Charlie Tyack – @psychosomnology Clinical Psychologist Thu, 21 Jan 2016 23:36:40 +0000 en-GB hourly 1 Charlie Tyack – @psychosomnology 32 32 75200330 Published Thu, 21 Jan 2016 23:30:53 +0000 Continue reading "Published"

My doctoral thesis research into tablet-computer based art interventions for people with dementia and their caregivers has been published. You can find the paper here, or here if you are on ResearchGate. I conducted the research with Paul Camic, Sabina Hulbert and Michael Heron. The research explored the impact of art-viewing on wellbeing, both quantitatively (with measures of happiness, wellness and interestedness built into the app) and qualitatively (through interviews I conducted with all the people who took part). As it was an exploratory study, we focussed on detailed evaluation of people’s experiences and as such the sample size was relatively small (12 pairs). The results suggest that art-viewing on a tablet computer can benefit the wellbeing of people with dementia, and have qualitative benefits for their relationships with their informal caregivers. On the path to finding those results, I learned a lot.

The process of conducting the research was a phenomenal learning-curve. The process went from pitching the idea, through obtaining ethical approval, to making (and maintaining) working relationships, recruiting people to take part with the invaluable support of people at the Alzheimer’s Society, collecting, interpreting and analysing the data, writing it up, then publishing. These parts of the process all overlapped, and especially towards the end several parts were taking place simultaneously. Using a mixed-methods design meant prioritising research-related activities (plus course and life demands) could sometimes be quite the headache!

Aside from the headaches, there were some surprises. One big surprise was the drop out rate: there wasn’t one. None of the people I recruited withdrew from the research and everyone took part in the interviews at the end. I found this remarkable and it was really valuable to hear the views of people who had reservations about the experience as well as people who were very positive about it. I am so grateful for everyone who generously gave their time to take part and I hope they gained something from the process.

Including my own photographs was something I had not anticipated, but when my supervisor suggested I did so, it felt like a privilege. I certainly had not expected to receive feedback on my own images as part of my Major Research Project, but that is what happened! It seemed that the image of the ice cream van at the top of this post tended to remind people of generally happy memories, and various other images took people to a range of places. Some of the more abstract images seemed to invite freer associations and the combination of reminiscences and these associations seemed to stimulate the viewers, and provoke enjoyable conversations. I was glad that my photos had been part of this, and very thankful for the images the various museums allowed us to include. Here’s some examples of my images from the app:

Click to view slideshow.

An honourable mention has to go to a piece of machinery I could not have completed the research without: my humble Honda NTV. My first motorbike, I chose it as MCN described it as “as reliable as death and taxes”, and it never let me down. It helped me travel to Dementia Cafes and various meeting places without a hitch, and when running it became an unnecessary extravagance towards the end of the course, I was sorry to sell it on. Thus, another thing I didn’t expect was to notch up about 12000 miles of motorcycling experience as part of my clinical training, but that happened too!


It has been quite a journey, and it would not have been possible without the support of the people I have mentioned, and some people who I have not mentioned: you know who you are. Finding myself at the end of one journey, I see now that I am at the beginning of several others. It’s a time to shift priorities, and see whether I can find more of a sense of balance after three years of training dominating my life, and to some extent that of those closest to me. I’m looking forward to it!


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Lost in transition Fri, 11 Dec 2015 12:37:45 +0000 Continue reading "Lost in transition"

I recently attended the BPS joint CPD event between the Faculties of Intellectual Disabilities and for Children and Young People entitled Making the Transition. The focus was on what happens when young people with intellectual disabilities reach the transition cliff from child and young people’s services to adult services, usually at the age of eighteen. This event was especially pertinent for me, as I worked in a service for people with intellectual disabilities that transitioned from seeing people of all ages to an adults-only service when I was a trainee, which involved actually handing clients over to the new provider.

Eric Emerson launched the day with a stark statistic: four-fifths of young people transition to no services at the age of eighteen. Whilst this might be seen as heartening if they no longer need support from services, evidence suggests that they are likely to still need support. According to Emerson, people with mild to moderate intellectual disabilities are over-represented in this group, whilst being more likely to have engaged in risky health behaviours. This process seems to be mirrored in the configuration of services for adults with intellectual disabilities, which tend to be moving towards limiting access to people with mild to moderate intellectual disabilities, in the hope that they can use mainstream services.

Emerson recommended that interventions to tackle the issue of people being lost at transition age should look at addressing the adversities people face, and on building resilience. He said that the priority should be on building resilience, which can be affected by people’s personal capabilities, such as their intelligence level, their sense of hope and their spiritualities. It could also be affected by the caring people around them in their families and professional networks, as well as resources such as schools, local authority services, social capital and wealth. Psychological support can maximise people’s abilities to reach their potential in these areas. Families with relatively low socio-economic status were more likely to be repeatedly exposed to the damaging effects of poverty, and all people with intellectual disabilities tend to experience poorer health outcomes which are often potentially avoidable. Emerson felt addressing adversity was beyond the scope of psychology, although community psychologists such as Psychologists Against Austerity might disagree.

