ofalloparenting. It takes more than oneperson simply to collect all the foodneeded to have a child growing up to areproductive age. You need a village toraise a child. So nothing against morecaretakers in the environment of thechild. The point is that in the first yearof life, children are easily overwhelmedby all kinds of stimuli, they need morestructure than older children. They aredependent on the moderation of stressby persons in the environment thatthey can rely upon. Attachment figuresare in fact external stress moderatorsfor infants in the first year of life.

Now if you put them into groupcare, that’s really quite some stressfulexperience. Some children won’t bebothered at all, depending on theirtemperament, but others will be. Ifparents don’t have the choice of stayingat home, I think that’s bad, that’s notenough options for parents ofsusceptible children who might need tobe at home.

The ‘orchids’?Maybe, yes. So that’s what I find

distressing in the US, the UK, in Holland,that parents don’t have the freedom tochoose. The second issue is of course quality

of care. You can have bad care in bothfamily and daycare environments withdetrimental effects on the mostsusceptible children. In Scandinaviancountries they seem to have strongregulations, and monitoring of them, tokeep quality of care high. That’s a lessonwe should learn. Young children areworth this investment, according toeconomists like Heckman.

You’ve researched a huge range oftopics, from the aftermath of genocidethrough sleeping children to adoption.What’s the common thread, whatvalues drive you in that work?The most important perspective is theinfluence of the environment, parentingand the family context on child


interview

Professor Marinus van IJzendoorn, Centre for Child andFamily Studies, Leiden University, The [email protected]


development. You know of course thebook by Judith Harris, that parents arenot important at all because it’s all geneswhich drives development? There’s now a very popular book in Holland by DickSwaab called We Are Our Brains. So in thepast 20 years we witness a very strongmain current that defines childdevelopment as a kind of autonomicprocess driven by genes and brainstructures, with only marginal influencefor the environment – prenatally, maybe,but whether after birth the work is reallydone, that’s what I doubt.

So you’re driven to counter that at apersonal level as well as a scientificlevel?Neglect of the environment is a bigmisunderstanding and, in the endchildren suffer… That’s what drives me. If you follow it through, with the brain as ultimate cause of any developmentalprocess, you can’t even criticise thatchildren grow up in an orphanageenvironment. We did studies inorphanages in different parts of the world,and what we see is that for every singlemonth they stay in that environmentthere is a bigger lag in their developmentof weight, height and head circumferencecompared to their peers growing up infamilies. Cognitive development goes intothe range of mental retardation. If theyare adopted, you see a tremendous catch-up in cognitive development, IQ recoversto a normal level, a difference of 15–20IQ points. This would be hard to explainon the basis of genes and brains being thecausal drivers of development.

That recovery, that resilience, bringsus back to the positive and negativeeffects of the environment… it’s not too late to intervene. Differential susceptibility theory makesclear that some children are quite robust,it doesn’t matter too much whatenvironment they’re raised in as long as it meets minimum standards. That’s quitehopeful because there’s quite a few ‘just

good enough’ environments around. Butthere are also a lot of children who arevery open to environmental pressures,these orchid children, who would reallyflourish in a better environment. Thatpotential is going to be wasted if we feelit’s only genes and brains that createdevelopment. It’s a waste of talent, a wasteof potential, if we are seduced by adeterministic view of child development.

Genes are important, but it’s theinterplay with the environment, and toooften that’s lip service – on the part ofthose who study the genes, and on the

part of those who study the environment.You need a concept like differentialsusceptibility to study, in detail, theinteractions between the two facets.

Have you had your own behaviouralgenes assayed, or would you not thinkthat’s important because it all dependson the interplay anyway?These concepts, genes and environment,they all work on the level of samples,they don’t work on the level of theindividual. It’s a misunderstanding if youfeel one might predict the individualcourse of life on the basis of candidategenes, one gene in more than 20,000,without any insight into theenvironment… but even if you had exactinformation about the environment pastand present, I still think on the individuallevel prediction would be quitedisappointing.

Looking to your own future, can youpredict where this research path is

taking you next?There’s distressingly little experimentalresearch done on gene by environmentinteractions. We were the first to do agene by environment experiment –changing the environment and seeinghow that interacts with genes. It’s somuch more powerful statistically. We have to work on better assessments of the environment, better assessments ofgenotype (for example genetic pathways),but also better designs to be able to reallytest and examine differential susceptibilityand gene by environment interplay in

general. So what we would like to do are large-scale experimentalstudies in which we have a closerlook at the mechanism itself. Weplan to use fMRI as a pre- andpost-test assessment, to see ifdifferences in brain activationmediate the effects of ourintervention on the behaviour ofparents and children. It is tryingto get a more detailed andmechanistic view of howinterventions work moreeffectively in certain subgroups of participants who are more opento the environment.

I think we’re going to continueour work with the oxytocin sniffs,because it’s intriguing how it ismoderated by childhoodexperiences. It’s still shown inonly three or four experimental

studies. This is shaky in terms of theassessment of childhood experiences,so the first step will be to see how itis moderated by adult attachmentrepresentations, but it would be great

if we could also include it in longitudinalstudies where we may observe negativechildhood experiences moderating theeffects of oxytocin.

Is there a lot of funding in that area?We just received a seven million eurogrant from the national sciencefoundation to conduct experimentalstudies on differential susceptibility. Butthe pharmaceutical industry is not reallyinterested in our oxytocin research. I justread Ben Goldacre’s Bad Pharma and feltlucky that industry does not see anyprofit in oxytocin. Maybe this is thereason why published results of oxytocinstudies are diverging and sometimesdisappointing. Our recent meta-analysisin Translational Psychiatry shows theproblems of clinical applications ofoxytocin. I love to do independentresearch because it is difficult enoughwithout a big company looking over yourshoulder and having an interest in theoutcome.


interview

read

ing Bakermans-Kranenburg, M.J. & Van IJzendoorn,

M.H. (2011). Differential susceptibility torearing environment depending ondopamine-related genes. Development andPsychopathology, 23, 39–52.

Bakermans-Kranenburg, M.J. & Van IJzendoorn,M.H. (2013). Sniffing around oxytocin.Translational Psychiatry, 3 e258.doi:10.1038/tp.2013.34

Van IJzendoorn, M.H. & Bakermans-Kranenburg,M.J. (2012). Differential susceptibilityexperiments: Going beyond correlationalevidence. Developmental Psychology, 48,769–774.

Potential is going to be wasted if we feel it’sonly genes and brains that create development

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‘big picture’ pull-out www.thepsychologist.org.uk i

Annual Conference 2014The keynote speakers for the conference are:

Registration is open –earlybird rates are

available until 27 March

Our programmetimetable is now

available to download

Professor Sir Simon Wesselybest known for his work on unexplained symptoms,syndromes and military health

Ben Shepharda military and medical historian, author anddocumentary maker

Susan van Scoyoca psychologist specialising in psychotherapy, hasworked within the legal system for over a decade

Professor Marinus van IJzendoornrecipient of awards for his research on attachmentand emotion regulation across the life-span

Professor John Aggletonuses anatomical, behavioural and clinical methodsto understand how brain regions interact

www.bps.org.uk/ac2014

7-9 May 2014International Convention Centre, Birmingham

psy 02_14 pi_iv bigpic_Layout 1 21/01/2014 11:20 Page i

leads journalists like me, to ask questionsof our role and responsibilities ininterviewing those who are defined, in2011 guidelines published by Ofcom, thebroadcasting watchdog, as ‘vulnerablepeople…those with learning difficulties…mental health problems…the bereaved…people who have been traumatized orwho are sick or terminally ill’.

Both Ofcom and current BBC editorialguidelines stress the importance ofproviding ‘a voice to people confrontingcomplex challenges’. They warn againstusing discriminatory language and urgecareful reporting of suicide. However,much of the news media tends to focuson whether the contributor is well

enough to give informed consent. Whatconstitutes ‘informed consent’ in thecontext of someone who has experiencedsevere trauma, or who has a complexmental health problem, is not, I’d argue, a question asked by every news journalist,who are sent out to report on a breakingstory and quickly gather the thoughts ofthose involved.

Interviewing objectivesIn nearly 30 years at the BBC, I’veinterviewed many people at violent ortraumatic events, from the HillsboroughStadium disaster, to the Paddington rail

Three years ago I interviewed PCDavid Rathband, who as an unarmedpoliceman sitting in his car had been

shot and wounded by the gunman RaoulMoat. He was blinded permanently by theattack and some of the shotgun pelletswere still embedded in his face. Hewanted to talk about what had happenedto him, to raise awareness and funds for a charity he’d set up for other injuredofficers, called the Blue Lamp Foundation.He was in training for the LondonMarathon and doing endless runs tetheredto a sighted police colleague; but when heran, he did so in darkness and he loathedit. Raoul Moat, David said, was constantlyon his shoulder, no matter how far he went and how hard he pushedhimself. During the hour-long interview,David talked about his visions andnightmares. How the picture inside hishead was relentlessly dark and ugly. Howhe felt less of a father and husbandbecause he could do nothing for himself.How his police uniform was hanging inhis wardrobe, yet he didn’t know how andwhen he could put it on again.

It was an emotional interview, Davidcried and often reached for my hand. Hecouldn’t see my producer and he wasn’taware of the microphone, all he couldhear was my voice. I asked whether hewas comfortable that such an intimate and personal conversation was going to be edited to less than a quarter of itslength, and broadcast on Radio 4 to more than two million people. He saidyes, he wanted his story heard, however

uncomfortable it felt.So, the interview was broadcast, won

plaudits and was listed among the bestever broadcastinterviews by theRadio Times. Lessthan a year later PCDavid Rathbandkilled himself.

Opening the‘sluice gates’ The brilliant USbroadcaster StudsTerkel says the job of a radio intervieweris to mine for the‘precious metal’ in anindividual, and thatquestioning shouldtake the form of acasual conversation,but one in which ‘intime, the sluice gatesof damned up hurtsand dreams (are)open’. The motive is to provide anentertaining,informativebroadcast, revealingthe life experience of others, so theaudience can betterunderstand what liesbehind those ‘hurts and dreams’.

But the mining process sometimes

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Evans-Lacko, S. et al. (2012). Mass socialcontact interventions and their effecton mental health-related stigma andintended discrimination. BMC PublicHealth, 12, 489.

Holstein, J.A. & Gubrium, J.F. (2004). Theactive interview. In D. Silverman (Ed.)Qualitative research (2nd edn,pp143–161). London: Sage

Oakley, A. (1993). Essays on women,medicine and health. Edinburgh:

Edinburgh University Press. Skehan, J. et al. (2006). Reach, awareness

and uptake of media guidelines forreporting suicide and mental illness:An Australian perspective.International Journal of Mental HealthPromotion, 8, 4.

Teplin, L. et al. (2005). Crime victimisationin adults with severe mental illness.Archives of General Psychiatry, 62,911–921.

references

OPINION

Voices of the vulnerable Broadcaster, journalist and psychology student Sian Williams reports from thefrontline on the responsibilities of broadcasters towards those they interview

‘He wanted to talk about what had happened to him, to raiseawareness and funds for a charity he’d set up for other injuredofficers, called the Blue Lamp Foundation’

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crash, to the Asian tsunami and thePakistan earthquake. My role involvesgetting something on-air fast, and thatoften entails talking to people who arestill in shock. In longer, recordedinterviews in a studio context, there ismore time to discuss what to ask and howto ask it with the editorial team. There’salso the chance to conduct relevantresearch. However, the objective is thesame – to get an interview that willmake the audience think.

In semi-structured interviewsconducted in a psychological setting,researchers collect information andinterviewees are often seen as ‘passivevessels of answers…repositories offacts, reflections, opinions’ (Holstein& Gubrium, 1997). The power in the dyad in a broadcast interview, as in a psychological one, is with the personasking the questions, but thejournalist is often not trained to talkto those who are vulnerable and is rarelycovered by a professional ethics code.Also the giving of help is not the purposeof the interview. As Oakley (1993)remarked: ‘What is good for theinterviewer is not necessarily good forinterviewees.’

