Psychology - was the fish farmer right?

Media vs reality: psychiatric care

When I was 19, I worked some vacation days dredging out aquaculture ponds with a Harrietsham fish farmer who asked me "What use is it studying them 'ologies then - no good for getting a job?".  So - I'm writing now as I'm on my 5-week psychiatry rotation, and it's time for a bit of hindsight on the 6 years I spent with my head deep in psychology to see what I still need to learn.  My BSc (Hons) Psych took me up till 2005, and I spent 3 years of postgrad research work with it at King's, Kent and Dublin.   Life-affirming university social times alongside (which I wouldn't change for the world), what has the psych taught me that's of any use now, particularly in the medical career?

To put it to the test, as I was learning the academics of psych I worked under the impression that it could help me do 3 things - (1) understand myself - coming of age in my early 20s, (2) help people out suffering with their mental health and (3) develop some job skills / wield some influence on others.  There's also an unsurprising number (4) that's become apparent since - quirky psychology for pub chats, started in the Interval bar.  That it could definitely do...

(1) Did psychology improve my self awareness?  Yup!

Cognitive psychology - TICK - helped me understand how I learn and think

• Ever wondered how your memory works?  Neural networks: learning and retrieval takes place in a network of interconnected nodes.  Hebb's law - the more one node is stimulated with another, the stronger their connection becomes (and hence learning information in context sticks better), and that's a way to restimulate those memory traces too.  I've found this ever since as a very simple way to understand memory and how familiar contexts can jog your memory.
• Your thoughts and your feelings are separate but related - I hadn't distinguished the two as a child.  You can cognitively reappraise emotions and experience them differently (e.g. a man walks into you -> anger, then you realise he is blind -> empathy).  We also remember emotion-laden information better (you're not going to forget if someone tells you your grandpa has been crushed by a falling boulder), so if you can find personal relevance of facts you're trying to get into your head, all the better.
• Brain structure is remarkably complex - when you get beyond the very basics of sensation, motor function, primitive emotion and language, higher functions like decision making and memory storage are diffusely represented in the brain, you can't slice through the brain tissue and pop these bits out.  This is cognitive neuropsychology, and taught me there are some things I'll never quite understand!

Child psychology - TICK exploring what a reasonable childhood should feature, may come in handy one day

• What does the outcome of a good childhood look like?: I wrote my dissertation on this - determined that the goals of childhood are realignment of social relationships towards peers, development of identity and positive self-concept, preparation for the working role, development of morality.  A social worker I spoke with recently summarised simply the most important influence on this: "you have to have an adult who's invested in you".
• Outcomes of adventure programmes: long-duration outdoor adventure programmes (1 month +) have greater effects on character (e.g. leadership, social competence & cooperation, independence); shorter duration programmes are more likely to influence outcomes that are closely taught at the time (e.g. mapreading, knowledge about boats).  And stretching tasks should be just within a child's limits.  However, doing this outcomes research didn't translate into any helpful suggestions to the course organisers!
• Unconditional positive regard essentially means people blossom when they're accepted just as they are.  The idea was coined by a warm psychologist called Carl Rogers - and it features in good therapy, healthy parenting, and is one reason for the psychological benefits of having a faith.  A bit too passive when dealing with challenging behaviour in the workplace, I discovered (for a rather more cynical view of this, read Office Politics by Oliver James).

(2) Did psychology help me help others?  Not much yet...

Clinical Psychology & Psychopathology - good for context of how to gauge a problem and how services work TICK, just not immediately for skills in how to treat them CROSS!