Jill McGarry and Dave Williams talked to the session about the approach they have implemented in Salford to give person-centred service planning. An interesting facet of their ethos was to “not be too distracted by newly introduced policy”, as all policies tend to stress similar goals, and over-adherence to specific policies can lead to deviation from overall service vision. Their main priority was to bring people back to Salford. They stressed several factors in achieving this, founded on a pro-active approach. Forging strong partnerships with local service providers and local authorities was key, and sometimes this could apparently lead to potentially blurred boundaries between professionals. The need for clarity around roles was therefore stressed. A helpful practical aspect of this was all staff working together in a large open-plan office, which facilitated discussion and sharing of ideas. Pooled budgets were coordinated with teams to make sure people were able to use the best possible care packages, and access to mainstream services was promoted, where appropriate. Attending monthly meetings with the eight local authorities was also prioritised. Members of the team also provide training to local service providers.

The Salford approach to building and maintaining community services has had striking results: physical restraint has been abolished for all but two clients in the area. This was attributed to the shift towards pro-active and not re-active interventions: the trigger for their challenging behaviour pathway is a change in behaviour, and not someone being in a crisis as is often the case in services. Positive Behavioural Support is used universally, which has apparently made a huge difference once implementation was complete. Services are also made aware that consultation is available prior to a referral at any time, potentially reducing eventual referrals. This openness to consultation facilitates communication between agencies and would therefore hopefully also help to cut the chance of people being lost at the stage of transition from child to adult services.

Clients from Safety Net Youth, a Hammersmith and Fulham service for young people transitioning to adult services, generously gave their time to tell us about their experiences of using the service and their hopes for the future. It was great to hear their perspectives.

Moving forwards, suggestions for potential ways to improve people’s experiences as they transition from services for children and young people to adults services included clinicians having split posts, so they were embedded in both child and adult services, which seems to make a lot of sense: they would span the gap between services. The possibility of trainees also having placements in adult and child services for people with intellectual disabilities was also mooted. I had a more radical idea too, albeit one which might be hard to implement: how about services linked to generations rather than age groups? In this structure, teams would be assigned to people based on their generation, and then travel with them throughout their lives. This would mean that clients would not have a health service transition, even if they did with other services, allowing for continuity of care and for valuable information about clients to be held within the team throughout their lives. If this is unrealistic, perhaps we need to consider other ways that we can support continuity for people, especially at a life stage that is challenging for everyone.

Killing (your demons) with kindness Sat, 12 Sep 2015 15:34:43 +0000 Continue reading "Killing (your demons) with kindness"

A recent study has found evidence to suggest that performing acts of kindness can reduce the degree to which people with social anxiety avoid situations they might find anxiety-provoking.

This finding resonated with me quite strongly because I gave blood for the second time recently, and remarked on the same day that I felt more positive towards other people. I felt more optimism in relation to other people’s intentions and actions, and was more talkative with other people at the centre and later that day.

Historically, I experienced significant social anxiety. I gradually worked to reduce this in a similar way to the way I reduced my fear of injections – I exposed myself to it. The most radical part of this, which I instigated semi-unconsciously, and might be more aptly labelled flooding, was to go to Japan on the JET Programme as an English teacher. I remember the moment when I received the acceptance call from JET which meant that the thing I had hoped to do for so long became a real prospect. I was excited, but I soon realised I was also fearful: the job would entail a lot of public speaking!

On arrival in Japan, my first professional order of business was to speak at assembly at my base school to all the staff and students in Japanese, of which I could not speak a word. The gulf between this and where I believed my capabilities to lie was comically large, and perhaps it was the very preposterous nature of it that allowed me to work with my colleagues to cobble some words together, and do it. Maybe a presentation to a smaller group would have been more difficult. Perhaps the fact that it was not in English also helped: if I messed up the speech, I wouldn’t know! I imagine that the fact that at that point I really did not know anyone around me might have helped too: the situation provided a perfect laboratory to try new ways of being, and as such gave me lots of chances to face and overcome my fears.

The residue of my social anxiety remains: I am aware of feeling it, but I know I can push through it and things will tend to be okay. My experience with feeling better the other day paradoxically reminded me of the historic anxiety, but it was good to have first-hand experience that meant I could really believe the findings of Trew and Alden’s study.

Trew and Alden’s findings remind me of an article exploring the Benjamin Franklin Effect, which suggests the best way to garner good feelings from others is to ask them for a favour. This links with the behavioural aspects of cognitive-behavioural therapy, which can seem counterintuitive, such as when people are asked to engage in activities before they feel motivated to do so, which can lead to the development of motivation to engage in the activities, perpetuating a virtuous cycle which can boost mood. Essentially, behaviour leads to one’s construction of reality, just as thoughts and words contribute to construct it.