Jack Douglas’s 1985 book CreativeInterviewing suggests using ‘strategies and tactics’, based on ‘friendly feelingsand intimacy’, to optimise ‘cooperative,mutual disclosure’. However, anydisclosure in, or before, a broadcastinterview is usually neither mutual norcooperative. The broadcaster’s objective is not to offer advice, but to produce aninformative, entertaining interview. Falseintimacy may be encouraged by theinterviewer asking casual as well asdirected questions, disclosing just enoughof themselves to gain trust, and thusprovide stimulating radio or television.

The broadcast environment, familiarto the interviewer yet unfamiliar to theinterviewee, further strengthens theasymmetry. The control lies with thebroadcaster; an interview can be cut froman hour to 10 minutes, with unpalatableor controversial aspects removed, to‘protect’ the interviewee from adversereactions from the listener, or to shieldthe audience from unacceptable languageor behaviour. If a taped interview ischanged, drastically shortened, ordropped altogether, this may heighten an already vulnerable person’s anxietythrough ‘confirmation bias’ – the humantendency to focus on evidence thatsupports existing beliefs. One broadcastjournalist told me of a recorded interviewwith someone recovering from a braininjury, which was removed from theprogramme at the last minute. His clinical

psychologist contacted the teamafterwards to say that removing the itemwithout warning had caused him distress.

Those with a mental health problemmay also believe themselves to be oflower status, may worry about beingjudged and could struggle to perform wellin an interview context. Their story could

be reshaped or their contribution droppedaltogether, potentially affecting how theysee themselves.

The power and the storyThe media typically use medicalisedlanguage, reducing an interviewee to a condition or problem. Words like‘schizophrenic’ or ‘depressive’ can createstereotypes and schemas, which, whenactivated and left unchecked, can creatediscrimination or prejudice.

When the charity, Mind, conducted a survey in 2000 into how people withmental health problems thought theywere viewed by society, half of therespondents pointed to media coverage as having a negative effect on their mentalhealth. In their submission to the LevesonInquiry into the Culture, Practice andEthics of the Press, the Mind and RethinkMental Illness charities suggested thatprejudice develops because of thelanguage used in the media, especially in print. People with mental health issuesare sometimes described as a victim, ordangerous, with descriptive words usedlike ‘psycho’ or ‘crazed killer’. Mind callsthis the creation of ‘the dangerousnessmyth’, pointing to research suggestingsomeone with a mental health problem is actually more likely to be a victim thana perpetrator of crime (e.g. Teplin, 2005).

Even though studies highlight print media as being most responsible for creating the ‘dangerousness myth’,other media can perpetuate it. In a 2011survey for Mind, only a third of over two thousand adults with a previous orexisting mental health problem said theythought the media as a whole portrayedmental health in a sensitive way.

In 1954 Gordon Allport suggestedfour factors to help reduce prejudice:equal status, common goals, intergroupcooperation and support of authorities. A recent meta-analysis (Evans-Lacko etal., 2012) showed that if there is socialcontact that meets all of Allport'sconditions, it could help reduce stigma

and discrimination.Knowing or meetingsomeone with a mentalillness is a powerful wayto improve attitudes and behaviours.

In Australia charitiesand organisations thatpromote mental health areusing the ‘social contact’

findings to try to bringabout attitudinal changetowards people with mentalhealth problems, through themedia. Journalists and

broadcasters have been invited to meetpsychiatrists and people with mentalhealth problems, with accompanyingeducational programmes and joint teamprojects. Research and subsequentguidelines on suicide and mental illnessreceived national funding from June2002, with briefings and the distributionof books, quick reference cards and CD-ROMs to media organisations. A studyinto the effectiveness of this strategyfound most respondents reported thatthere had been organisational change inattitudes towards mental health, with‘improved attitudes and confidenceamong staff about reporting suicide andmental illness and their improvedawareness of the key issues to consider’(Skehan et al., 2006).

Protecting the vulnerableThe value of giving the vulnerable a voice is clear. It enables people who arenot normally heard on mainstream media,a chance to explain a lived experience,and challenge stereotype and stigma, ifdone with careful attention to the issuesand language. Personal and emotivetestimony is a powerful way of engagingan audience and encouraging them tothink differently. What broadcasters needto be aware of, is how to use that powercarefully.

In the UK, there have beenimprovements in the way much of themedia covers mental health issues overthe past few years, with many sensitivedocumentaries and news articles.Guidelines for broadcasters on reportingmental health and suicide were publishedin 2008 by the Department of Health inthe form of a media handbook called


opinion

“What constitutes ‘informedconsent’ in the context of someonewho has experienced severe trauma,or who has a complex mental healthproblem, is not, I’d argue, a questionasked by every news journalist”

I Sian Williams is in the final year of an MSc in Psychology andis a trained Trauma Risk Management assessor

‘What’s the Story?’. It urgedjournalists to report fairly andaccurately, to use quotes from peoplewith mental health issues and to giveout numbers of helplines like theSamaritans. The journalists’ union,the NUJ, has issued somethingsimilar. However, much more can bedone.

Broadcast organisations would do well to create their own trainingschemes and provide instantresources. Guidelines for newsreporters and producers couldemphasise the importance of the useof language in mental health issues,including suggestions on how to helpthe participant create and shape theinterview and information on thepotential pitfalls, arising from theediting process. Recently, the BBCagreed to make a video for its trainingwebsite, highlighting the mostcommon errors. I’d urge mediacompanies to do similar and gofurther. Increased education andscientific literacy, with training inmental health matters and instantaccess to the tools and resourcesneeded to understand problems andconditions, can reduce stigma, as theAustralian model shows.

The interviewer could discuss the structure and tone of the conversationwith the interviewee before the recording,to clarify how best to allow them to telltheir experience. Transparency is vital ifthe interviewee is to feel comfortable andrepresent themselves as effectively aspossible.

During the research process,broadcasters could speak to charities thatrepresent those considered vulnerable; tomake sure the right language is used.

In its 2013 guidelines fordocumentary producers, Mind suggestsmeeting mental health groups, listeningto different voices and reading blogs bythose with mental health problems. Mindalso recommends giving the contributorclear ideas of question areas, remindingthem they can withdraw at any time,telling them honestly about the editingprocess, and, if their contribution isdropped, explaining why.

Even if guidance has been given,training taken and all ethical practisesconsidered, there’s another vulnerablevoice that many journalists need toconsider and protect – their own.Sometimes, news crew run to a story with a tape recorder or camera, but are illprepared for what they experience whenthey arrive. Whether it’s a war zone,disaster area or reporting from a courtcase with graphic and upsetting evidence,

the adrenalin and the pressure of adeadline kick in and any uncomfortablethoughts are pushed to the back of themind to be dealt with later, if at all.

Vulnerability on both sides After a week reporting from Pakistanfrom the epicentre of the earthquake in 2005, I remember returning to acomfortable hotel in Islamabad, taking offmy boots and frantically scrubbing them,again and again. Even when the detritushad gone, I kept washing them. When I returned home to the warmth of myfamily, images of devastation and decay,the cries of distress and the sickly smell of disease and death lingered.

As always, news crew are witnesses tohorrors others live through. We can leave,they can’t. The suffering of those leftbehind in such events is immeasurablyworse than anything reporters canexperience, so it feels self-indulgent toacknowledge any difficult emotions. Yetsometimes, you just can’t shake them off.

Various research findings suggest thatpost-traumatic stress disorder symptoms inreporters covering traumatic events rangefrom around 6 per cent to 28 per cent,with war correspondents experiencinglevels similar to combat veterans.

Despite that, some news crew stillbelieve it’s a sign of weakness to seek

help, that there’s a stigma attached toadmitting distress. But that attitude maybe changing. Broadcast organisations havebegun to develop peer support traumanetworks – I’m one of a team trained toassess colleagues who have returned fromdifficult and challenging environments.Other resources, like those offered by theDART Center for Journalism and Trauma(see www.dartcenter.org), provideguidance on how news crew can reporton trauma responsibly, while alsoprotecting their own mental health.

The challenge is getting thatawareness directly into newsrooms andembedding it into the culture. Journalistsneed to feel they have the skills andtraining to fairly represent those caughtup in challenging events, or those whoare experiencing mental health issues,while also feeling confident that they havethe understanding and resilience toprotect themselves. Perhaps there willalways be a conflict between the needs ofthe broadcaster and those caught up inthe news, but the media can be betterprepared to make it a rewardingexperience for both, and an enlighteningand engaging one for the audience.

I Sian will be speaking at the Society’s AnnualConference gala dinner, at the Crowne PlazaHotel in Birmingham, on 8 May. To book, seewww.bps.org.uk/ac2014

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Journalists’checklistI Can the guest give informed consentand do they fully understand theinterview process?

I Is their support team aware of theircontribution?

I Have you contacted charities ororganisations to get help andinformation about the issue underdiscussion?

I Have you asked the guest what theywould like or expect from the interview?

I Have you reassured them aboutcontent, duration and publication date?

I Have you ensured they are seen as aperson, not a diagnosis?

I Are you using the right language andterminology?

I Should you provide a helpline numberafter the interview?

I Have you considered your own mentalhealth, and sought support ifnecessary?

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434 vol 22 no 5 may 2009

I interviewed Claudia Hammond in aLondon café on the day before the firstepisode of her new BBC Radio 4 series

was broadcast. State of Mind tells the storyof mental health care in the UK from the1950s to the present. Many readers will

know her regular programme All in theMind, perhaps the most important sourceof psychological ideas in the UK media.

Early on in the interview the café fusebox blew. Struggling to scribble notes inthe gloom increased the anxiety of

interviewing someonequoted on the BBC Radio4 website as saying: ‘Thegreat thing about this jobis getting to interviewsome of the mostbrilliant researchers inthe world...’ and whocommented: ‘It’s a reallyluxury to be able todecide what I want to askthem.’

So, how did Claudiabecome one of the mostlistened to and read UKpsychologists after aperiod as a greyhoundtipster? And why doesshe tend to be seatednext to new-ageenthusiasts at weddings?

I asked her whatcame first – psychologyor the media. ‘I was at achildren’s book festivaland, after I had queuedup to get Roald Dahl’sautograph, he asked mewhat I wanted to dowhen I grew up. I’m toldI said “I want to work inradio”. That was the first

my parents knew about it. It was probablythe first time I realised.’

It seems radio work was the constant.Claudia worked local stations in parallelto and between school and university. Herinterest in psychology developed out ofthat. ‘Claudia’s Sunday Requests onHospital Radio Bedford was not an award-winning production’, she says (thoughClaudia is still listed on their website). ‘Istarted it when I was 14. I went round thewards asking for requests and I foundmyself going in earlier and staying longer.Patients told me their stories and detailsof their illnesses and treatments. This waswhat got me interested in psychology,maybe what even led to me doing apostgraduate degree in health psychology.’Not that this educational path was aforegone conclusion. ‘Before going toSussex to do a degree in appliedpsychology I worked at Three CountiesRadio as a newsroom assistant. Watchingnews stories come in and going in andout of the studios during live programmeswas incredibly exciting. Occasionally I’dget on air too: the first time was givingblood on the breakfast programme. So Ican say I’ve given blood for the BBC! Ithought about staying on but wasconvinced I should get a degree. Myfriends thought I’d do media studies, but Iwanted to learn about something new. SoI did a degree in applied psychology atSussex.’

