Health Psychology Update

Co-ordinating Editor Neil Coulson Deputy Editor Diana Harcourt Co-Editors Mark Cropley Pauline Fox Marcus Munaf Daryl OConnor Rory OConnor Sarah Christie

Contents Editorial Neil Coulson & Diana Harcourt Individual Articles: Systematic reviews in health psychology: How and why they should be conducted Christopher Bridle Putting pain to paper: A qualitative study of chronic pain patients experiences of using a two-week self-report pain diary Katie Reid, John Asbury, Raymond MacDonald & Michael Serpell Spousal caregiving in Huntingtons Disease: An issue for health psychology Aimee Aubeeluck What can multidimensional scaling and facet theory offer health psychology? Simon Cooper & Ian Donald 2 1

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Publication of the Division of Health Psychology

Volume 12 Issue 4 October 2003 ISSN 0954-2027

Health Psychology Update

is produced by the Division of Health Psychology (DHP) of the British Psychological Society four times a year and is designed to serve as a forum for discussion of issues related to the scientific analysis of psychological processes of health, illness and health care and the development of professional skills in research, practice, consultancy and teaching/training. Health Psychology Update (HPU) aims to: disseminate information to the membership on behalf of the DHP relating to the training and continuing professional development of health psychologists at all levels of competence; stimulate debate among the membership and to provide a forum for the discussion of issues relating to teaching, research, consultancy and the practice of health psychology; disseminate information which may impact on members as with respect to changes in national and regional practice and policy. Submission to HPU HPU contains regular features, such as training update, postgraduate update, forthcoming events and book reviews. Other features will also appear over each volume, such as themed issues, Research in Brief, current debates and conference updates. Suggestions for themed issues and debates are particularly welcome. Papers should be submitted in accordance with the notes for contributors on the inside back cover to the appropriate editor. HPU editorial team The Co-ordinating Editor of HPU is Dr Neil Coulson and Deputy Editor is Dr Diana Harcourt, with up to six other co-editors responsible for specific features (see inside back cover). Editors reserve the right to edit and cut all copy published (with the exception of letters), although all reasonable attempts will be made to contact the writer. Disclaimer Views expressed in this publication are those of the individual contributors and not necessarily views of the DHP. Publication of conferences, courses, organisations and advertisements does not necessarily imply DHP approval or endorsement. Any subsequent promotional piece or advertisement must not indicate that an advert has been previously placed in Health Psychology Update. Advertising Advertising space is subject to availability and is accepted at the discretion of the editors. Cheques should be made payable to the Division of Health Psychology. The cost is: Full page Half page Section Members 10 5 Others 20 10

Copyright Copyright for published material rests with the DHP and the British Psychological Society unless otherwise agreed. Permission should be obtained from the DHP for any other use. Subscriptions for non-BPS members HPU is mailed free of charge to all members of the DHP. It is available on subscription to non-members of the DHP by contacting The Division of Health Psychology, The British Psychological Society, St Andrews House, 48 Princess Road East, Leicester LE1 7DR.

Editorial

Editorial

October 2003 issue of Health Psychology Update (HPU). Wed like to start our editorial by saying a huge thank you to all those involved in organising the recent Division of Health Psychology Conference, which was hosted by Staffordshire University. It was a great success! We begin this issue of HPU by considering the role of systematic reviews in health psychology. Chris Bridle from the University of the West of England outlines the problems of the traditional literature review and argues why such reviews are of low scientific quality, are non-reproducible and may lead to biased conclusions. The systematic review methodology, in contrast, offers more explicit methods of locating, appraising and synthesising research evidence and Chris guides us carefully and with great depth and insight through this process. A convincing argument is put forward as to why this methodology is of great utility to health psychology. Our next article by Katie Reid from the University of Glasgow continues with a methodological theme by writing about her work with chronic pain patients and their experiences of using a two-week selfreport pain diary. From this we turn our attention to Huntingtons Disease (HD), where Aimee Aubeeluck from the University of Derby discusses the issues raised by caring for an individual suffering from this rare dementia. In her article, Aimee describes the unique stressors faced by HD carers and why it is important to establish the factors which may enhance or compromise their quality of life. Simon Cooper and Ian Donald also write for this issue of HPU. In their article, they pose the question What can multidimensional scaling and facet theory offer health psychology? They describe
ELCOME TO THE

their use of a facet design and analytic approach to examine the convergent and discriminant validity of the Theory of Planned Behaviours components. In so doing, they aim to provide a theory-driven rationale for extending the model. We next offer a series of shorter research in brief papers which outline work either in progress or recently completed. Our first contribution comes from Sara Cox and colleagues at the University of Nottingham who discuss the role of dental anxiety in oral health promotion. Cath Jackson and colleagues from the University of Leeds discuss their work in the area of implementation intentions. Maggie Donovan-Hall and Lucy Yardley then outline the need for a multidisciplinary and multinational approach to the prevention of falling in older people. We are delighted to have in this issue two articles on training in health psychology. Our first comes from James Elander at the London Metropolitan University who is also the Chief Examiner of the BPS Board of Examiners in Health Psychology. In this article, James outlines the form of the BPS Stage 1 qualification in health psychology, the procedure and aspects of the regulations as well as the 2003 past papers. Next, Sandra Horn from the University of Southampton offers her thoughts on how best to acquire and demonstrate competence in consultancy as part of Stage 2 training. We also include in this issue two forensic health psychology articles. The first article is by Mike Berry and Sarah Rockliff from Manchester Metropolitan University who discuss the psychological implications of stalking. The second article is by Iain McLean and Val Balding from the University of Manchester who discuss the work of the St. Marys Sexual Assault Referral centre in Manchester. 1

