COUPS Conference 2014: 'Psychological Perspectives on Health and Wellbeing'

On a damp and chilly November morning, Dr. Alan Pechey kicked off this year's OUPS Cambridge Region's Autumn Day Conference: Mental Health & Wellbeing.

A packed audience had enjoyed a sumptuous breakfast of pastries with lashings of piping hot tea and coffee during registration, before taking their seats for what promised to be a fascinating series of presentations!

Prof. Helen Odell-Miller, Professor of Music Therapy at Anglia Ruskin University and Director of the Music for Health Research Centre, took centre stage to present on: Music therapy and mental health in the 21st century.

In the UK there are 750 music therapists and 7 training courses and research (Gold et. al., 2009) has shown that this type of intervention can help people with schizophrenia to experience improved motivation and feel less confused.

Helen discussed a fascinating case study of "M", a man suffering with dementia, and how his memory and musical ability (he had previously been a talented pianist) could be "prompted" with Music Therapy. Helen played audio clips to show how her singing would engage "M", seated at a piano, and encourage him to accompany her.

A trained singer and musician, Helen would carefully select and hit notes that would register with "M", who would then play along in accompaniment on the piano. The rapport which developed was significant and shows very elegantly how music therapy enables people with dementia to relate better to others and can reduce the need for medication.

Always at the heart of this is the movement between the musical rapport through highly skilled musicians (doing the work) and the thinking - and Helen acknowledged at this point the important work carried out in the field of forensic psychotherapy.

Music Therapy is not only useful for individuals who are, or were, musicians but is very effective generally for engaging patients who, once attending to a piece of music or song that they recognize, may start to sing along with the therapist, thus demonstrating a stimulated memory.

Carers themselves can also benefit from Music Therapy as it has applications in stress reduction and relaxation.

Following a break, during which more pastries, tea and coffee were consumed, our waistlines thickened only very slightly, as Professor Jamie Hacker Hughes took up his strategic position and dug in at the front of the room to present: 100 years of British military psychology. Looking back and looking forwards: The mental health and well-being of British military personnel and their families.

Professor Hacker Hughes has a list of qualifications that would possibly use up my entire word count, so suffice to say that he is a clinical psychologist, psychotherapist, clinical neuropsychologist, EMDR consultant and PTSD and trauma specialist with special expertise in military and veteran mental health. HeisalsoPresidentElectoftheBPS.

Resplendent in red polo-neck sweater and matching trousers for the forthcoming Remembrance Sunday (they matched his poppy), Professor Hacker Hughes took us through the history of British military psychology and also discussed the present and the future.

Delivered with erudite wit and charm his Powerpoint presentation was like a "who's who" of psychology - and where his Powerpoint presentation was missing a photograph of a famous psychologist, he would substitute it with something amusing...yet (somewhat) relevant nonetheless!

A historical overview showed that the earliest documented account of post-traumatic stress/psychological problems in battle was thought to be 490BC (Battle of Marathon) - but evidence now shows that post-traumatic stress as a result of battle goes back as far as 3200BC in Ancient Mesopotamia.

More recently, WW1 saw the birth of British military psychology and psychiatry. In 1914 C.S. Myers and others were deployed in support of British troops and operated from Field Hospitals and Casualty Clearing Stations. There were many cases of what was then known as shell shock - initially thought to have been caused by the concussive effects on the central nervous system of artillery air-bursts. Problems manifested with tremors, gait and speech difficulties - all now known to be totally psychological. Casualties were seen by psychiatrists, neurologists and psychologists.

Incredibly, PTSD sufferers (not known as such at the time) were often shot at dawn as they were seen as cowards.

WW2 combat caused much PTSD also, despite significant moves forward in psychiatry in the British military. Nonetheless, PTSD was still not recognised and the charge of "lack of moral fibre" was brought against those unfortunate service personnel who suffered psychologically and became unable to face mission after mission - they even had to wear special LMF stripes on their arm and be sent for psychological treatment. They would either return to combat or depart from the military in disgrace.