It has often been suggested that there is no such thing as a selfless act: that when we do things for others, ultimately we are also serving our own needs. Indeed, my blood donations have a partly selfish motivation: they allow me to expose myself to my fear of needles. Trew and Alden’s findings about kindness also support the idea of selfish underlying motivations, even if they might not be conscious. It may or may not be the case, but if it ultimately reinforces our doing good things for others, then perhaps it is just a natural reward for doing the right thing. Of course, the right thing to one person might not be so to someone else, but it is hopeful to think that there might be a system built into the human psyche that guides us towards and rewards us for being kind.

On practicing what you preach Thu, 26 Feb 2015 23:25:35 +0000 Continue reading "On practicing what you preach"

Sometimes in practice, I have found I feel somewhat hypocritical. An example of this was when I was a primary care mental health worker, helping people to work on their blood / needle / injury phobias.

Whilst I could explain the principles,  support people to build graded exposure ladders, talk about how blood-related phobias are the only ones where you actually can faint owing to some sort of presumably protective physiological response, I never felt like I could be truly authentic. This was because on the inside, I was also experiencing the same fears my clients were bringing. On the one hand, this made empathy easy, although at that stage in my development of a clinical identity, I did not feel confident to disclose my experiences, even though it might have been helpful at times. I felt this lack of authenticity might have meant that I might have been less effective when working with people experiencing that sort of problem. I decided that I wanted this to change.

Thus my journey towards what happened today began. Often, the ultimate goal, if people felt brave enough to aim for it, would have been to give blood. At the beginning of my journey, I did not even think that would have been possible. I could have injections but would avoid them unless absolutely necessary, and would be racked with anxiety and vivid images of what might happen in the days before any anticipated jab. Gradually, in little steps, I managed to work towards that and it happened today.

The first steps were changes in approach to needles and related objects that I encountered in my work in GP practices. Rather than avoiding them, I started to seek them out, paying attention to the sharps bins and looking at syringes and needles in drawers. This helped me to get used to them, and before long I was accustomed to them.

The next stage was to seek out and take all the opportunities to have immunisations that I could. Seasonal flu, other flus, jabs for frontline staff and so on: I made sure I had them all and gradually became less fearful of the process. I also read that not looking at the needle when the injection takes place reduces the reported pain. Previously, I had tried to make myself look, as I thought that might help. Switching to not looking seemed to make things easier.

Finally I realised that I might actually be ready to give blood. I read about it, signed up, and they started sending me letters. Initially, I still did not think that I could, but something made me sign set an appointment. Perhaps it was that urge for authenticity, but also the sense that it is a genuinely useful thing to do, and a will to conquer the fear seemed to play their roles.

As the nerves arose in the days preceding the appointment, I tried to distract myself from pointless unfounded thoughts of things that might go wrong, sometimes through relaxation exercises, but often by just thinking about other things on my mind that I could do something about. This did not necessarily mean that I always got those things done, however…

Finally, the day came. After a blustery, rainy motorcycle ride to near the venue, I changed and jogged down, half wondering if part of me had conspired to make things run so that I didn’t have much time to think beforehand, and potentially change my mind. The actual process was really straightforward. I explained it was my first time, and they were great about it. They said they get a lot of people trying to overcome fear of needles, and a lot of bikers, who sometimes show up en masse to donate.

Five years ago, when my journey towards giving blood today began, I am not sure if I would have believed it was possible. I’m really pleased to have done it, both for my sake and for the sake of other people who will receive blood, as well as for the impact it might have on my ability to be authentic when I talk to people about overcoming phobias: how hard it is, but also how exposure does work, even if it happens gradually!

Screens – worthy addition or wasteful addiction? Tue, 10 Feb 2015 15:02:17 +0000 Continue reading "Screens – worthy addition or wasteful addiction?"

I recently attended a seminar about screen addiction led by Dr Aric Sigman. I was intrigued by the information about how excessive recreational screen-use has a detrimental impact on people, and how each new generation seems to be increasingly glued to screens. I weighed this up against the research I have looked at which aims to develop touch-screen based interventions, some of which act as cognitive prostheses for people with dementia. I wondered where we can draw a line, however arbitrary, between the benefits and the costs of the screens we surround ourselves with.

Dr Sigman presented those assembled with some potentially harrowing statistics: the average child will have spent one year of their life looking at screens by the age of seven. At the current rate of screen use, the average eighty year old will likely have spent two decades looking at screens. We were shown studies with people who play excessive sounding amounts of online games: about seven hours each day. Unsurprisingly perhaps, this apparently leads to physically observable changes in the structure of the brain. I wondered about how one might find a control group for this: what other activities would be similar, and could people stay motivated to do for 8 hours a day? Race driving, perhaps? Motorcycle racing might not be sufficiently sedentary. Is it possible that doing any one thing for eight hours a day during waking hours is likely to be problematic for people?