• Psychopathology is extraordinarily complex (297 disorders in DSM-IV) - every case with a varying set of family and personal dynamics that may be relevant to care.  Even the psychiatric labelling is contentious, as treatments for two patients with the same 'disease' may need to be vastly different.  That said, the psychiatrists helpfully discuss diagnostic labelling as a useful summary aid to communicating with each other (one doctor's acute stress reaction / early onset psychosis is immediately understandable by another, and provides some predictive power about the course of the disorder).  It emerged that there's still quite some disagreement about how to treat the mentally unwell, and the evidence for lots of the talking therapy is only modest.
• Academic psychology heavily valued psychotherapy, which was a bit shortsighted.  There is a lack of research into many therapies aside from cognitive behavioural therapy (CBT: Australian Psych Society, 2010), though some more specific approaches, e.g. DBT for EUPD, family therapy in bipolar disorder & schizophrenia have an evidence base.  Focusing on CBT, the effect size is modest - if you're a CBT practitioner for moderately depressed patients, for just one of your patients to achieve a better result than placebo you'll need to treat 8 patients, and this is roughly comparable with antidepressant effectiveness: Cochrane).  As another way to look at it, 20% of patients on psychotherapy waiting lists for depression improve to 'recovery' by themselves, and approximately 32% of those that initially engage with psychotherapy move to 'recovery').  In schizophrenia, effect sizes of psychotherapy are also modest.  Essentially even if you're good at delivering talking therapy, you're not going to 'solve' most of the cases by yourself, you need the multi-disciplinary team, and much of that attention is aimed at managing rather than solving the case.
• NHS psychiatric services' structure are nothing like as glamorous as Freud's academic setting with its chaise longue - the reality is waiting lists, regular medication, simple low-intensity interventions, community management, and the occasional hospital stay if things get too chaotic.  Here in Nottingham (and also much of the acute inpatient services in London), there isn't funding for psychological intervention as an inpatient.
• In societies without mental health services, severely ill patients can either fester hidden by their families, or rave on the streets.  25% of countries in 2001 had no mental health legislation or basic psychiatric drugs available in primary care.
• Inpatient psychiatric services seem to enable severely unwell patients to experience the basics on Maslow's hierarchy - stability, food, safety.
• Emotions are contagious - if you engage with an angry man, you'll feel angry.  It's therefore emotionally exhausting spending all day with psychiatric patients - mental health professionals burn out.
• When you're formulating (i.e. trying to understand) a psychiatric case, there's a structure to identifying the problem.  You can pick apart predisposing, precipitating, perpetuating and protective factors which explain the problem.
• Patients with common mental health problems (mild depression, anxiety) often benefit from a bit of psychoeducation about this - for example helping them to understand what perpetuates their problems.
• Every disease has a structure: antecedents, a course of development, symptoms, prognoses.  Understanding this structured categorisation of each was one of my spurs into medicine - that it could be understood.  Important not to neglect the social context, too.
• The theories of psychology and psychiatry are irrelevant without practical exposure to patients.  Books about psychosis gave me little insight until I worked on wards; a psychology degree with any intention of preparing students for clinical work should therefore arrange some patient exposure as part of the course.
• A good therapeutic relationship requires the therapist to be of stable mind and station - just like a reliable friend.
• Neurological deficits can produce very unusual disorders of language and perception (as per Oliver Sacks' Man who mistook his wife for a hat).
• There's no benefit to debriefing trauma victims en masse - it should be targeted.  Hearing this from David Clark put me off attempting to chase down a career providing the basics of psychology to victims of major disasters
• Lots of people are lay counsellors - hairdressers, pub landlords, personal trainers, nurses - so the structured formulation/engagement approaches of clinical psychological input (e.g. socratic questioning to challenge negative thoughts, behavioural experiments, imagery, behavioural activation) have to show benefits beyond that of the softer supportive, chit-chat nonspecialised skillset.  While psychotherapists do have an edge in areas like structured motivational interviewing (substance abuse) and dialectical behaviour therapy (emotionally unstable personality disorder), David Richards & David Ekers (2016) have shown that simple behavioural activation techniques can be just as effective as the more complex CBT for depressed patients: Ockham's razor in action.
• The only way to really get your head around your patient cases is to chat them over with other people, be it over a coffee or elsewhere.  Talking behind each others' backs is necessary.  I've Judy Cairns to thank for that tip.
• It's possible to do an awful lot of tests and assessments on a patient, define their problems very specifically, but not necessarily have specific tools to help with those deficits.  I learned this with brain injured patients at Headway Ireland.  It's helpful to know the deficits, but the value lies in the patient's functional outcomes, mood outcomes, or others - not just in being able to label it.