Claudia’s book Emotional Rollercoasterdisplays her fascination with researchfindings. This started during her firstdegree. ‘I liked the experimental aspect of the work – setting up a hypothesisthen testing it. I also found I liked therange of psychology – the number ofdifferent areas it studies and affects, thedifferent ways of doing it. I knew I didn’twant to be a clinical psychologist,although I did think about going intoresearch. But at the time I was also

A rollercoaster rideIan Florance talks to Claudia Hammond about how she has put her background inacademic psychology to good use in her broadcasting career

www.psychapp.co.uk is now open to all.Advertisers can now reach beyond theprime audience of Society members thatthey reach in print, to include the manyother suitably qualified individuals online.

Society members have the added benefit ofbeing able to sign up for suitable e-mail andRSS alerts, and we are looking to add more

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Please help us to spread the word.Recruiters can post online from just £750,and at no extra cost when placing an ad inprint.

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CARE

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seek and advertise at www.psychapp.co.uk 435

careers

working at Radio Sussex so I was tornbetween psychology and radio.’

Claudia undertook an MSc in healthpsychology at Surrey University,researching doctor–patientcommunication in a breast cancer unit.Her first job on national radio – as ajournalist on Radio Five Live – marked a real change. ‘I’d done the greyhoundracing tips on local radio, but now I wasdealing with sports stories as well asbreaking news. I’m hardly an expert onsport. This, along with watching a pieceon horse insemination involvingrecording people doing extraordinarythings with drainpipes, are two of myodder media experiences.’

Claudia stressed that she’s always beenand remains freelance rather than a staffmember. ‘In a sense I was trying to keepparallel careers going, as a reporter on theone hand and as a psychology lecturer onthe other.’ But whatever strange tasks sheundertook as a journalist, she was alwayslooking to develop items on psychologyand wider health issues. ‘I began to startreporting on Radio 4 series such asWoman’s Hour and All in the Mind.’

Claudia was then able to bring thetwo together, presenting a wide range of programmes that reflect her earlierfascination with psychology’s breadth: it covers memory, group psychology,positive psychology, conformity andsports psychology, among many othersubjects. There’s also a strand that looksat wider health and biological scienceissues: fingerprints, the experience ofmiscarriage. ‘I have a weekly programmeHealth Check on the BBC World Service.This has led to some extraordinaryexperiences and gives me a chance to geta more global view of health provision.Visiting the biggest brothel in the worldwas quite extraordinary.’ (You can readher fascinating Guardian article on this attinyurl.com/da49oq).

Claudia also has a regular column inPsychologies, originally a French magazinebut now available in a number ofEuropean editions. She describes it as a‘women’s glossy monthly magazine that’sdifferent from any other, because there’sno fashion’. Her first book, on the scienceof emotions, was published in 2005 toexcellent reviews.

She chairs conferences and lecturestoo. ‘I started at the OU and now lectureon two courses – Social Psychology Issuesin the UK and Health Psychology forBoston University’s UK base. I love doingthis. Students challenge you and exposeyou to different views and I like having tokeep up to date for those lectures.’

Claudia must also surely be the onlypsychologist to appear alongside bands,

comedians, novelists and poets at theLatitude Festival in 2008.

In the gathering gloom of the Londoncafé it was sometimes difficult to keep upwith the sheer range of Claudia’sactivities. What is the common threadrunning through them?

‘Sometimes if I go to a wedding I’mput next to someone who is “interested in psychology”. Quite often, this personturns out to want to talk about chakras,read my aura, compare crystals or someother new-age topic. People are fascinatedwith psychology but they don’t alwaysunderstand what academic psychologycovers. They link it to fringe beliefs andactivities. There can be amisunderstanding among people who setout to study psychology. Sometimes theythink it will help them work throughtheir problems.’

In an interview included in her book,Claudia expanded on this. ‘It’s not a self-help subject… for the most partpsychology today is about the study oflarge numbers of people; it’s not aboutintrospection.’

So Claudia says she is trying to ‘givepeople a better understanding of the rolepsychology plays. Helping peoplearticulate and get across a seeminglytechnical piece of good research is centralto my approach. I also like bringingdifferent specialists together – it’s amazinghow often people who are hugely expertin one area of psychology know next tonothing about related work in a slightlydifferent field. I really enjoy it when twopeople involved in a discussion exchangecards on the way to the lift and decidethey might do some work together. Onesuggested I set up a matchmaking servicefor academics!’

You’ve met some very well-knownpsychologists. Do they intimidate you? ‘Iinterviewed Philip Zimbardo in his houseand he cooked pizza for us. It’s a privilegeto meet and listen to such people. But,the advantage is that I’ve got a role, anexcuse for being there as an interviewerfor the BBC - and I’ve done myhomework. So I’m not frightened. I liketo be in control, so that I don’t get in theway and you hear the ideas from thehorse’s mouth. Reading journal articles isone thing, but hearing someone actuallytalk about their research can really bringit to life.

‘I can’t emphasise too much how myexperience as a reporter and producer inmy early media career has helped me.Understanding how the media works aswell as knowing your subject is crucial.But it’s more than that. The experience ofworking in a local radio newsroom and at5Live taught me about balance and

fairness in discussions, something that’scrucial even in non-news programme likeAll in the Mind. My personal opinions areirrelevant when it comes to a programmelike that – it’s all about letting everyonehave a fair say and critically questioningtheir research and viewpoints.’

This led us on to Claudia’s advice forpsychologists seeking too communicatetheir ideas. Here are her key points.

I Be choosy: don’t accept everything. I Popular programmes are fine –

‘I sometimes go on Richard & Judy totalk about psychological research –but if I think a show is going to dumbit down, I say no. And sometimesthey’re looking for is a qualifiedtherapist, and that’s not me.’

I Ask plenty of questions beforehandon the phone (not when you arrive at the studio), so that you can thinkabout what you’re going to say.

I Don’t agree to talk about subjects youknow nothing about. Have someresearch in mind that backs up whatyou’re saying, but be realistic abouthow detailed you can be – this isn’tthe place for a critique of researchmethods and stats.

I If you choose the programme well,the interviewer and interviewee are init together. The interviewer wants tomake the interviewee look goodbecause its makes a betterprogramme.

I Psychology is something worthtalking about. ‘It’s a pity when goodresearchers are nervous about gettingtheir research out there where thepublic can hear about it. There’s suchan appetite for psychology amongstthe public that it would be great tosee some really good TV programmesmade on the subject.’

In near pitch blackness I asked Claudiawhat her plans were for futureprogrammes, series and books. I wasaware that this might be asking her togive too much away about submissions tothe BBC or her publishers and she thoughtlong and hard about it. The next day Ireceived an e-mail which is worth quoting:

‘What I hope might happen in the future is that just as the field ofeconomics is suddenly catching on to the decades of psychological research ondecision-making, that other fields mightstart to do the same and to realise thatthere’s all this research out there whichcould be put into practice. Expert panelsand commissions wouldn’t dream of notincluding an economist. I’d like to see a day when they all have a psychologisttoo.’

careers

742 vol 25 no 10 october 2012

Allen, F.J. (1896). Mirror-writing. Brain,19, 385–387.

Angelillo, V.G., De Lucia, N., Trojano, L.,& Grossi, D. (2010). Persistent leftunilateral mirror writing. Brain andLanguage, 114, 157–163.

Balfour, S., Borthwick, S., Cubelli, R. &Della Sala, S. (2007). Mirror writingand reversing single letters in strokepatients and normal elderly. Journalof Neurology, 254, 436–441.

Chan, J.L. & Ross, E. (1988). Left-handedmirror writing following rightanterior cerebral artery infarction.Neurology, 38, 59–63.

Cornell, J.M. (1985). Spontaneousmirror-writing in children. CanadianJournal of Psychology, 39, 174–179.

Critchley, M. (1928). Mirror-writing.London: Kegan Paul, Trench,Trubner & Co.

Cubelli, R. & Della Sala, S. (2009). Mirror

writing in pre-school children.Cognitive Processing, 10, 101–104.

Davidoff, J. & Warrington, E.K. (2001). Aparticular difficulty in discriminatingbetween mirror images.Neuropsychologia, 39, 1022–1036.

Dehaene, S., Nakamura, K., Jobert, A. etal. (2010). Why do children makemirror errors in reading?Neuroimage, 49, 1837–1848.

Della Sala, S. & Cubelli, R. (2007).

‘Directional apraxia’: A unitaryaccount of mirror writing followingbrain injury or as found in normalyoung children. Journal ofNeuropsychology, 1, 3–26.

Della Sala, S., & Cubelli, R. (2009).Writing about mirror writing. Cortex,45, 791–792.

Durwen, H.F. & Linke, D.B. (1988).Temporary mirror writing and mirrorreading as disinhibition phenomena?

Mirror-writing is the production of letters, words or sentences inreverse direction, so that they looknormal when viewed in a mirror.Some people may mirror-writeintentionally; but unintentionalmirror-writing is surprisinglycommon amongst young children,and in brain-damaged adults.Unintentional mirror-writingsuggests a tension between atendency for our brains to treatmirror-images as equivalent, and a culturally imposed need todistinguish between them forwritten language. This articleexplores the various manifestationsof mirror-writing, and the ideas putforward to account for it.

Picture yourself in a taxi on a cold,rainy day, condensation on thewindows. You want to write ‘bye-

bye’ to your daughter waving at you fromthe house. In order to be read by her, youwould need to write in reverse on theinside of the window, transforming yourhabitual writing actions to do so. This is‘mirror-writing’ – reversed writing thatlooks normal when viewed in a mirror;like the sign on the front of an ambulance.Since Western scripts typically run fromleft to right, this reversed form is alsoknown as levography (Critchley, 1928) or sinistrad writing (Streifler & Hofman,1976).

Mirror-writing is striking andmysterious. It has been practiseddeliberately by some notable individuals,most famously Leonardo da Vinci, andportrayed to powerful effect in literatureand visual art (see Box, right). Mirror-writing is of special interest topsychologists because it can sometimesarise in people trying to write normally.For example, unusual writing demandscan sometimes mislead us into writingbackwards. If we write onto paper pressedagainst the underside of a table, or againstour forehead (Critchley, 1928), we may failto transform our actions to compensate forthe altered plane of performance, and ourwriting may come out mirror-reversed.Mirror-writing is also common amongstchildren learning to write, and is noted inadults following brain damage, usually tothe left hemisphere.

But what do these phenomena tell usabout our brains? Do we each harbour alatent looking-glass world, poised to usurp

the everyday given the right conditions? Is mirror-writing after brain damage arecurrence of the childhood form, ordifferent? More than a century of sporadicscientific literature, and some of our ownrecent observations, suggest answers tothese tantalising questions.

Explanations of mirror-writingDoes mirror-writing imply reversedperceptions, or is it only that the actioncomes out backward? This captures thedichotomy between perceptual and motorexplanations of mirror-writing, from theclassical literature to the present day. Onthe perceptual side, Orton (1928)suggested that, for every word or objectwe recognise, an engram is stored in thedominant (left) hemisphere, and itsmirror-image in the non-dominanthemisphere. Mirrored-forms emerge inchildren, due to incompletely establishedhemispheric dominance, but aresuppressed in adults unless released byleft-hemisphere damage. Subsequentperceptual accounts, such as the spatialdisorientation hypothesis (Heilman et al.,1980), share the core idea that mirror-writing is one aspect of a more generalmirror-confusion. Perceptual explanationspredict that mirror-writing should beassociated with perceptual confusion, andeven with fluent reading of reversed text.And if the mirroring arises at a perceptuallevel, then mirror-writing should emergeregardless of which hand is used.

On the motor side are those who arguethat action representations are critical tomirror-writing (e.g. Chan & Ross, 1988;Erlenmeyer, 1879, cited in Critchley,1928). The basic insight is that learnedactions are represented in a body-relativescheme, not in external spatial coordinates.Thus, for a right-handed Westerner, thehabitual writing direction is not left-to-right per se, but abductively outwards fromthe body midline. If executed by theunaccustomed left hand, this abductiveaction will flow right-to-left, unless it istransformed into an adductive inwardaction, much as we need to transform our

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Schott, G.D. (2007) Mirror writing:neurological reflections on an unusualphenomenon. Journal of Neurology,Neurosurgery & Psychiatry, 78, 5–13.