In the past, children who watched too much television were called square-eyed, and this was framed negatively. Roald Dahl caricatured the phenomenon six decades ago in Charlie And The Chocolate Factory with his character Mike Teavee. The Mike of the book was a smart but short-tempered boy who was addicted to watching television, enjoyed watching TV shows about gangsters, and carried eighteen guns which he pretended to fire when watching TV. In the seventies film (which on a recent re-watch was astonishingly disturbing in places), he watched cowboy films. In the noughties version, the character had evolved to enjoy first-person shooter games in addition to watching television. It seems that the profile of this child is nothing new, but what is it that people find so objectionable about it? Perhaps it is related to the idea of a perfectly good brain going to waste.

Gaming can have significant impacts on cognition. Tetris apparently invalidated some cognitive tests when it took the world by storm in the nineties, since large sections of the population got a lot of practice at rotating two-dimensional shapes in their minds. This meant that the tests had to be redesigned. Tetris is also potentially of benefit to people in the aftermath of traumatic events, reducing the number of flashbacks they experience. Tetris might appeal to researchers because of the relative simplicity of the game: the possible benefits of modern, more complex games might be harder to evaluate as it would be difficult to determine which aspects of the game had caused the effects.

My literature review suggests that there are various potential benefits of touch-screen based interventions for people with dementia and their carers. The Computer Interactive Reminiscence and Conversation Aid (CIRCA) project set up as a result of research conducted at the University of Dundee by Norman Alm and colleagues is a project that aims to offer a cognitive prosthesis for people whose working memories might be compromised, and helps them to become more equal participants in conversations by providing a source of topics to discuss via visual and auditory media. Off-shoots of the project include “Living in the Moment” games and ExPress Play, which allows people to play music regardless of their level of musical prowess. Research suggests that these activities are enjoyable and of benefit not only to the people with dementia but also to the people around them as new memories can come to light, conversations can become more natural, and the focus of shared activities can shift towards creativity.

Other studies have been conducted with touch screen art software, a range of iPad apps, applications that integrate with the household and hand-held devices. The studies seem to consistently show that people with early to mid-stage dementias are able to learn to use touch-screens, and that when certain design aspects are taken into consideration, they and the people around them can find them to be of benefit.

Screen use is becoming increasingly pervasive, as we all tend to carry arrays of portable screens around with us. Some people seem to find them addictive, but the media that can be delivered via screens also has the power to help. Perhaps it would be useful to think about the ways in which we use screens, audit our own screen use and think about ways to optimise it in terms of potential benefit to ourselves and others.

What about now? Wed, 31 Dec 2014 12:44:08 +0000 Continue reading "What about now?"

It is customary, at least in the culture I grew up in, to look back over the past year, and think about the coming year on the last day of a given year. It is also customary to make resolutions, which in my experience can be summed up as “idealistic, knee-jerk plans founded on guilt about recent, primarily health related, shortcomings, which are almost certainly doomed to failure as one realises the financial impact of end-of-year related festivities”. Examples of resolutions might include giving up a certain kind of food, or health-damaging habit, or resolving to do something impressive, like doing a large amount of exercise in one go (and telling everyone about it on social media, of course). Amidst all of this looking to the past and the future, we lose sight of the here and now, which is something that proponents of mindfulness and related endeavours might frown upon. Of course, one might resolve to practice mindfulness more, which might alleviate their consternation.

When I look back on this year, I am aware of a few key points:

  • I managed to leave Facebook. Second time lucky, I guess. I think that mindfulness came in useful with that process. The first time I tried to leave, I fell foul of the cunning slow-leaving protocol that Facebook employs, which means that there is an enforced two-week period, during which your account is frozen in carbonite, ready to be reanimated if you press the button. I broke, but realised that on balance, I still wanted to leave. The second time, I managed it. I imagine the data I painstakingly deleted is safely backed up all over various agencies’ sites, but at least the flow was stopped. I was disturbed and fascinated to learn that Facebook now has a search facility, which allows the searching of one trillion posts with similar ease to Google. Incidentally, after I left Facebook, I found the quality of my social life improved.
  • Our cat nearly died. He’s fine now, but I was amazed by the intensity of emotion it evoked in me. He inadvertently taught me something about what really matters, as it seems I needed a reminder.
  • Getting away from everything was really important. A trip to the middle of nowhere in France was a tonic for the soul, as was a cycling trip with old friends. When I started the clinical psychology training course, I was not aware of the toll it was to take on my life, and by extension the lives of those I care most about. The words “careful what you wish for” now have added resonance for me. I don’t regret doing the course at all, but it is of course not to be taken lightly.
  • I have reinvigorated my photography. Whilst I never stopped taking photos, I noticed that over the past couple of years, the intense quality of the photos I was taking had diminished, and that I was taking less of them. I sought advice from friends, and ended up getting into 500px. It has reignited my passion for producing images that move. It is also a welcome respite from the sometimes overwhelmingly abstract work that the course entails. On a related note, my Flickr stream also reached one million views.
  • Little projects have helped to broaden horizons. The most satisfying was probably turning a Raspberry Pi computer into a silent homewide file and media server that fits behind the books in a bookshelf.
  • Strava has also been a fun diversion, turning every ride or jog into a game. This has been boosted by my long-distance placements ending. Now I am placed close enough to where I live to cycle to work, I can enjoy the sublime feeling of cycling, and when time allows, I can take longer, hillier routes home. If you’re into cycling or jogging, I highly recommend some form of gamification system. Although, if Russell Brand is right, it’s all building towards some sort of voluntary technologically-mediated panopticon.