Much research (at Kings College London) has taken place over the last 25 years yielding interesting findings. The overall rate of psychiatric problems in the military is lower for the UK than for the US armed forces.

Rates of PTSD are higher in UK Reserve Forces compared to regular forces - partly because Reserve personnel join as "singletons" to already formed units but also because at the "decompression" stage of return they are not part of the main body of personnel.

Today, a minority of those with mental health issues in the armed services actually seek medical help and this is a serious problem; the "Don't bottle it up" campaign to counter this has enjoyed limited success. Unfortunately, stigma remains a powerful barrier to accessing help in the UK Armed Forces.

However, PTSD is not the biggest problem; more common are:

  • adjustment disorders

  • depression

  • alcohol abuse

  • Risky-driving behaviour (this is also deployment-related, e.g. in Iraq it may be necessary to drive without seat-belt to get away quickly and escape from vehicle easily/quickly - life-saving in Iraq - but not here!)

Today's military mental health system is more aware and more robust than any time previously, with Depts. of Community Mental Health being professionally staffed by Community Mental Health nurses and Mental Health Social Workers.

In conclusion, general findings of mental health in the military are:

  • Royal Marines < Navy < RAF < Army

  • Females > Males

  • Other ranks > officers

  • Most common diagnosis is Adjustment Disorder (65%)

Dr. Nicola Morant then presented onHearing the voice of service users: The role of qualitative methods in mental health research. This fascinating presentation started by providing an overview of qualitative methods ofresearch and provided some interesting illustrations of therapeutic relationships in acute residential care and research into working in Social Firms before concluding with a look at the implications of these for understanding wellbeing and mental health.

It was reassuring to note that the qualitative v quantitative debate is still alive and kicking, as Dr. Morant's presentation showed. Clearly, qualitative methods deal with, and are interested in, meaning and have regard to the social aspect of psychology. Real life is not usually neat and tidy and so qualitative methods aim to record the reality with all its messiness and loose ends and then try to apply a framework that can organise the data and interpret it in a meaningful way.

An overview of various qualitative methods (including semi-structured in depth interviews; focus groups; observations and first-person accounts) and how the data can be analysed was followed by an example which neatly compared experiences in traditional psychiatric wards with those in crisis houses.

The research examples used by Dr. Morant employed both qualitative and quantitative methods and whilst results from both approaches shed some light on why service users may be more satisfied with crisis houses than acute hospital-based care, the qualitative component undoubtedly yielded very (narrative) rich information. Conclusions around staff-based, environmental and organisational factors were highlighted as instrumental in a preference for crisis houses. Such factors could be targeted to improve the experience of acute residential care by service users - for example training in how to value and acknowledge human skills.

Dr. Morant's second example (The SoFARR Study) focused on Social Firms which are market-led enterprises set up specifically to create good quality jobs for people disadvantaged in the labour market. Such organisations are a form of social enterprise and workers are paid market rates, with profits being reinvested in the business.

Hitherto, the most common approach to getting people with mental wellbeing issues back to work has been Individual Placement and Support (IPS) initiatives. However, whilst this approach has had some positive effect, it has not been problem free, and therefore Social Firms provide an interesting alternative.

The qualitative data gathered in this study led neatly to conclusions that the supportive ethos of social firms promotes openness about mental health; flexibility in working arrangements and both management team and peer support. As in the previous study, the narrative rich data gathered in the qualitative approach gives depth and texture to findings and a "human feel" which is intuitive and readily understandable.

In summary, the qualitative data shed light on why there is a significant degree of job satisfaction in social firms. Furthermore, whilst these two studies highlight the importance of basic human issues such as social relationships they also go beyond this to underline the importance of organisational and environmental settings in helping or hindering recovery.

After lunch and the poster session delegates returned, replete and eager to learn more, as Amy Lennon presented her personal experience of Living with Obsessive Compulsive Disorder.