Della Sala, S. & Cubelli, R. (2007).‘Directional apraxia’: A unitaryaccount of mirror writing followingbrain injury or as found in normalyoung children. Journal ofNeuropsychology, 1, 3–26.

Is mirror writing a perceptual or amotor phenomenon? Is it the samephenomenon in young children as inbrain-damaged adults?Why would it be useful for our brains totreat mirror-image objects and actionsas equivalent?

ARTI

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Mirror-writingRobert D. McIntosh and Sergio Della Sala explore some intriguing phenomena

psy 10_12 p742_747 mcintosh_Layout 1 17/09/2012 14:44 Page 742

action when writing on a window for a reader on the other side. On this view,children might mirror-write with eitherhand if they have yet to learn aconsistent direction, but literate adultsshould do so only when attempting towrite with the left hand whilstcognitively impaired or distracted, sothat the required transformation isomitted. Since perceptual factors playno explanatory role, motor accountspredict that mirror-writing should notentail perceptual confusions or mirror-reading.

Of course, perceptual and motoraccounts need not be mutuallyexclusive: the manifestations of mirror-writing may be too various for anyunitary account (Critchley, 1928; butsee Della Sala & Cubelli, 2007). As weshall see, the facts favour a motorinterpretation in most cases; but thereare possible exceptions, and interestingnuances to the story, as well as someunresolved puzzles.

Spontaneous mirror-writing in childrenAs any nursery or primary teacherknows, mirror-writing is very commonamongst children learning to write.These productions are not mereconfusions of legal mirror-imagecharacters (such as ‘b’ and ‘d’) but caninvolve the reversal of any character, andeven whole words and phrases. A childmay sign her name neatly but back-to-front. Interestingly, some characters aremore likely to be reversed than others,particularly those such as ‘3’ or ‘J’ inwhich the correct form ‘faces’ leftwards.This suggests that during exposure towritten language, the child implicitlyextracts the statistical regularity that mostcharacters ‘face’ to the right, then over-applies this ‘right-writing rule’ (Fischer,2011).

Several myths surrounding mirror-writing in children should be dispelled.Most prominent is the traditionallyassumed association with slow intellectual

development, arising from early anecdotalliterature (e.g. Orton, 1928) and studies of‘mentally defective’ children (Gordon,1920), and propounded as a visual motifthrough popular works (e.g. Winnie-the-Pooh, the Far Side cartoons). Recentstudies have converged in showing that the likelihood of mirror writing does notcorrelate with intellectual abilities. Cubelliand Della Sala (2009), for instance,reported no significant difference inintelligence between mirror-writing andnon-mirror-writing children of the sameage (cf. Fischer & Tazouti, 2011). There issimilarly little truth in the idea that mirror-writing is more common in left-handers.Mirror-writing in childhood does of coursecorrelate with age, but the true underlying

factor here is the stage of acquisition ofwriting, with occasional mirror-writing asan intermediate stage between no writingand correct writing (Della Sala & Cubelli,2009; Fischer & Tazouti, 2011).

Situational factors further modulate the likelihood of mirror-writing at anygiven moment. For instance, childrenshow sequential biases, tending to faceeach character in the same direction as thepreceding one. An example from Fischer(2011) concerns the character pair ‘C3’, as written by 300 five-to-six-year oldchildren: the probability of mirror-writingthe ‘3’ was far greater (0.73 vs. 0.10) if the‘C’ had been correctly written (i.e. right-facing) than if it had been mirror-written(i.e. left-facing). Spatial constraints are also

Examples in literature and film‘And how was the anonymous letter written?’‘Backhanded.’ Again the abbe smiled. ‘Disguised.’‘It was very boldly written, if disguised.’

The Count of Montecristo by Alexandre Dumas père

He wrote, Dear Henry Phipps, in a violet-coloured ink. He did not write these words from left toright, but thus: He wrote fluidly, as if long accustomed to that distrustful art.

…The Thief-taker has given you the mirror.Jack Maggs, a novel by Peter Carey

Since the occurrences we are about to consider (as impartially as possible), he has found theutmost difficulty in writing except from right to left across the paper with his left hand.

The Plattner Story, a novel by H.G. Wells

Mirror-writing has also been portrayed in films: in Christopher Nolan’s Memento, the ‘facts’ aretattooed on Leonard's chest in mirror-writing sothat he can read their reflection; in StanleyKubrik’s The Shining, Danny writes REDRUM onthe door, which is MURDER backwards (Maggiedoes the same with her toy blocks in the Simpsonsepisode Reality Bites). Mirror-writing also featuresin the Simpsons episode ‘Brother from the sameplanet’; the Scooby-Doo episode ‘Mystery maskmix-up’; The 25th Hour; Alvin and the Chipmunks;

and Flowers for Algernon. For further examples, seeDella Sala and Cubelli (2009).


mirror-writing

A case study. Neuropsychologia, 26,483–490.

Fischer, J-P. (2011). Mirror writing ofdigits and (capital) letters in thetypically developing child. Cortex, 47,759–762.

Fischer, J-P. & Tazouti, Y. (2011).Unraveling the mystery of mirrorwriting in typically developingchildren. Journal of EducationalPsychology. doi: 10.1037/a0025735

Gordon, H. (1920). Left-handedness andmirror-writing especially amongdefective children. Brain, 43, 313–368.

Gottfried, J.A., Sancar, F. & Chatterjee, A.(2003). Acquired mirror writing andreading: Evidence for reflectedgraphemic representations.Neuropsychologia, 41, 96–107.

Heilman, K.M., Howell, G., Valenstein, E.& Rothi, L. (1980). Mirror-readingand writing in association with right-

left spatial disorientation. Journal ofNeurology, Neurosurgery andPsychiatry, 43, 774–780.

Lambon-Ralph, M., Jarvis, C. & Ellis, A.(1997). Life in a mirrored world:Report of a case showing mirrorreversal in reading and writing andfor non-verbal materials. Neurocase,3, 249–258.

Orton, S.T. (1928). Specific readingdisability – strephosymbolia. Journal

of the American Medical Association,90, 1095–1099.

Parsons, L.M. (1987). Imagined spatialtransformations of one’s hands andfeet. Cognitive Psychology, 19,178–241.

Parsons, L.M. (1994). Temporal andkinematic properties of motorbehavior reflected in mentallysimulated action. Journal ofExperimental Psychology: Human

Danny writing on the door in The Shining

Dear Henry Phipps

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mirror-writing

important, and children as old as sevenmay write their name backwards ifrequired to start from a point on the pagethat leaves inadequate space to write itforwards (Cornell, 1985; Fischer &Tazouti, 2011). That a simple spatialrestriction can elicit mirrored scriptsuggests a dominant role for motor factors,rather than perceptual confusion.Consistent with this, Della Sala andCubelli (2009) found that the frequency of mirror-writing was no higher amongstchildren who had difficulty discriminatingmirror images than amongst those who didnot. Uncertainty about how letters shouldlook does not seem to drive mirror-writingin children.

Rather, childhood mirror-writing may tell us something about how writingactions develop. Specifically, it implies thatthe general shape of a letter is learnedmore rapidly than the direction for writingit. The key to understanding this may beto regard mirror-writing not as intrinsicallyerrorful, but as a feat of actiongeneralisation. It is a neat trick for a childto produce a perfect mirrored-form, whichthey have never been taught, as readily asthe correct form that they have beenshown repeatedly. For most actions, thismirror-generalisation would be useful,because anything that we do one way mayneed to be done in reverse at another time;we do not learn separately to turn a tapclockwise and anticlockwise, only to turnthe tap. Writing, however, belongs to anunusual, evolutionarily recent, class ofactions that have a culturally setdirectionality, and for which thisgeneralisation is unhelpful. Acquiring the correct direction for writing in one’sculture may be a matter of stamping outthe unwanted alternative after havinglearned the general shape of the action.

Involuntary mirror-writing after brain damageChildren grow out of mirror writing, butin some adults it makes an unexpectedreturn. Mirror-writing is quite commonfollowing stroke, though usually

transient. Frequencyestimates vary from2.5 per cent(Gottfried et al.,2003) to 13 per cent(Tashiro et al., 1987),but are much higher(24 per cent) if onlyleft hemispherelesions are considered(Wang, 1992). A review of singlecases confirmed that mirror-writingfollowing stroke is overwhelminglyassociated withdamage to the lefthemisphere (93 percent) and with use ofthe non-dominant lefthand (97 per cent)(Balfour et al., 2007).The prototypicaladult mirror-writer isa right-hander who loses right-arm motorfunction following left-hemisphere stroke,being forced to write with the left hand.

Given this profile, could the strongassociation of mirror-writing with left-hemisphere damage be an artefact of forcedleft-hand use? Would mirror-writing beelicited in other groups simply byrequesting writing with the left hand?When this tactic was tried, it yieldedmirror-writing rates that did not differstatistically between right- and left-hemisphere damaged people (14 per centof 36 cases vs. 20 per cent of 50 cases)(Balfour et al., 2007). Even amongst 86healthy controls, writing with the left handproduced at least some reversals in 7 percent of people; but writing with the righthand never did.

These results fit the motor hypothesis,according to which involuntary mirror-writing in adults reflects left-handedexecution of a right-hand action, withoutmotor transformation. The transformationrequires cognitive resources, so would besusceptible to attentional lapses, andespecially vulnerable after brain damage.

We must stress that the sporadic reversalsobtained by asking brain-damaged peopleto write with the left hand are of a differentorder of severity from florid clinical cases,which may involve consistent reversal ofwords, multi-digit numbers and sentences(see Della Sala & Cubelli, 2007). To fullyaccount for severe and persistent mirror-writing may require more pervasivecognitive insufficiencies, perhapscombined with anosognosia (lack ofinsight) or anosodiaphoria (lack ofconcern) (e.g. Angelillo et al., 2010).

So, children may mirror-write becausethey are unsure of the correct direction,whilst adults retain the correct (abductive)direction, but fail to modify this motorhabit for the unaccustomed hand.However, an alternative motor account,which relates involuntary mirror-writingmore closely to the childhood form, hasbeen advanced by Della Sala and Cubelli(2007). This ‘directional apraxia’hypothesis proposes that involuntarymirror-writing reflects loss of knowledge of the direction of learned actions, withexecution instead governed by a preference

Perception and Performance, 20,241–245.

Pegado, F., Nakamura, K., Cohen, L. &Dehaene, S. (2011). Breaking thesymmetry: Mirror discrimination forsingle letters but not for pictures inthe Visual Word Form Area.Neuroimage, 55, 742–749.

Pflugshaupt, T., Nyffeler, T., vonWartburg, R. et al (2007). When leftbecomes right and vice versa:

Mirrored vision after cerebralhypoxia. Neuropsychologia, 45,2078–2091.

Russell, J.W. (1900). A case of mirrorwriting. Birmingham Medical Review,68, 95–100.

Streifler, M. & Hofman, S. (1976).Sinistrad mirror writing and readingafter brain concussion in a bi-systemic (oriento-occidental)polyglot. Cortex, 12, 356–364.

Tashiro, K., Matsumoto, A., Hamada, T. &Moriwaka, F. (1987). The aetiology ofmirror writing: A new hypothesis.Journal of Neurology, Neurosurgeryand Psychiatry, 50, 1572–1578.

Turnbull, O.H. & McCarthy, R.A. (1996).Failure to discriminate betweenmirror-image objects: A case ofviewpoint-independent objectrecognition? Neurocase, 2, 63–72.

Wade, J., & Hart, R. (1991). Mirror

phenomena in language and non-verbal activities: A case report.Journal of Clinical and ExperimentalNeuropsychology, 13, 299–308.