Looking forwards, this year my training journey is scheduled to end. I am concerned that at times, and for various reasons, the sense of fun and excitement that I have in relation to psychology has been sucked away, in a similar way to how the joy of photography left me. When I was doing my undergraduate psychology degree, I had a wobble following a bout of glandular fever. After a GP unhelpfully gave me the prognosis, “You will feel awful for another three weeks, you will be depressed for a year and you will have low energy levels for the rest of your life” I resolved to make changes. Some were positive, like gradually building up my activity levels. Some were less useful, like changing courses from psychology to computer science. A lightbulb moment came when my friend said to me “Charlie, when you came home  each day you used to tell me interesting facts about things you had learned, but you just don’t do that any more.” He made me realise that psychology was something I lived and not simply learned, and so I switched back as soon as I could. At times when my motivation diminishes, I hope to remember the things about psychology that fascinate. After all, if we cannot enjoy what we are doing, what is the point?

Optical illusions: a reminder that perception is not reality:

Split-brain phenomenology: which side of your brain is in control?

The Robber’s Cave Experiment: a foundation of reality television:

In terms of realistically achievable resolutions, I think something we often miss is to simply experience and hopefully enjoy the moment. Edward Abbey put this into words rather beautifully with:

“One final paragraph of advice: do not burn yourselves out. Be as I am – a reluctant enthusiast….a part-time crusader, a half-hearted fanatic. Save the other half of yourselves and your lives for pleasure and adventure. It is not enough to fight for the land; it is even more important to enjoy it. While you can. While it’s still here. So get out there and hunt and fish and mess around with your friends, ramble out yonder and explore the forests, climb the mountains, bag the peaks, run the rivers, breathe deep of that yet sweet and lucid air, sit quietly for a while and contemplate the precious stillness, the lovely, mysterious, and awesome space. Enjoy yourselves, keep your brain in your head and your head firmly attached to the body, the body active and alive, and I promise you this much; I promise you this one sweet victory over our enemies, over those desk-bound men and women with their hearts in a safe deposit box, and their eyes hypnotized by desk calculators. I promise you this; You will outlive the bastards.”

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Parallels between psychology and fishkeeping Wed, 10 Dec 2014 23:21:25 +0000 Continue reading "Parallels between psychology and fishkeeping"

When I think about my hobbies, which include photography, cycling, motorcycling, hacking and fishkeeping, I sometimes think they’re quite diverse. After all, some of them usually take place outdoors, and others are very much indoor activities. They also seem like a diversion from the often overly cerebral world of clinical psychology. On further reflection however, there are parallels between all of them and psychology. In what might become a regular feature (at least until I run out of hobbies), I shall describe what I consider to be parallels between them and clinical psychology. The first hobby I shall consider is fishkeeping.

A bit of history: I never really intended to become a fishkeeper. Fishkeeping found me, when I was bought a tropical tank for my birthday some years ago, with no prompting. It proved to be a hit, and immediately I started doing something that all clinical psychologists tend to do: researching. I researched the best way to “cycle” the tank so that the water was safe for fauna. I researched ideal temperatures, pH balances, fish species for beginners, plants to make the tank look good and take up nitrates from the water, food varieties that would not pollute the water, optimum filling-heights, lighting regimes and so on. As with clinical work, whilst there are certainly broad dos and don’ts, there is no simple right or wrong way to go about setting up and running a tank. It requires a mix of scientific and creative thinking. After a few months, the tank was up and running.