Any danger of nodding off with a full stomach after lunch was elegantly dealt with by Amy's announcement that aged 18 she quite literally ran away with the circus and worked as a professional figure skater around the world! Having experienced a sudden onset of OCD at the age of 10, triggered by a poster warning about the dangers of meningitis, Amy became obsessed with contracting the illness. This led to compulsions around repeating procedures like washing, tapping and touching items a certain number of times. Numbers became "good" or "bad" - 10 being the worst as it represented the number of letters in the word "meningitis".

This led to what effectively became ritualistic behaviour and provided a short-term solution to the disorder but in the long term it simply increased anxiety and reinforced Amy's fears. Eventually, and perhaps inevitably, the obsessions spread to other fears beyond meningitis.

Amy started to feel isolated and confused, internalising the compulsions and becoming embarrassed in public; experiencing feelings of shame. Aged 14, Amy overheard class-mates talking about OCD and for the first time realised that she was suffering an illness.

At 17 Amy's OCD brought with it depression, coinciding with a number of other factors which led her to seek help from her GP. Therapy was suggested but Amy did not feel ready to take this route, instead embarking upon a course of medication including anti-depressants such as SSRI (selective serotonin reuptake inhibitors - believed to increase the extracellular level of the neurotransmitter serotonin by inhibiting its reuptake into the presynaptic cell).

And so, aged 18, she packed her bags and toured the world as a professional figure-skater, appearing in ice shows around the globe. Amy had always found skating to be therapeutic and it served to clear her mind.

After several more years Amy felt ready for therapy and was referred for group CBT through the NHS. Although it was no magical cure, it equipped Amy with a set of tools to help her regain control. The CBT challenged thoughts and behaviours by exposing her to fears in a carefully controlled and gradual process. Over time her confidence increased and her anxiety subsided.

The approach and ideology of CBT very much resonated with Amy, encouraging her to push herself and devise creative ways of facing and tackling her irrational fears - she even ate cereal off the floor to prove to herself (and demonstrate to other group members) that a cleanliness obsession was just that: An obsession.

Indeed it was being part of a group that Amy found to be a positive experience. The support; being with others who understood and were experiencing similar issues and the encouragement was of great help. Her symptoms improved significantly and she enrolled on her first OU course!

Today, Amy's pragmatic and positive approach enables her to maintain control over compulsions and her thoughts; she views her recovery as a work in progress rather than a cure. Her positive experience with group CBT resulted in her becoming a mentor with the NHS, helping to deliver CBT to people suffering with depression and low mood. Her first-hand experience of OCD gives her credibility when supporting others.

Amy concluded by maintaining that no one should suffer alone because there is much help and support available - and talking about mental health and wellbeing more will help to break the stigma that still shrouds the subject. OCD does not define Amy. Although she still experiences good days and bad days, she acknowledges that she remains in control and has the final word, her mantra being: Thoughts are not facts!

Sarah Hughes, CEO of Mind in Cambridgeshire, followed Amy's presentation seamlessly with a presentation entitled: Shame no more - mental health today which explored and discussed questions such as: Is society changing its attitude towards mental health quickly enough? Are we still too afraid to talk about mental illness? Should we disclose how we are really feeling - are we likely to get help or be victimised?

Such questions are wholly relevant, even at a time when we see increasing numbers of media personalities disclosing their own mental health issues and an increase in campaigns promoting awareness of mental wellbeing. The mental health charity Mind, along with Rethink Mental Illness, is a partner in "Time to Change", England's most ambitious campaign to end the stigma and discrimination faced by people who experience mental health problems.

Sarah spoke eloquently and passionately about the stigma that still surrounds the subject of mental health and the discrimination suffered by many: Stigma which is borne out of ignorance - a lack of knowledge and understanding; prejudice - negative, hostile attitudes based on poor knowledge and discrimination - and unfavourable actions, behaviour or treatment based on prejudice.