Wang, X-de (1992). Mirror writing ofChinese characters in children andneurological patients. ChineseMedical Journal, 105, 306–311.



mirror-writing

for abductive movements. This impliesthat the direction of an action is not onlyacquired later than its shape, butrepresented separately, and vulnerableseparately to damage. It is not clearwhether this account improves on thestandard motor account in explainingdocumented cases of mirror-writing, butfurther data on the influence of languageand handedness may prove decisive.Directional apraxia predicts that mirror-writing should affect the left hand forrightward scripts such as English, but theright hand for leftward scripts such asHebrew or Arabic, regardless of the writer’shandedness. There is one report, which fitsthis prediction exactly, of a man whomirror-wrote in Hebrew but not in Frenchwith his right hand, yet produced theopposite pattern – mirror writing inFrench but not in Hebrew – with his lefthand. However, the observation isanecdotal (Marinesco, cited by Russell,1900), and requires replication.

The role of mirror-perceptionsMirror-writing does not entail anadvantage for reading mirrored text; a fact that considerably bolsters a motoraccount (Critchley, 1928). But analogousphenomena can affect perception. Parietallobe damage can induce an inability totell apart mirror-images, even thoughsubtle changes in shape or rotation arespotted (Davidoff & Warrington, 2001;Turnbull & McCarthy, 1996). Suchmirror-confusions sometimes co-occurwith mirror-writing (Durwen & Linke,1988; Heilman et al., 1980; Wade & Hart,1991). In other cases, perception may be

systematicallyreversed, yieldingfluent mirror-reading (Gottfriedet al., 2003;Lambon-Ralph etal., 1997;Pflugshaupt et al.,2007). If thesepeople also mirror-write, it may bedeliberate, andsome state thatthey do so in orderto be able to readwhat they write.However, the mostunusual report isof a polyglotwoman who,following aconcussion,mirror-read and

wrote her firstlanguage, Hebrew (a

right–left script), but not Polish orGerman (left–right scripts) (Streifler &Hofman, 1976). Her mirror-writing wasapparently involuntary, affecting thedominant right hand (the left hand wasnot tested); and she displayed a range of other reversals, perceptual andconceptual (confusion of opposites like inside/outside, above/beneath). The language-specificity of her mirror-reversals is challenging to explain, but the tight parallel between her reading and writing suggests that involuntarymirror-writing can have a perceptual (or conceptual) basis in some cases.

Like mirror-writing, acquired mirror-reading recalls the errors of childhood;and, as for writing, perceptual confusionsin children may reflect a broadlyadvantageous mirror-generalisation. Innature, mirror-images are invariably twoinstances or views of the same thing, so itis efficient to represent them as equivalent.On the other hand, we sometimes need todistinguish mirror-forms, and nowhere isthis more vital than in decoding writtenlanguage. Functional neuroimagingsuggests that a region of the leftmidfusiform gyrus (the ‘visual word form area’) may be critical to mirror-discrimination in reading (Dehaene et al.,2010; Pegado et al., 2011). Thedevelopment of this capacity presumablysuppresses mirror-reading errors duringlearning.

Deliberate mirror-writingWriting in Brain in 1896, F. J. Allen, a neurologically healthy Professor ofPhysiology, recorded his subjective

experience of fluent left-handed mirror-writing, speculating that the ability maynot be rare, just rarely practised. Heproposed that ‘mirror-writing is often asymptom of nerve disease; but the diseaseneed not be the cause of the existence ofthe faculty, but only the cause of itsdiscovery’ (p.385). As already noted,mirror-writing is adopted deliberately bysome brain-damaged people with reversedperceptions. It is also cultivated by somehealthy, albeit unusual, people; often to a high level of skill. Celebratedpractitioners include Lewis Carroll, who experimented with spatial as well as logical inversions, and was a skilledmirror-writer. Amongst the 100,000letters that he wrote were a series of‘looking glass letters, designed to be readin a mirror. Mirror-writing also appears inhis stories and poems. In Through theLooking-Glass one of Alice’s firstdiscoveries is a book printed in mirror-script. There was also Leonardo da Vinci,who wrote thousands of pages of hisnotebooks in mirrored script, with his lefthand. Could deliberate mirror-writingoffer insight into the nature ofinvoluntary mirror-writing in brain-damaged adults?

We have recently had the chance toaddress this issue with Kasimir Bordihn(KB), a German artist, who has practisedvarious forms of mirror-writing for morethan 50 years. KB is a natural left-hander,schooled to write with the right hand, who‘discovered’ mirror-writing aged nine,finding that he could halve his timewriting lines by writing forward with hisright hand and simultaneously backwardwith his left. He later practised andextended this technique, writing forwardor backward with either hand, includingvertical as well as horizontal flips, andincorporating these into a distinctive‘mirror-art’ (see cover). We have begun a case study of KB’s abilities, which isproviding clear support for the motorhypothesis of mirror-writing, and someless expected results.

First, whilst KB writes skilfully in anumber of different directions, his mostfluent form, and the only non-standardform that closely resembles his normalforward right-handed script, is horizontalmirror-writing produced with his left hand.This special status is consistent with theview that left-handed mirror-writingreflects the untransformed execution of a learned right-hand action. Second, whenwriting with both hands, his performanceis far better if his hands move mirror-symmetrically to produce opposite scripts,than if they move in tandem to producesimilar scripts. It is the motor and not theperceptual congruence that counts. Third,


as with most involuntary mirror-writers,KB’s versatility with a pen confers noperceptual benefit: he is as baffled bymirrored text as any other reader. Thesecharacteristics match a motor account ofmirror-writing.

As well as asking KB to read mirroredtext out loud, we assessed his recognitionof reflected letters by psychophysicalmeans, finding nothing unusual. But when instead we asked KB to discriminatepictures of left and right hands, he showeda consistent inability, performingdramatically worse than matched controls,and on one occasion faring no better thanchance. This was not a general problemwith body parts, as he could discriminatethe laterality of feet very well; and it wasnot due to rushed decision making, as hishand discriminations were both slow andinaccurate. Rather, KB revealed a specificimpairment for the discrimination of leftand right hands.

This body-part identification task isused widely as a test of motor imagery.People solve this task by mentally rotatingtheir own hands or feet to confirm amatch to the viewed picture (Parsons,1987, 1994). One possible interpretationof KB’s result is that his unusual facility for

(and/or history of) executing right-handactions with the left may entail anabnormal degree of overlap in the neuralmotor representations of the hands. Hemay thus rotate his hands mentally tomatch the picture, yet fail to identifyintrospectively which hand has made thematch. This is a highly preliminarysuggestion, but the observation is certainlyintriguing. One more flippant implicationmight be that Leonardo da Vinci, for all ofhis genius, may have had more troublethan the average Renaissance man intelling his left hand from his right.

Final reflectionsAs children, we make mirror-errors inreading and writing. These perceptual and

motor confusions are not tightly linked,but arise from parallel strategies ofmirror-generalisation in perception andaction. If we then learn to write with ourright hand, mirror-writing may be thelatent natural script of our left, and vice-versa, requiring only certaincircumstances to emerge.

Mirror-writing in its various forms –spontaneous, involuntary and deliberate –has long fascinated observers in art andscience. Beyond its obvious curiosity value,it provides compelling insights into howwe learn about, and represent the worldand our actions within it.

The story is intriguing, yet incomplete.We think there will be more to learn about ourselves in this particular looking-glass.


mirror-writing

Sergio Della Salais at Human CognitiveNeuroscience, Psychology,University of [email protected]

Robert D. McIntosh is at Human CognitiveNeuroscience, Psychology,University of [email protected]

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Research. Digested.

The British Psychological Society’s free Research DigestBlog, email, Twitter and Facebook

‘Easy to access and free, and a mine of useful information for my work: what more could I want?I only wish I’d found this years ago!’Dr Jennifer Wild, Consultant Clinical Psychologist & Senior Lecturer, Institute of Psychiatry

‘The selection of papers suits my eclectic mind perfectly, and the quality and clarity of thesynopses is uniformly excellent.’Professor Guy Claxton, University of Bristol

psy 02_14 p106_117 ads_Layout 1 21/01/2014 10:59 Page 113

lobes. Along with HM, one other case had the most ‘radical’ surgery, intended to remove the full extent of thehippocampus. In six of the remainingcases the surgery was more restricted as it was intended to reach only the front of the hippocampus or only midwaythrough the structure. Within this groupof patients, HM was unique as his was theonly surgery for the relief of epilepsy. Theother patients received psychosurgicaltreatments intended to relieveschizophrenia (n = 7) or bipolardepression (n = 1). The failure ofScoville’s surgeries to reduce thesepsychiatric symptoms inevitably posedproblems for their cognitive assessments,and the formal testing of three of theseschizophrenic cases was incomplete.Added problems would have arisen fromthe fact that schizophrenia is itselfassociated with appreciable memory loss.

Despite these issues, several featuresof the original study on HM seem tocreate a compelling case for theimportance of the hippocampus. Mostcritically, comparisons among all ninepatients revealed that severe memorydeficits were only seen after radicalresections involving most of thehippocampus. Unfortunately, the realextent of the surgeries could only besubsequently determined for HM, forwhom there is structural MRI data(Corkin et al., 1997). We are, therefore,reliant on Scoville’s surgical notes for theother eight patients. In fact, we nowknow that Scoville failed to remove thecaudal 2cm of HM’s hippocampus, despitehis intention to do so (Figure 1). (Moreprecise information will become availablewhen HM’s post-mortem findings arepublished.) It is, therefore, notunreasonable to suppose that there wereinconsistencies between the intended andactual extent of tissue removal in theseother eight cases.

There are additional concerns.Scoville’s surgeries approached the medialtemporal lobe from its front (i.e. via thetemporal pole), an inevitable consequenceof which was the removal of tissue in

The amnesic HM is the most famoussingle-case in neuropsychology, andpossibly the best known case in all

of psychology. Over one hundred studieshave been published involving HM, andwhen he died in 2008 it was worldwidenews. Interest in Henry Molaison (as wethen discovered) was so high that whenhis brain was sectioned the procedure wasfilmed for the internet, prompting, amongother things, a stage play. Ironically, HMalways remained unaware of his fame(Corkin, 2002). The question posed hereis whether it is time for us to reciprocate –should we forget HM?

Almost every introduction into theneural basis of memory describes how in 1953 the surgeon William Scovilleremoved tissue in both medial temporallobes of HM’s brain in an attempt to treathis epilepsy. Immediately thereafter, HMdisplayed severe anterograde amnesia –a failure to retain new day-to-day events –which remained throughout the rest of hislife. This catastrophic outcome ensuredthat HM’s surgery was not repeated, somaking him unique.

As has been often described, HMshowed preserved IQ despite his loss of long-term memory. He also showedpreserved short-term memory (e.g.immediate memory span) and a goodknowledge of past factual information.(episodic memory). Subsequent researchrevealed his spared ability to learn newperceptual-motor skills, e.g. mirrordrawing (Corkin, 2002), discoveries thathelped to establish emerging distinctions

between explicit and implicit learning.Much of the impact of HM arises,however, from Scoville’s surgery and howthat inadvertently established theimportance of the hippocampus forlearning and memory.

Given this impact it seems churlish toquestion the legacy of HM Indeed, it mustbe made clear that this article is not acriticism of research on HM (which hasconsistently been of an exceptional leveland deservedly praised); rather itconcerns how key elements of this hugelyinfluential body of research have beenmore generally interpreted and reported.

Does hippocampal pathologycause anterograde amnesia?The Russian neurologist Bekhterev isoften credited as the first person to signalthe involvement of the hippocampus inmemory. Bekhterev’s research was,however, suppressed after his death, quiteprobably on the orders of Stalin who mayhave had Bekhterev killed (Lerner et al.,2005). It is, however, indisputable thatScoville and Milner (1957) drew newattention to the importance of thehippocampal formation for long-termmemory, and did so in a way thatprofoundly altered neuroscience.