Outcome measurement is a key part of clinical work, although it can be contentious as some clinicians feel it interferes with the process of work. There are different ways to measure outcomes: quantitative methods tend to focus on scores for things related to feeling anxious, low or other concerns. Quantitative methods of measuring fishkeeping progress could be chemical measures of water parameters, or simply counting the numbers of various organisms that can live healthily in the tank, or rates of offspring (although high snail counts often mean that something has gone awry). Qualitative methods are more related to free-flowing interviews or discussions and people’s views. These can be seen as more meaningful, but are less easy to package up as the simple answers to complex questions that commissioners and politicians like to consider when making funding allocation decisions. Qualitative measures of aquarium success might be people’s comments about your tank, either in person or (shudder) on YouTube.

A new timesuck...

Endings and their management are a key part of clinical work with people, and can evoke strong feelings related to past ending that went well, or not so well. Fishkeeping has its fair share of endings too. In my experience, they are usually unhappy ones, as fish become unwell and often do not recover. Sometimes, treatment is possible, but this raises another parallel with clinical work: ethical dilemmas. For example, when my became hosts for Camallanus parasitic worms, the prognosis was poor. One option is treatment with Nematol, which kills invertebrates. Unfortunately, I had Amano Shrimp in my tank but I did some research and it was suggested that larger invertebrates can sometimes tolerate it. Faced with an array of stricken fish, I duly dosed the tank. The outcome was pretty awful: the ill fish recovered somewhat, but eventually all died. That said, the spread of the worms halted and no further fish were infected. Meanwhile, the shrimp had complications when they shed their skins, and expired. It was really gutting. As a contingency plan, I now have a separate tank for invertebrates, so that if something similar happens in future, they can go on holiday for a while and survive.

Male Amano Shrimp - Caridina multidentata

Another dilemma was when I had a Malaysian Trumpet Snail population explosion after some got into the tank accidentally on some plants I introduced. Following the Nematol disaster, I resolved to go down the biological control method, and tried to find a predator that would control the snail numbers. It turns out that the ideal predator is another shelled-beast: the assassin snail. I put a couple into the tank and within a week the snails were under control, and the tank was strewn with a macabre array of empty shells.

Assassin Snail - Clea Helena

This was one example of the formulation one has to do as a fishkeeper. Another was when I had problems with high nitrate levels, discovered using the testing kit. All the forums and experts were saying to do more water changes, so I duly did, but this seemed not to work, and if anything seemed to exacerbate the problem. I tried measuring the water parameters more regularly, and it was when I measured the nitrates pre-and-post a water change that I realised the nitrates were coming from the tap water itself, which was confirmed by a test of the water, and looking at Thames Water’s stats. Apparently the cause was likely to be attributable to fertiliser runoff, or even a decomposing animal in the water supply! Thus I had to reformulate and account for factors in the wider system which required new strategies to address: much like in clinical work when new information comes to light which changes the course of the work.

Psychologically-minded people might find fishkeeping interesting owing to the fantastic array of behaviours that the animals in tanks display. Fish establish territories and hierarchies, and their behaviours change when they are attempting to breed. It is important to have a good “boss-fish” that will not bully its tankmates as this promotes harmony: thus in a tank, as with people, systemic issues need to be considered. I introduced the Amano shrimp to try to control rampant algae growth, and soon found that shrimp were very interesting in their own right – they have a wide array of legs adapted for different purposes: walking, eating and swimming. They also have complex behaviours like having to exuviate, or shed their shells, on a regular basis as they grow. They are also transparent, so you can see what’s going on as they produce eggs, food travels through their digestive tracts and so on.

In summary, what I thought would be a light-hearted diversion from the rigours of psychological work became, at least in my hands, another involving, complex and rewarding process. It can be all of those things in differing amounts, depending on what you put into it and your expectations. I find the diversity of tank-life endlessly intriguing, and it gives rise to an ongoing process of learning and curiosity, just as psychology should too.

Talking about ‘the gap’ Thu, 27 Nov 2014 16:11:53 +0000 Continue reading "Talking about ‘the gap’"

In a previous post, I described the thoughts Clinical Psychology Forum 261 – a special about the gap between clinical psychology and psychiatry.  A letter summarising those thoughts was published along with other responses to CPF 261 in this month’s Forum, which is somewhat poignantly a special about ‘Remembering the bio in biopsychosocial’.

I was struck by the variety of responses in the other letters, showing the breadth of opinions held by psychologists in relation to this issue. Matthew Fish described how the issue was useful to an outsider to the profession as it gave a sense of what differentiates (clinical) psychology from psychiatry. Huw Green talks about how the range of ways in which issues are described using diagnoses and formulations could be seen as metaphors for our inability to fully  understand our ‘complex psychic system’. Simon Stuart described how the issue highlighted how often we tend not to pay attention to the views of service users. Certainly, I believe these should be at the heart of our clinical practice, and I hope that things are gradually moving that way, with the potential for increased use of community psychology approaches to future interventions. Isabel Clarke describes the point as being that ‘psychiatry has lost its way and landed up a blind alley’. She describes hopes for the future in the form of the Psychosis and Complex Mental Health Faculty and the New Paradigm Alliance. Dr Peter Scragg goes so ar as to suggest that the CPF might be renamed ‘Anti-Psychiatry Forum‘, and challenges clinical psychologists to produce empirical proof of the clinical value of formulation as opposed to diagnosis.