After those years, I still knew almost nothing about... CROSS

• How to structure the process of delivering basic psychological therapy to the neurotics: I had some basic pointers to offer people experiencing mild anxiety, depression and stress (relaxation; psychoeducation on exercise, eating, socialising, sleeping, doing something productive, structured reflective writing; behavioural experiments to try them out).  However, my 6 years in psychology gave me no confidence in how to deliver them.  Nick R (my mental health worker buddy's) simple take for counselling these mildly neurotic patients is helpful: during conversation it's a delicate art of having a menu of approaches at the back of your mind: say nothing/psychoeducate/prompt behavioural goals/challenge unhelpful thoughts/encourage mindfulness.  Similar to the advice you'd give a buddy in distress, but (1) you can medicate your patients, and (2) as docs we delegate the responsibility for taking distressed mates out for a bit of fun to various support workers/organisations.  
• What to say / what drug or other interventions work with other mental health conditions: despite bits of exposure, I didn't have a structured management plan in mind for any of the rest of the gamut of disorders - just a slightly unclear sense of where psychological input could be relevant, with a rejected approach to diagnostic classifications and an insufficiently refined symptom-based model to replace it.  Now from medicine, I have a framework and a balanced approach for how to intervene (and where not) with patients with acute stress reactions, PTSD, OCD, adjustment disorder, bereavement, self-harm, anorexia, bipolar disorder, personality disorders, schizophrenia, balancing psychological, social and follow-up approaches with the medication in the care package.
• Describing behavioural characteristics, though the years have granted me some helpful vocab to label characteristics in colleagues and patients (I loved Paul Blomfield's 'prickly'; Tom Craig's 'hostile and guarded'), it's not a confident framework I could draw from post-psych, and it's a helpful to be structured when teasing out premorbid personality from our patients.  Being prompted by this medical course to look back over the 16PF trait model (the Big Five) has been handy here. Warm/open/receptive vs unsentimental/reserved; self-controlled vs lively & tolerant of disorder; dominant&vigilant vs shy&deferential; emotionally stable vs tense&reactive; extroverted vs introverted.  It's often hard to pick the right word to describe people (18,000 terms in all, according to Allport & Odbert in the 1930s) - but satisfying when you find it.  

(3) Did psychology give me some general job skills?  Hmmm...

Occupational psychology - taught me nothing I could use in the workplace CROSS

• As an HR job, OccuPsych has a role in recruitment: assessment centres (0.68) and work samples (0.54) are much better at predicting worker performance than 'instinctive' interviewing (0.33) or references (0.13). 
• People also like their work varied.  Reality check though: these occupational psychologist characters have been noticeably absent in big business, I've not seen them evident anywhere I've ever worked.

Statistics and research - made a social science researcher of me, which was good in some jobs TICK

• When you're reading a study, critique it in your mind and particularly the data work in it - many journalists misinterpret academic data, and ever more so these days stats are repeatedly Chinese-whisper requoted such that the context becomes lost - and that's assuming the academics collected it properly in the first place
• Doing depth interviews is like taking a history - introduce in detail - and ask questions slowly and structuredly enough to be able to think while you ask (the PANSS scale was an excellent grounding in this).  Psychometrics we used (like the WAIS) are also much like the measures we use in Mental state assessment.
• Giant funded research projects can be for nothing (our £4m Perceive project, and €€ Barretstown study as an example), but they do require a lot of careful organising to deliver their outcome.
• If you're going to do research, join a team (my dissertation outdoor project was out on a limb)
• It's possible to get very lost in written research detail - the real world of patients, business, travel, music, parties, family is out there, and it can't be understood only from books.
• Almost anything can get published if you submit it to enough journals (and almost any topic can be measured).  This doesn't mean it's important.  
• If you don't understand a subject, buy a book on it, (thanks Charlie)
• But - all this academic rigour was clearly a little misplaced in my flirtations with BigData, technology market analyses and other research pieces while at Accenture - statistical rigour flies out of the window when people want key performance indicators - percentages are about all you need!

Dealing with difficult people - helped me accept them, no chance of using it for influence! CROSS

• People's unreasonable behaviour can often be explained - even if it's not necessarily obvious at first - it's best to work on the assumption that the decision makes sense in those people's heads.  This doesn't mean it's a rational weighing up of pros and cons, however.
• Diagnosing the challenging characters: handy technique for dealing with poor behaviour - label it, as some syndrome or a milder form of some personality disorder.  Aids explanation to your like-minded friends, but the clinical textbooks don't have techniques for dealing with difficult employees, though...
• Attribution error: people are more likely, and incorrectly so, to attribute behaviour to dispositions (i.e. personality) rather than situations.  However, situation is far more important than disposition for predicting behaviour (picture the behaviour you have on a sportsfield vs that at the opera).  Good to be conscious of this to sidestep the focus if sparks start to fly.  Interestingly, major depressive patients are particularly prone to self-blame, i.e. internalise failure as due to their disposition rather than externalise it as due to others (Zahn et al., 2015)

Project organising - great - TICK TICK TICK

• I wrote my first newspaper articles while an undergraduate (my first published piece was on animal testing in our psychology labs, now consigned to history), kept my first blog (now defunct), and organised more events than I can remember.  This is why I'm still writing today!
• That said - the expectations are much greater when organising major corporate events, and the crowds tend to be a lot less grateful!