It is because HM is regarded as uniquethat his case has had such influence, yetin their landmark paper, Scoville andMilner (1957) described eight cases inaddition to HM who received bilateralremoval of tissue in the medial temporal

612 vol 26 no 8 august 2013

Aggleton, J.P. & Brown, M.W. (1999).Episodic memory, amnesia and thehippocampal anterior thalamic axis.Behavioral and Brain Sciences, 22,425–466.

Bachevalier, J., Parkinson, J.K. &Mishkin, M. (1985). Visual recognitionin monkeys: Effects of separate vs.combined transection of the fornixand amygdalofugal pathways.Experimental Brain Research, 57,

554–561.Brown, M.W., Warburton, E.C. &

Aggleton, J.P. (2010). Recognitionmemory: Material, processes, andsubstrates. Hippocampus, 20,1228–1244.

Corkin, S. (2002). What’s new with theamnesic patient H.M.? Nature ReviewsNeuroscience, 3, 153–160.

Corkin, S., Amaral, D.G., Gonzalez, R.G. etal. (1997). H.M.’s medial temporal

lobe lesion: Findings from magneticresonance imaging. Journal ofNeuroscience, 17, 3964–3979.

Diana, R.A., Yonelinas, A.P. & Ranganath,C. (2007). Imaging recollection andfamiliarity in the medial temporallobe: a three-component model.Trends in Cognitive Science, 11,379–386.

Lerner, V., Margolin, J. & Witztum, E.(2005). Vladamir Bekhterev: His life,

his work and the mystery of hisdeath. History of Psychiatry, 16,217–227.

Mishkin, M. (1978). Memory in monkeysseverely impaired by combined butnot by separate removal of amygdalaand hippocampus. Nature, 273,297–298.

Murray, E.A. & Mishkin, M. (1998). Objectrecognition and location memory inmonkeys with excitotoxic lesions of

references

LOOKING BACK

Understanding amnesia –Is it time to forget HM? 55 years since the famous amnesic’s case was first described, John P. Aggletonquestions its value when debating the neuroanatomical basis of memory

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front of the hippocampus. This tissueincluded most of the amygdala andpyriform cortex. The surgeries alsoproduced variable amounts of tissue lossin other regions adjacent to thehippocampus (the ‘parahippocampalregion’, which includes the entorhinal andperirhinal cortices – see Figure 1). Thereis no shortage of evidence that additionaldamage to these adjacent areas canexacerbate memory deficits (Aggleton &Brown, 1999; Diana et al.,2007). A closely related issueconcerns the consequences ofany white matter damage inHM as the surgical techniqueused by Scoville would havedestroyed both white and greymatter. White matter damage ispotentially very important as itmight disrupt the functions ofsites far removed from thehippocampus.

While MRI data (Corkin etal., 1997) indicate that Scovilleprobably spared the tractimmediately lateral to thehippocampus (the temporalstem), he would have removedfibres linking the temporalpole with the frontal lobe.Other tract damage in HMwould almost certainly includethose temporal stem fibres thatleave the temporal lobe bypassing directly through thelateral and dorsal amygdala.Studies with monkeys haveshown that cutting these fibresadds to cognitive impairmentsin tasks such as recognitionmemory (Bachevalier et al.,1985). It can, therefore, beseen that HM did not sufferselective hippocampal loss andthat damage to adjacent areasis very likely to havecontributed to his memoryproblems. As a consequenceHM does not confirm that hippocampalcell loss is either ‘necessary’ or ‘sufficient’for temporal lobe amnesia.

Subsequent comparisons using othercases with more localised hippocampaldamage (Spiers et al., 2001) have, in fact,often supported the principal insightsdrawn from HM as these later cases alsosuffered clear losses of long-term memorythat contrasted with spared semanticknowledge acquired prior to the amnesia.That said, HM’s amnesia appearsappreciably denser than that in cases with more circumscribed hippocampal

damage. While there are several possibleexplanations for this difference, includingthe extent of hippocampal damage in

HM, it remains highly likely that thecombination of additional white matterdamage and the loss of tissue instructures adjacent to the hippocampus(e.g. the amygdala) added to his memoryproblems. Finally, his long-term use ofanti-epileptic drugs may have causedcerebellar atrophy (Corkin, 2002).Consequently there are numerous reasonswhy the amnesia in HM may have beenparticularly dense, and these reasonsreflect more than just hippocampalcell loss.

Hierarchical models of medialtemporal lobe functionConsult almost anyneuropsychological text and there willbe a figure highlighting those medialtemporal lobe connections moststrongly linked to memory. This figurealmost always comprises a series ofconnected boxes, with thehippocampus placed at the top (Figure2, overleaf). Such figures inevitablyconvey a hierarchy with thehippocampus overseeing all othermedial temporal lobe memoryfunctions.

Although such depictions ofmedial temporal lobe anatomy werenot created by research on HM, thepersistent emphasis on hippocampaldysfunction in HM has surelyreinforced and maintained thishierarchical view of medial temporalfunction. This perspective is all themore understandable when it isappreciated that the dominant modelof medial temporal lobe memorysystems has been one in which othertemporal lobe structures are primarilycritical for the ingress and egress ofinformation to and from the medialtemporal lobe, but it is thehippocampus that orchestrates thisinformation (Squire et al., 2007;Wixted & Squire, 2011). This

influential view of medial temporal lobeorganisation now looks increasinglyuntenable.


looking back

the amygdala and hippocampus.Journal of Neuroscience, 18,6568–6582.

Scoville, W.B. & Milner, B. (1957). Loss ofrecent memory after bilateralhippocampal lesions. Journal ofNeurology, Neurosurgery & Psychiatry,20, 11–21.

Spiers, H.J., Maguire, E.A. & Burgess, N.(2001). Hippocampal amnesia.Neurocase 7, 357–382.

Squire, L.R., Wixted, J.T. & Clark, R.E.(2007). Recognition memory and themedial temporal lobe: A newperspective. Nature ReviewsNeuroscience, 8, 872–883.

Tsivilis, D., Vann, S.D., Denby, C., et al.(2008). A disproportionate role for thefornix and mammillary bodies inrecall versus recognition memory.Nature Neuroscience, 11, 834–842.

Vann, S.D. (2010) Re-evaluating the role of

the mammillary bodies in memory.Neuropsychologia, 48, 2316–2327.

Vann, S.D. & Aggleton, J.P. (2004).Themammillary bodies – two memorysystems in one? Nature ReviewsNeuroscience, 5, 35–44.

Wixted, J.T. & Squire, L.R. (2011). Themedial temporal lobe and theattributes of memory. Trends inCognitive Science, 15, 210–217.

Figure 1. HM’s surgery and the medial temporal lobe. Theupper level shows views of the underside of a brain (withthe cerebellum removed). The brain on the left indicatesthe intended extent of the medial temporal surgery in HM(region in brown). The dashed line shows approximatelyhow far back Scoville’s surgery actually went according toMRI evidence, leaving an area of potential sparing in theposterior hippocampus. The solid line shows the level ofthe coronal sections in the lower part of the figure. Thecoronal section on the left indicates the suspected area oftissue loss in HM, which clearly extends well into theparahippocampal region.


The pivotal issue is the extent towhich other temporal lobe structureshave memory functions independent ofthe hippocampus. Much of this debateoriginally centred on therelative importance of thehippocampus and theparahippocampal region forrecognition memory (theability to detect when an eventis repeated). One highlyinfluential model supposesthat the hippocampus isequally important for bothrecall and recognition,consistent with its position atthe top of an anatomicalhierarchy (Squire et al., 2007;Wixted & Squire, 2011). Thismodel assumes that damageimmediately beyond thehippocampus produces moreof the same dysfunction,reflecting this sharing offunctions. This concept is verypertinent because it directlyimplies that any extra-hippocampal damage in HMdisrupted processes thatprimarily depend on thehippocampus, and so do notmaterially affect his core status as a hippocampal amnesic.

Other models have challenged this view. One class of model supposesthat while the hippocampus is vital forrecognition memory based on the explicitrecall of past experiences, adjacentregions including the perirhinal cortex areindependently important for recognitionbased on the feeling of familiarity(Aggleton & Brown, 1999; Diana et al.,2007). These ‘dual-process’ modelspredict that amnesics with pathologyrestricted to the hippocampus will havedisproportionate deficits in recall, asrecognition can be partially supported byfamiliarity. Such cases do exist (Brown etal., 2010). In addition, there is muchevidence that the parahippocampal regionhas cognitive functions independent ofthe hippocampus (Diana et al., 2007).

With regard to HM, he repeatedlyfailed to recognise near-neighbours andfriends who became acquainted with himafter his surgery. HM was impaired onboth verbal and non-verbal recognition,and for both yes-no and forced-choicetasks (Corkin, 2002). Consequently, thereseems little reason to suppose that HMshowed a relative sparing of recognitionmemory. Unfortunately HM’s amnesia isso strongly identified as beingfundamentally hippocampal, and hisdeficits for recall and recognition sowidely described, that these two

impairments have become fused. The problem with conflating these

impairments is beautifully highlighted bya pair of experiments with monkeys that

sought to replicate the combinedamygdala plus hippocampal surgery inHM. When the tissue was removed usingScoville’s surgical approach the monkeyswere very severely impaired on objectrecognition memory (Mishkin, 1978).When the same targets were removed byinjecting a chemical that kills neurons butspares white matter, the animals wereunimpaired on object recognition(Murray & Mishkin, 1998). Thiscontrasting pair of findings underlines thesignificance of dysfunction in HM beyondthe hippocampus, and its likelycontribution to recognition memory.

Looking beyond thehippocampusOne legacy of HM is that he reinforcedthe notion of different brain structureswith different roles in processinginformation, so supporting a modularapproach to memory. A related legacy isthat the hippocampus has become thekeystone for research into long-termmemory. One consequence is thatresearch into neurological disordersassociated with memory loss, includingdementias, remains dominated byhippocampal analyses, despite thepotential significance of other areaswithin the temporal lobe.

Damage beyond the temporal lobe can also cause anterograde amnesia. In

fact the first convincing evidence thatdamage to a specific brain site can causeamnesia concerns the mammillary bodies(the most posterior part of thehypothalamus), not the hippocampus(Vann & Aggleton, 2004). Remarkableclinical cases, such as BJ who had asnooker cue forced up his nose,damaging the base of this brain, havealso specifically implicated themammillary bodies (see Vann &Aggleton, 2004). Likewise, a large-scale study of memory after tumors inthe middle of the brain has highlightedthe importance of the mammillarybodies (Tsivilis et al., 2008).

A number of other sites have beenalso implicated in amnesia (e.g. theanterior thalamic nuclei, parataenialthalamic nucleus, medial dorsalthalamic nucleus, retrosplenial cortex),and the fact that many of these

structures are directly interconnectedwith the hippocampus has been givengreat significance. The assumption hastypically been that these other regions areof secondary importance, and that theprimary memory influences begin andend with the hippocampus. While suchmodels are anatomically plausible, theyhave an inherent weakness if they fail toexplain why the hippocampus mightbenefit from such a return circuit. Theanswer is surely that these otherstructures provide new informationcritical for temporal lobe function.Indeed, recent research shows that itmight be more insightful to see theseother sites as primarily upstream, notdownstream, from the hippocampus(Vann, 2010), i.e. reversing the traditionalviewpoint. Such findings again emphasisethe need to move to a more balancedview of memory substrates.

In many respects, HM remains theprototypical amnesic. (In fact, it could beargued that HM came to define what isnow meant by the term amnesic.) Thereis little doubt that HM was unique, butthat uniqueness is a double-edged swordgiven the multitude of special factors thatmay have influenced his memoryperformance. It feels almost sacrilegiousto criticise the impact of HM, especiallygiven the quality of the associatedresearch. Nevertheless, the resultantnarrow focus on the hippocampus formemory and memory disorders couldwell have excessively biased our thinking,with far-reaching, unwittingconsequences.