How can we take this forward? It sounds like there might be places for different approaches in different situations and with different people. Perhaps if we keep service users’ perspectives in mind and welcome service users’ opinions more, we might gain more insight into what work for whom, beyond analyses of different dyadic and systemic approaches to working with people. We might look at what constitutes something working for someone: how outcomes can be measured in meaningful ways, and hopefully fed back to clinicians and clients alike. I look forward to hearing more about The New Paradigm Alliance.

Perhaps diagnoses could be framed more as potentially useful heuristic tools that convey a concepts, but not an irreversible labelling of someone’s mental state, temperament or character. At the risk of sounding facetious, all words effectively function as metaphorical heuristics or symbols for something else, and by moving away from diagnosis, might people not simply come up with new ways to describe conditions that they see recurrently? How might diagnoses be effectively eradicated from common parlance? Would they be diluted out of existence, or somehow banned from use? Might psychologists risk alienating themselves further by refusing to use diagnostic terms and replace them with descriptions that other professionals might see as unnecessarily circumlocutory? Might this provoke anger towards psychologists from other professionals who might not have as much time to think as psychologists are afforded?

I think the formulation-based approach that seems to be at the core of most of the clinical psychology work I have witnessed and taken part in is the most humane and inclusive way of conceptualising most of the problems that the  people clinical psychologists work with in NHS settings. It takes time, but qualitatively at least, it seems to be more helpful than simply telling someone that they might have a certain diagnostic label. Formulation done properly is an intrinsic part of the therapeutic process. Perhaps, to paraphrase Winston Churchill, formulation is the worst form of conceptualisation of people’s difficulties, except for all those other forms that have been tried from time to time.

Look into my eyes… Tue, 18 Nov 2014 10:52:06 +0000 Continue reading "Look into my eyes…"

Therapeutic use of hypnosis is perhaps most commonly associated with the archetypal psychoanalyst, using it to unlock memories and associations that might be inaccessible when people are fully conscious. This is one possible therapeutic use, but there are other areas where hypnosis is being trialled.

A recent Swiss paper by Cordi, Schlarb and Rasch has found that listening to an audio recording with hypnotic suggestions to sleep deeper led to people spending more of their nap time in slow-wave sleep, and a significant reduction in their time spent awake. This is a  potentially exciting finding because slow-wave sleep seems to be very important in the body’s repair processes, as well as brain function.  If people can be induced to spend more time in slow-wave sleep, following the experimenters’ logic, then it might improve their physical and mental health and well-being. This is potentially especially pertinent for healthy aging, as people tend to have less slow-wave sleep as they age, so a non drug-based intervention that increases amounts of slow-wave sleep could increase health and memory consolidation in an aging population. This could potentially mitigate the effects of dementias in people who were suggestible enough to be hypnotised.

It is worth noting that the increased slow-wave sleep was only observed in highly suggestible people, and in fact low-suggestible people’s slow-wave sleep significantly decreased in its amount. When people received suggestions to sleep shallower, there was no clear impact on their slow-wave sleep in either group of people. People’s suggestibility was measured using the Harvard Group Scale of Hypnotic Susceptibility.

An interesting part of this finding is that not only is hypnosis being used to communicate with non-conscious parts of the mind, but that the communication appears to be having a measurable physiological effect on sleep architecture – a process which occurs unconsciously. Words received and interpreted by higher cortical areas of the brain are presumably percolating down to areas concerned with deeper physiological functions of sleep, and actually changing the structure of the sleep people are having. This is perhaps even more striking than the apparent power of hypnosis to affect processes that take place when people are not asleep, such as heart rate, pain perception and sporting prowess.

A study in Cell recently demonstrated that if you measure someone’s brain waves, then synchronise the playing of pink-noise to them on the up-stroke of their slow wave sleep oscillations, not only are the slow-wave oscillations seemingly reinforced, but also the participants’ memory functions improved in subsequent tests. This might have implications beyond sleep problems in the realm of memory research. However, to do this more widely, one would need people to be connected to EEGs while they slept, limiting the wider applicability of the intervention, at least until more portable EEG devices are developed. If hypnosis-based interventions can be helpful in the reorganisation of people’s sleep architecture, it seems that further research would be beneficial.  This could look at the possibility of using hypnosis with different groups, and see if there are unanticipated side-effects of the intervention. The intervention itself seems inobtrusive, after the somewhat lengthy process of screening people for their susceptibility.