Such stigma can easily become self-stigma, a prejudice turned against themselves by people with a mental health diagnosis. This manifests itself in a range of negative thoughts, beliefs and behaviours which only serve to lower self-esteem. Tragically, this is often reinforced by family and friends!

Although statistics show that there has been an improvement in society's attitudes towards mental health over the last 3 years (4.8% improvement since 2011) it is staggering to learn that around 90% of sufferers still experience stigma. When considered in the context of 63% of the population knowing someone who has a mental health problem, it is clear that, as a society, we still have much work to do in educating ourselves about the reality of mental health.

Much good work is being done by high profile individuals and organisations: For example the "State of Mind" programme was established in 2011 with the aim of improving the mental health, wellbeing and working life of rugby league players and communities ( ). This typically macho sport seeks to blow away the myth that men should be tough and not cry or seek help for psychological issues. Ruby Wax's "Black Dog Tribe" initiative aims to eliminate the anxiety experienced by people searching for answers and help for depression by both reassuring them that their symptoms are normal and helping them locate others who are feeling the same way.

The message which Sarah brought was communicated both loudly and clearly, in what was no doubt her own unique style: As a society we are becoming more aware of mental wellbeing issues, but there remains much, much more work to be done!

Following a break for tea and coffee, Dr. Elizabeth Fistein, a psychiatrist whose research interests include clinical, legal and ethical perspectives on compulsory treatment, gave her answers to the question:

How can detention in hospital for compulsory psychiatric treatment be justified?

Dr. Fistein started by giving an overview of the history of English Law and International Law and its relation to mental health. In England, the 2007 Mental Health Act is not without its problems and presents some controversy, being seen as a "missed opportunity" (The Mental Health Alliance, 2007), "...disappointing and a cause for concern..." (Sainsbury Centre for Mental Health, 2007) and "discriminatory" (Law Society Parliamentary Unit, 2007).

According to Dr. Fistein, studies show that changes to mental health law can have surprising results and that reforms in general are resisted when they are seen as shifting the focus away from patients' treatment needs. The uncertainty and questions that may surround current mental health legislation is one thing, but if current legislation is not perfect, how might it be improved?

Dr. Fistein presented a potential alternative approach: One of integrated empirical ethics, which is a model for bringing together practical observational empirical data about the way ethical values are enacted and theoretical reasoning about the underpinnings of those values. By her own admission, this was a complex model and Dr. Fistein looked at how the relevant concepts were developed in theory and at how those different conceptions of those concepts played out and were used by the practitioners in real world practice.

A single underpinning idea brought together aspects of looking at theory, different laws and different jurisdictions and then looking at practice in one area of jurisdiction. Whilst these may appear to be quite separate and discrete projects, they were all about thinking about how we use words to create a justification for action.

Her empirical study was time-consuming and labour-intensive, including: Direct observation supplemented by semi- structured interviews; biographic- narrative interviews; 8 hours of practice, 16 hours of accounts, work of 27 clinicians, and 411 pages of text for discourse analysis!

Clinicians' justifications for their decisions to detain patients were based on very detailed and specific criteria (as would be expected) and included, for example, considering and ultimately ruling out alternatives to detention based on, for example, community treatment not being viable due to risk, lack of patient engagement or even exhaustion of carers.

Dr. Fistein's study made a number of suggestions for future practice, including continual consideration of patients' capacity and treatability (without imposing one's values on others!); approaching with caution by allowing awareness of risks to outweigh other criteria; using MHA for protection of vulnerable adults and to promote "best interests".

The findings suggest that a regulatory framework which separates the public protection and paternalistic justifications for limiting individual liberty may assist in the development of appropriate conditions for lawful detention.

The conference then concluded and had offered fantastic value for money with first class speakers/presenters and excellent networking opportunities...not to mention the splendid refreshments!

Interviews with Dr Elizabeth Fistein and Sarah Hughes can be found in the Interviews article category.