614 vol 26 no 8 august 2013

looking back

I John P. Aggleton is in the School ofPsychology, Cardiff [email protected]

Figure 2. Potentially misleading hierarchical diagramportraying the interconnections between thehippocampus, entorhinal cortex, perirhinal cortex, andparahippocampal cortex. The cortical regions at thebottom provide sensory information to the region. Thethickness of the arrows reflects the strength of thevarious connections.



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Growing up with TV

January 2007

30


FAMILY life, with all its ups anddowns, is a constant presence onour television screens. There is a

huge public appetite for guidance onparenting. In September 2006 a MORI pollwith a representative sample of 3938 adultsacross Great Britain, for the NationalFamily and Parenting Institute, showed thatmost parents with young children havewatched at least one ‘parenting’ televisionprogramme and more than three quarters ofthese parents said that they had adopted aparenting technique and had found ithelpful to them personally.

Developmental psychology has much tooffer parents, and clearly televisionprogrammes are a potent way of reachinglarge numbers of parents, but this particularknowledge transfer is not an easy matter.The messages that we might wish totransmit do not necessarily sit well with thepriorities and narrative styles ofbroadcasters.

In this article, we reflect on ourexperience of working at the interfacebetween academic research and publicbroadcasting, through our work on theBBC1 series Child of Our Time,affectionately known as ‘Coot’.

An extended familyCoot is a unique project, of which theprime-time broadcasts on BBC1 are onlyone facet (see figure opposite). Starting in1999, 22 couples were filmed as theyprepared for the births of their ‘millenniumbabies’. Since then, they have beenfollowed and filmed year-on-year to build arich record of the progress of the childrenand their families. The filming has coveredlife in the family homes, and the children’sand parents’ experiences in other settings,such as work, playgroups and schoolclasses. There has also been a series ofassessments and observations made of theparents and children, based aroundtechniques used by psychologists. Inaddition, numerous experts have beenbrought in to comment on various topicsand on the children’s and parents’participation in ‘tests’.

The committed aim of the project is tofollow this cohort of families until thechildren are 20 years old; the longest-running project in the BBC’s history. Thefocus will continue to be on ‘what makesus what we are’.

The Open University joined the projectas a co-production partner in 2002 and hasbeen developing its involvement

substantially since then. Working on theproduction of the broadcasts involvesplanning the themes for forthcoming series,developing ideas for assessments andactivities for the families to illustrate thethemes, and participating in the finalnarrative and editing work for theprogrammes. At the same time, we areworking on building content for the

website on Open2.net, commissioningessays and designing interactive materials,downloads and surveys for the site, andproducing sets of activity cards, linked withthe programme themes, for parents to orderfrom the Open University. Print runs of50,000 cards were fully taken up.

The public interest in Coot offerings ismassive. Viewing figures for the seriesregularly exceed 4 or 5 million, with veryhigh audience appreciation ratings. Thetraffic to the website immediatelyfollowing the broadcasts is also very highand continues at high levels for someweeks. Enquiries to the Open Universityfollowing on from the broadcasts, websiteand cards have been running at over 40,000a year for the last two years. The OUconsiders that the cost of dealing with thisvolume is economically justified in termsof follow-through into entry level coursesand other educational offerings.

For the last three years, we have addedsurvey activities to the site, collecting datafrom children and adults on topics such asself-image, leisure preferences,expectations of parents and lifestylechoices. The website also showssummaries of these data as they build. Forthe 2006 series the survey was based onestablished research instruments and isgathering data on links among self-esteem,optimism, locus of control and moralaction choices. Initial analyses from morethan 16,000 respondents’ data werepresented at the 2006 BPS Developmental

Psychology Section conference, and arefeatured on the Coot website.

Concerns and issuesConcerns are often aired about the impacton families of participating in televisionprogrammes. The families in the Cootproject are always consulted about thecontent of the programmes, and are shownedited versions for their comments.Sometimes, one or other family memberdoes not want to be shown in a particularprogramme, and these wishes are alwaysrespected.

Negotiating informed consent forparticipation is something that is anongoing process with the families, andthere is also a conscious effort on the partof the production team to renew consent(or perhaps more accurately, assent) fromthe children as well, in terms that they canunderstand. The BBC has a comprehensivecode for working with families, which isincluded in the guidelines that everyproducer is required to follow, and the Cootproduction team has developed substantial

JOHN OATES and DAVID MESSER

on their maturing relationship with

the BBC’s Child of Our Time, which

returns in 2007.

‘The programme opens up alternative visions

of parenting’

BBC

CH

ILD

OF

OU

RT

IME

additional guidance for the unique natureof the long-term involvement with these 22families.

It is not sensible to draw direct parallelsbetween television programme making andresearch ethics guidelines such as those ofthe British Psychological Society or theBritish Educational Research Association,since one of the common key principles inthese research ethics codes – thepreservation of anonymity – is clearly notfeasible for broadcasts. However, theunderlying principles of respect forindividuals’ autonomy and well-being aremost definitely applicable, and theprocedures followed by the Cootproduction are explicitly designed to followthese ethics.

One aspect of this is taking pains not toencroach on the individuals’ privacy, andalthough Coot does show family life, theaim is not to be invasive in so doing.Linked to this is the ethic of confidentiality.Information collected from or given by thefamilies, where they wish this to remainconfidential, is closely protected by BBCprotocols which conform with therequirements of the Data Protection Act.

The showing of each year’s new Cootseries is often the stimulus for local newsstories, and the families do gain a sense ofvalue from being featured in this way. Atthe same time, Coot quite consciously doesnot seek to make the families into ‘stars’.

In a way, it is the ordinariness of thefamilies that makes them special.According to Rachel Coughlan, the seriesproducer: ‘Although this is an on-goingproject, we don’t spend 12 months a yearwith the families. We pick out key eventsfor filming. Some of the families have toldme that although they regard theirparticipation in the project as important,they also recognise that it is just a part oftheir life and for the rest of the time theirlives tick over like any other family.’

Another more general concern involvesthe context and implicit messages of theprogrammes. We see one of the strengthsof the Coot series as providing viewerswith examples of children’s developmentand information about research findings,but without a strong message about whatare the right and wrong things to do. Thevery diversity of the families in terms oftheir structure, environments and resourcesprovide contrasts that raise questions aboutwhether or not you as the viewer wouldrespond in a similar way. Similarly, theway families cope with difficulties and theviews of parents about ‘doing the best’ fortheir children can raise similar questionsabout one’s own beliefs and assumptions.

Thus, a considerable strength of theprogramme is that it opens up alternativevisions of parenting, and allows viewers tothink more generally about this processwith examples that are located outside oftheir normal environment and experience.Viewers should be empowered by beingable to think about issues themselves andto make their own decisions. Rather than

experts providing a standard recipe forparenting, issues are often left open so thatparents can think about the contrasts andcome to their own view about what wouldbe best to do.

There is an important issue here aboutthe more general context in whichpsychologists wish their findings andexpertise to be communicated. The media,more generally, are often interested in whatis ‘best’ for children. However, it is oftennot recognised by those in the media thatthis question has to be unpicked not just interms of psychological outcomes, but alsoin terms of value systems. In concreteterms this can involve thinking about whatactivities and behaviours are generallythought to be ‘best’, but also taking intoconsideration that such activities andbehaviours are not valued by all.Furthermore, there are so many dimensionson which to carry out this discussion italmost becomes an impossible task.

Often psychologists are reluctant to gobeyond their normal expertise to engage inthis debate, a territory that is unfamiliar tomany of us. However, it is one thatincreasingly needs to be addressed inrelation to what some would see asdesirable government support to parentsand children and others see as the ‘nannystate’ taking away individual decisionmaking. Our own view is that it can beuseful to move away from these oppositesto a consideration of not only theimmediate effects of advice andintervention on children’s behaviours, butalso the way in which parents feel that their

January 2007

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Child of Our Time

self-esteem, control and autonomy havebeen affected by their experiences.

A two-way relationshipWork on Coot provides a very usefulmodel for the way that the needs of themedia and psychologists can be met. It isimportant that programmes adopting thisgenre meet the agenda for publicbroadcasting by containing informative andrelevant content. Consequently, programmemakers like to include the latest ideas andtheories, but there are risks for them infocusing on maverick opinions. Oftenprogramme makers will spend quite a bitof time talking to a range of researchers tobuild up a picture of current thinking abouta topic. Even though these conversationsmay not directly feed into a programme,they provide an extremely valuable context.

Useful ideas come out of theseconversations about how psychologicaltheory and findings can challenge orsupport commonsense views about childdevelopment; for example the way thatgiving rewards for drawing reduceschildren’s liking of the activity incomparison to children who do not receiveany rewards.

Naturally enough there are pressures tomaintain a large audience to justify fundingof the programme. As a result, acompromise has to be reached betweeninforming and entertaining. Sometimes itcan seem that academic psychologistsreject this compromise by their emphasison informing rather than entertaining. Theycan be caricatured as being primarilyinterested in the reactions of a limitednumber of fellow experts rather than thoseof the millions of viewers, in over-elevatingtheir own interests, and a preference forlong, complex and difficult-to-understandmessages with many ‘ifs and buts’.

Happily this description is very much acaricature. Most psychologists recognisethat entertainment helps withcommunicating information, and this oftenhas formed a basis for productive relations.

We have been impressed by how keenthe Coot producers are to discuss andexplore modern ideas from developmentalpsychology theory and research, and towork with us on turning these intoentertaining, as well as informative,viewing. An example from the 2006 serieswas translating issues about locus ofcontrol into a task where children had tocarry a full bowl of water without spillingit, and asking children whether theinevitable messy spill was due to thedifficulty of the task or their own inability.This was probably more interesting andmemorable for many viewers than seeing achild answer a set of psychometricquestions. Rachel Coughlan comments:‘Quite often the tests that we use for thepurposes of television have to be mademore visual whilst retaining their validityand we have found that our psychologyacademics have been open and willing inhelping us achieve this. They also guide usin terms of the themes that are appropriatefor the age of the children, and evaluatesome of the assessments in order to make aparticular point clear to our audience. Thesynergy between the television and thewebsite works extremely well for ouraudience, who are able to follow up themesin the programme in greater depth if theyso wish. This is an area we are keen toexpand in the future.’

Towards the futurePsychologists are becoming much moreaware of the increasing pressures to informa wider audience. There is an obligation tocommunicate publicly funded researchfindings, and when applying for researchfunding there is increasingly a box that hasto be filled about ‘dissemination ofresearch’. There also is a growingawareness that public interest inpsychological research can feed intopositive views about research funding, andcan even encourage student uptake ofhigher and further education.

Thus, there is a measure of inter-dependence. Programme makers need up-to-date expert advice to provide credibilityfor a programme as well as helping to meetwith public agenda and well-being issues.Researchers can benefit, albeit indirectly,from public interest and understanding.

There is a strong wish amongst those ofus in the Open University and the BBCwho are involved with Child of Our Timeto strengthen the synergies betweenresearch and the project. The BritishPsychological Society has recently givenpublic engagement funding for additionalcontent production for the Coot website, toprovide more extended and in-depthcoverage of developmental psychologytopics. Also, the ESRC has commissioneda scoping study which is exploring howlinks can be built between the Child of OurTime resources and research activities, suchas the Millennium Cohort Study and otherlarge surveys. This study is being carriedout by a team of researchers includingourselves. We would be very interested inhearing from anyone who would like tocontribute to this ongoing work.

■ John Oates and David Messer are inthe Centre for Childhood, Developmentand Learning at the Open University. E-mail: [email protected].

January 2007

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Child of Our Time

DISCUSS AND DEBATEWhat key messages from psychological research

would be of most value for parents?

How can parents be encouraged to evaluate‘parenting’ messages critically?

Is there a value in giving more attention to children’svoices in debates around parenting?

What ‘blue sky’ ideas can we come up with toimprove public engagement with psychologicalresearch through a variety of media?