Storage of people’s susceptibility status (and by extension the record of their having been given hypnosis-based therapy) would probably need to be confidential: perhaps knowledge of who was susceptible might be of use to people or forces that might want to exploit that susceptibility. In a future where NHS records might be more widely shared, this and related confidentiality issues could be something worthy of deeper consideration.


  • How would people feel about an intervention being delivered beyond their conscious awareness or direct control?
  • Does this type of intervention have similar ethical dilemmas to pharmacological interventions?
  • Might therapists have a role in the development of bespoke hypnosis recordings for people’s specific needs?
  • What other concerns might hypnosis be capable of affecting?
  • What might the long-term effects of repeated hypnosis for sleep architecture alteration be?
  • Does the onset of dementia affect people’s susceptibility to hypnosis?


Photo – “Punk Chicken” – Copyright Charlie Tyack

Which came first, the sleepiness or the culture? Is there more narcolepsy in Japan? Tue, 21 Oct 2014 21:39:57 +0000 Continue reading "Which came first, the sleepiness or the culture? Is there more narcolepsy in Japan?"

I’ve been reacquainting myself with sleep-related issues of late, as half of my current placement is in a sleep disorders team. When looking into narcolepsy, I was intrigued to note that rates of narcolepsy are about four times higher in Japan according to self report than they tend to be elsewhere. This got me thinking about my sleep-related observations from the two years I spent there, and I wondered about differences in the way that sleep seems to be conceptualised in Japanese culture.

When I lived in Japan, I saw a lot of people asleep during the daytime. Coming from the UK, I was initially taken aback by this, especially when it occurred at work in educational settings. In Japanese culture, presence is more important that attention: it is okay to be asleep as long as one is present at an event, which conveys the sleeping-yet-present person’s respect for the occasion. It is also (perhaps paradoxically to a Westerner) perceived as evidence of how hard they work. Learning this allayed my dismay somewhat when I taught a demonstration lesson at a local high school with the head of English from my base school, and some of the teachers in the audience went to sleep!

Another frequent sighting was of people sleeping in cars outside offices. I asked about this, and apparently it related to the Japanese approach to punctuality: to be early is to be on time, to be on time is to be late, and to be late does not happen. Thus, these sleepers had arrived so early for their meetings that they had time to sleep. Being spotted sleeping might also communicate their respect for the person they were meeting with.

My students were often visibly tired and with good reason: after school, they were made to attend juku, or cram-school until around midnight every weeknight. Apparently, they learned “how to be Japanese” at daytime school, then learned how to pass their exams in the evenings. This meant that the post-lunch classes could feel like the graveyard shift, as starch and sleepiness conspired to send the students into a soporific stupor.

More recently, Japanese companies have encouraged their staff to take siestas in a bid to boost productivity. According to the linked article, Japanese workers tend to get less sleep than those in any other country. Napping seems to have been part of the Japanese approach for some time: anecdotally, I heard that there was an old saying that “when a Samurai is not fighting, he sleeps”. There seems to be an implicit balance between fierce activity, and sleep, which seems to be reflected in modern-day Japanese life. The tendency towards napping means that people opportunistically sleep in various locations, and might also have contributed to the pragmatic genius of the capsule hotel (see photo atop this post for visual elaboration).

Interpreting the Japanese data in relation to increased incidence of narcolepsy in a clear-cut way is difficult. Firstly, this was based on self-report surveys of thousands of people of working age who were in work, and school-age people who were at school, in a country whose culture encourages people to be seen to be working hard, and where being sleepy at work or school is framed positively. This means that respondents might have been more likely to report feeling sleepy during the daytime than respondents from other countries, where feeling sleepy and sleeping at work might be looked on less favourably. The reliance on self-reports from participants, and the fact that no polysomnography was conducted to objectively verify and quantify the extent of their narcolepsy serves to make the data somewhat less compelling. This would be required in the UK. Still, the figures suggest that there are differences in narcolepsy rates and I wondered about other possible hypotheses.

Perhaps having a culture in which sleep is positively framed results in people sleeping more during the day, which in turn gives rise to difficulties sleeping at night as people have less need to sleep. Other cultures which have siestas do not report such high levels of narcolepsy, but perhaps they tend to have more time set aside and the sleep is not so opportunistic, so the quality of sleep might be better, leading to less unwanted sleepiness.

Perhaps people in Japan are generally more prone to intrusive daytime sleepiness than people in other countries, and their relatively homogeneous society has meant that this trait has been preserved. Perhaps this gave rise to their cultural permissiveness of sleep and sleepiness, and the increased incidence of self-reported traits of narcolepsy. Maybe there is an interaction of these factors. Perhaps there are other factors at play. Maybe I’m just a little sore about people falling asleep in my class, and this post is a desperate defence against the possibility that my teaching was sleep-inducingly boring!

Photo – Capsule Hotel by Charlie Tyack