Relevance to medicine - you don't need a psychology degree to work here, but it helps TICK 

• History taking and tests - we practised this in our PANSS depth interviews, we deployed endless psychometrics from WMS neuropsych tests to GAD-7, we had to tease out the aspects of the history from copious handwritten notes. 
• Science must be translated into real life: understanding that it's irrelevant to view the science of medicine in a vacuum away from the services that deliver them, like you can't learn about parties from books alone.  This means I'm prioritising time spent on the ward during my rotations, and every time I'm learning about a service area on my rotations, I'm keeping some notes about how the services interrelate so I can understand them better.
• Minor mental health intervention - familiarity with CBT theory and motivational interviewing in mental health has been helpful.  I'd like to drive the success of this home - it's a skillbase that can be useful in lots of places.  The puts the patient in the driving seat, since they've the ownership from having been proactive in finding the solutions to their problems.
• Public health intervention - I appreciate the value of theory-based brief interventions for smoking, inactivity, poor diet, alcohol use.  These are the things which will most likely kill our patients.  I've developed a structure for brief stop-smoking advice, but would like a stronger approach on each of these.
• Medicine in global health - I've reviewed the career pathways and delivery of psychological services through various job descriptions and project roles I've engaged with as part of my psychology (and consulting) career analyses, and this means I have a more rounded global context of how medicine is delivered globally too.
• Concordance with medication - understanding in advance that patients may not do as they pledge (doing home physio, taking medications, etc.), and that they need to be involved and bought into the decision making 
• Extraordinary processing: human language and vision requires extraordinarily complex neural processing.  For example - edge and shape recognition.  Hence - once the visual or linguistic parts of the brain are damaged we're decades behind able to apply a direct fix: a sobering insight in the importance of therapy in stroke patients but the limitations of surgery.
• Outcomes-focus - it's been an important insight into myself that I like to see outcomes and gratitude for my work (hence insoluble problems aren't for me), and that I don't like to be restricted in my aspirations (hence being able to prescribe drugs and appraise the physical causes of psychiatric problems was important for me too).  This helps me with picking my specialty.
• Research - I've been through ethics, delivery, publication before.  This helps.

(4) Has psychology been good for pub chats?  Yup!

Artificial intelligence - has made for a fascinating pub chats or two.  TICK

• Computers can run a driverless car, they can beat people at chess, but they couldn't beat people at 'Go' while I studied - it's too instinctive, requires too much of a feel.  How things change.
• Computers may also have the same processing power as the human brain by 2029.
• Integration of artificial intelligence into clinical decision support tools with clinician workflows is tough, though some public symptom checker tools like iTriage are growing in popularity (50 million uses per year).

Psychology is full of intriguing trivia TICK

There's so much in psychology:

• Psychology has a lot to say about the coffee break and its associated rituals.  
• Kissing serves important mate-selection functions.
• The story of personality trait identification, including the lexical hypothesis underlying Cattell's Big 5 traits.
• There are similarities between OCD and romantic love neurochemically
• Intensive text/email checking behaviour is to do with operant conditioning
• You'll buy more coffees on a 10-stamp card if instead it's a 12-stamp card and the first two boxes are filled in.  
• There are countless films touching on psychology, and I love the take of learning psych by seeing actors' representations of pathologies
• And a million other things, including some great debunkings of folk wisdom
• though I think we could do with a bit more comedy in psychology

Psychology can make you unusually hyperanalytical: CROSS

• the undergrad schooling in how to critically assess questionnaires, and dismantle our closely held folk wisdoms doesn't always go down so well.  As an example, I've an inability to swallow those cod colour-based teamworking profiles and concepts of learning styles in the workplace.  Fortunately not quite to the point of "Do you love me?"  "Well, that depends what you mean by love, dear..." 

And finally, was the fish man right?

• The fish farmer may have had a point in that there was barely a mention of careers on the psych course - definitely a shortcoming, and despite a lot of students' interest, there wasn't a hint of scheduled clinical exposure, so we had to sort this out for ourselves.
• But, I've never been short of work, largely on the back of the degree and the things I did alongside.  Fortunately a youthful critical mind, a few ideas and the rep that came with a degree-level education in a classical-ish-sounding-subject was more than enough.
• One thing did become apparent about keeping my mind adequately occupied: while that summer's exercise on the fish farm was great, neither would the limited workout for the brain at a few fishponds cut it for me, and nor would a caseload of a few hundred psych patients carping on.  Without clinical supervision at home, that would be a little too much - a fish too far.

Psychology comedy.  Ish.

Thanks to Nick Rosewell for a thorough review, particularly for some of the academic references and reflections on talking therapy, and crystallising these thoughts over the years.