Have your say on these or other issues this article

raises. E-mail ‘Letters’ on [email protected] or

contribute to our forum via www.thepsychologist.org.uk.

WEBLINKSOpen University Child of Our Time site:

www.open2.net/childofourtime/2006/index.html

BBC site: www.bbc.co.uk/parenting/

tv_and_radio/child_of_our_time

BBC JAM child development materials, using

footage from Coot to provide curriculum

enrichment for GCSE Psychology:

https://jam.bbc.co.uk

BBC

CH

ILD

OF

OU

RT

IME

https://jam.bbc.co.uk

http://www.thepsychologist.org.uk

http://www.open2.net/childofourtime/2006/index.html

http://www.bbc.co.uk/parenting/tv_and_radio/child_of_our_time


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in the dichotomisation of mental healthservice providers and their patients, butthere are also intrapersonal factors atwork. Clinical psychologist LucyJohnstone (2000) explains this by statingthat ‘[some] staff need patients tocontinue to be patients for their ownpersonal reasons’ (p.206). She argues thatthis is because of (broadly) a desire forjob security (as effective clinicians makesthemselves redundant) and adherence toan enveloping system in which power isgranted to those who comply; meaningthose with the most power are the mostinvested in the system. Johnstone goes onto report the great anti-psychiatrist LorenMosher’s suggestions for the four deadlysins (in the eyes of upholders of theorthodoxy) of critical psychiatry (and onewould imagine applied psychology): de-medicalising madness, de-hospitalisingpeople, de-psychopharmacologising andde-professionalising. This might besummed up in Johnstone’s later statementthat ‘psychiatry has not been well servedby the philosophy of “studying people asif they were things”’ (p.252). The august,albeit fictional, ‘headologist’ EsmeWeatherwax (in Terry Pratchett’sDiscworld novels) agrees, stating: ‘…sin,[young man], is when you treat people as things. Including yourself. That’s whatsin is.’

This ‘treating people as things’ mayalso be explained by the cognitivedissonance set up in some clinicianswhen they come across a patient who,due to contextual factors, such as anadvanced degree, substantial income, etc.,upset the clinician’s conceptions of what a mental health patient should be like (fora brief discussion of clinician stereotypingsee Byrne, 2000). The clinician mayattempt to resolve the conflict betweenthe apparent facts and their conception of the patient with one of three methods:classing the patient as an exception to therule; suggesting that the patient is notreally a patient; or changing their mindabout the nature of psychiatric patients.This last possibility is seldom seen, and a reason why may be inferred from a

There is a dichotomy in mental healthservices: ‘them and us’, or whatPilgrim (2005, p.123) refers to as

‘two groups of humanity’. This is theprocess in which some clinicians,psychologists and allied professionals treatthe recipients of their services as being insome ineffable, but very real way, ‘other’.Buber (1958) refers to this as ‘I-It relating’in which we only see part of the otherperson and limit our view of them to that,rather than the ‘I-Thou relating’ that wedo when we recognise that the person infront of us is as fully human as we areourselves. I will argue that withinmedicine, psychology, social care andbeyond this may lead to iatrogenic‘illnesses’ which are the result of ‘care’ that necessarily positions the recipient as‘other’ (Johnstone, 2000; Laurance, 2003).

We can see this even in third sectororganisations’ conceptions of mentaldistress. For example, the current ‘Time to Change’ movement – a project with a budget of £18 million conducted by anaffiliation of Mental Health Media, Mindand Rethink, and evaluated by theInstitute of Psychiatry – has the statedmission: ‘To inspire people to worktogether to end the discriminationsurrounding mental health’. This mightseem a laudable aim. However, they go on to repeat the commonly used assertionthat ‘one in four adults experience mentalhealth problems in any one year’(tinyurl.com/mqhek7). Presumably theintention is to suggest that one in four isquite a high number of people and so

people with mental health issues shouldnot be discriminated against because theyare just like everyone else.

However, there are problems with the‘one in four’ estimate. Although seldomreferenced explicitly, it seems that itpertains to a 2000 Office of NationalStatistics study (Singleton et al., 2001) or to the World Health Organization’s(WHO) World Health Report 2001(tinyurl.com/msqmy7). The WHO reportrefers to one in four families rather thanpeople. A reading of the Office of NationalStatistics study demonstrates that thefigures do not allow such a simplebreakdown as ‘one in four’ as acumulative figure, because the study usesa variety of different timescales, evaluationscales, and different (not mutuallyexclusive) categories of mental distress.

Aside from the problems with thefigure itself, I suggest that the reading ofthe figure may be rather different from theintent of the bodies who so readily use it.That is, that if 25 per cent of people are inthe group who have a mental healthproblem then 75 per cent of people – thesubstantial majority in fact – are not. Itsuggests that the ‘one in four’ are differentfrom ‘most people’. This is concerningbecause as we know, difference (especiallyminority difference) is a cause ofdiscrimination (Infinito, 2003; Sherif,1956). Thus people with mental healthproblems are being situated as ‘them’ evenby the very organisations set up for ‘their’assistance.

There are clearly societal factors, then,

40 vol 23 no 1 january 2010

Buber, M. (1958). I and Thou (2nd edn,Trans. R.G.Smith). London:Continuum.

Byrne, P. (2000). Stigma of mental illnessand ways of diminishing it. Advancesin Psychiatric Treatment, 6, 65–72.

Deegan, P.E. & Drake, R.E. (2006). Shareddecision making and medicationmanagement in the recovery process.Psychiatric Services, 57, 1636–1639.

Fiske, S.T. & Taylor, S.E. (1991). Social

cognition (2nd edn). New York:McGraw-Hill.

Fowler, J.H. & Christakis, N.A. (2008).Dynamic spread of happiness in alarge social network. British MedicalJournal, 337, a2338.

Glover, H. (2005). Recovery based servicedelivery. Australian e-Journal for theAdvancement of Mental Health, 4, 8–11.

Hatfield, E., Cacioppo, J.T. & Rapson, R.L.(1993). Emotional contagion. Current

Directions in Psychological Science, 2,96–99.

Infinito, J. (2003). Jane Elliot meetsFoucault: The formation of ethicalidentities in the classroom. Journal ofMoral Education, 32(1), 67–76.

Johnstone, L. (2000). Users and abusers ofpsychiatry (2nd edn). London:Routledge.

Laurance, J. (2003). Pure madness: Howfear drives the mental health system.

London: Routledge.Menzies, I.E.P. (1960). A case study in the

functioning of social systems as adefence against anxiety. HumanRelations, 13(2), 95–121.

Oades, L.G., Crowe, T.P. & Nguyen, M.(2009). Leadership coachingtransforming mental health systemsfrom the inside out. InternationalCoaching Psychology Review, 4, 25–36.

Pilgrim, M. (2005). Key concepts in mental

refe

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‘Them and us’ in mentalhealth services Christina Richards looks behind the dichotomy and calls for change

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study by Fowler and Christakis (2008).This suggested that happiness spreadsdynamically within a social network andis mediated primarily by social, ratherthan actual, distance between people.

If social distance mediates happinessthen it might be reasonable to assumethat it mediates unhappiness too.However, Fowler and Christakis found no evidence for this, reporting insteadthat additional happy social contacts (to a maximum of three) increased

happiness, but additional unhappy socialcontacts had no effect. They do suggest,however, that ‘we might yet find that the“three degrees of influence” rule appliesto depression, anxiety, loneliness…’ (p.8),a comment that is echoed the work ofHatfield et al. (1993).

This, then, may be why some mentalhealth workers have grave concerns aboutbehaving in a friendly manner (not‘become friends’, which is a differentethical issue) with the people that usetheir services. It may be an implicit(questionable) concern, and reaction to, the possibility of socio-proximallymediated affective contagion: mentalhealth workers are trying to keepthemselves healthy through creating aningroup of ‘us’ and an outgroup of ‘them’.

This accords with the Fowler andChristakis (2008) finding (albeitregarding co-workers rather thanpatients), that ‘[there was] no effect of thehappiness of co workers…suggesting thatthe social context and distance mightmoderate the flow of happiness from oneperson to another’ (p.7).

Even if clinicians could be motivatedto change due to an understanding thatsocial prophylaxis through distance isunnecessary, it is possible that some

mental health professionals who havebeen practising for many years may findthe prospect of changing their practice to be more friendly to patients toothreatening to their psychic integrity tocountenance. Menzies (1960), in ahospital-based study within thepsychodynamic tradition, suggested thatthis is an internalised social systemicdefence against anxiety predicated onsystemically induced underdeveloped (or regressed) psychic defences.

While there appears to be little hardevidence in the literature pertaining tothis idea, I offer my own previousexperience of working with contemporaryclinicians as a start and a call for furtherresearch. The reasoning concerningclinician reticence to change runs thus: ‘I have been doing things this way foryears and will continue to do so as thisway must be right’ (because if I have beendoing it wrong for all these years look atall the pain I’ve caused/ time I’ve wasted/good I could have done). It boils downto: ‘I can’t act in the future, because thatproves I could have done so in the past’,although the resistance to change hashistorical roots that are often not inconscious awareness and the inferencethat it ‘proves that it could have beendone in the past’ may be faulty.

Interestingly this effect – let’s call it

the ‘Richards effect’, for narcissisticreasons – crosses domains. Clinically, I see it in patients in their forties andolder who seem stuck by the notion ofwhat they could have achieved, if onlythey had beat their depression or changedgender role earlier in life. To do so nowwould suggest to them that it is possible,and so by inference would have been inthe past; the very idea of which isintolerable. I also saw the effect in myprevious incarnation as a climbing

instructor, when people would beresistant to learn how to safely holdthe ropes for other climbers in the‘modern way’ – imagine the idea ofhaving been a dangerous climbingpartner despite your best intentions.The examples are endless.

Perhaps, rather than maintainingthese in- and outgroups of staff andpatients with all the associated costsattendant to that process (cf. Fiske& Taylor, 1991) and to the patient,we should look to the literature thathas shown the benefits of agenuinely collaborative effort (e.g.Ross & McKay, 1979) and to thenascent recovery approach (Deegan& Drake 2006; Glover, 2005; Oadeset al., 2009). In these approachesthere is a common effort towards theactualisation of the resources of the

person who is suffering, and a recognitionof the skills and experience that both thisperson and the professionals bring to theendeavour.

Perhaps, despite the distress it maycause those of the ‘us’ who work inmental health, we could combat stigmaand work more effectively and humanelyby realising that we are all just one big‘group of humanity’, one big ‘us’. Weshould understand that there is acontinuum of mental health that we allshare, rather than being on one side oranother of a ‘one in four divide’, and thatwe all need to rub along as best we can.

It can be done: not all clinicians createan ‘us and them’ dichotomy with patients.My current colleagues, perhaps becausethe unusual field we work in drawsexceptional workers, act as exemplars ofhow this situation may be resolved in away that is both professional andsensitive. But it requires us to accept therisks attendant to the professions,including cognitive dissonance, thepossibility of emotional contagion andsocietal pressures. As clinicians, we needto work to ameliorate any adverse effects,not through the alienation of patients, butthrough other endeavours such asensuring we take enough physicalexercise, cutting down smoking, eatingwell, meditating and the like.


opinion

health. London: Sage.Ross, R.R. & McKay, H.B. (1979). Self

mutilation. Lexington, MA: LexingtonBooks.

Sherif, M. (1956). Experiments in groupconflict. Scientific American, 195, 54–58.

Singleton, N., Bumpstead, R., O’Brien, M. etal. (Office for National Statistics) (2001).Psychiatric morbidity among adults livingin private households. London: TheStationery Office.

“some mentalhealth professionals

may find theprospect of changing

their practice to bemore friendly to

patients toothreatening to theirpsychic integrity to

countenance”

I Christina Richards is Senior Specialist Psychology Associate, West London Mental Health NHS [email protected]

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