Editorial

Finally, Tonja Schmidt from South West London and St Georges Mental Health NHS Trust provides a very informative overview of a career in mental health promotion. In her article, she discusses what this job entails and provides some helpful illustrative examples of likely activities as well as practical tips to secure such a position. As always in HPU we have our regular features and we are thrilled to have a piece from Lynn Myers who gives us a

profile of health psychology at University College London as well as piece from Jane Turnbull and Joyce Willock who offer a profile of Queen Margaret University College Edinburgh. We hope you enjoy this edition of HPU. If you have any comments on any of the articles featured or would like to contribute to future editions of HPU, please contact us. Neil Coulson & Diana Harcourt

Individual Article

Systematic reviews in health psychology: How and why they should be conducted
Christopher Bridle
University of the West of England.

Introduction
has grown exponentially since the latter half of the 20th century. In an attempt to reduce information overload and increase efficiency, many researchers summarise the evidence on a particular topic. These summaries, or traditional review articles, are of low scientific quality, are non-reproducible, and increase the likelihood of biased conclusions being drawn. Systematic reviews, in contrast, are of high scientific quality, are reproducible, and permit the drawing of evidence-based answers to empirical questions. This paper describes systematic review methodology and highlights criteria by which systematic reviews can, like other pieces of research, be critically appraised.

HE BIOMEDICAL LITERATURE

Background
Reviews in the psychological literature are almost as old as the discipline itself. However, attempts to collate existing knowledge or synthesise research have often failed to be methodologically rigorous. This is demonstrated by the fact that different reviewers reviewing the same evidence-base often reach very different conclusions. One initial problem is that traditional literature reviews are written by authors who rarely begin with an open mind as to the likely recommendations to flow from the review. For instance, authors of reviews may conduct a review, or may have been commissioned by journal editors to conduct the review, precisely because of

their accumulated experience, knowledge and professional opinion. Clearly, strong prior beliefs may impede an objective, dispassionate review of the evidence. More worryingly, reviews may be systematically biased by strong prior beliefs, with reviewers actively developing an argument to support their own beliefs and research position through the selective use of evidence. Indeed, this raises another problematic issue, traditional review articles do not report the methods by which studies are identified, appraised, and synthesised. Under such conditions it is impossible for the reader to determine the extent to which prior beliefs or other biases may have influenced the review process. Traditional literature reviews are widespread and continue to be influential. However, such reviews can justifiably be criticised for a lack of transparency regarding the methodology employed, and their very considerable potential for bias. The conclusions drawn from traditional reviews may thus derive from, or be influenced by, factors other than the evidence upon which they purport to be based. It would be beneficial if reviews of the literature were subjected to the same scientific rigour as that applied to the conduct of primary studies. Systematic reviews satisfy the need for scientifically rigorous methods of research synthesis.

Systematic reviews
In contrast to traditional literature reviews, systematic reviews employ explicit methods to locate, appraise and 3

Christopher Bridle

synthesise research evidence. In this way systematic reviews demand the same scientific principles as those required for primary research, e.g. a reproducible methodology. Thus, two systematic reviews conducted on the same topic by different reviewers should reach the same conclusions. Similarly, just as primary research is subject to critical appraisal, so too are systematic reviews. Methods for high quality evidence syntheses in biomedical research are well established, as are criteria for appraising the quality of systematic reviews (e.g. CRD Report 4, 2001). These methods and criteria include the following six essential points: defining an appropriate question, comprehensive literature search, critical appraisal of primary studies, extraction of relevant data, appropriate data synthesis, and the drawing of evidence-based conclusions. Each of these issues is discussed below. Defining an appropriate question The need for a systematic review is indicated wherever there is uncertainty concerning an empirical question. Traditionally systematic reviews in the biomedical and related literatures have been limited to evaluating the effectiveness of health interventions. These interventions have often involved pharmacological intervention (e.g. Bridle, Palmer, Bagnall, Duffy & Riemsma, 2003), and occasionally interventions that use alternative or complementary medicines, such as those falling under the rubric of homeopathy (Bridle, OMeara, Wilson & Kleijnen, 2002). Increasingly, however, some researchers have sought to apply the principles of evidence-based medicine to the evaluation of behavioural interventions. Systematic reviews of behavioural, or health psychological interventions, have focussed on evaluating the evidence related to specific health issues, such as childhood obesity (Bridle, OMeara, Wilson, Rogers & Kleijnen, 2002) or reducing unintended adolescent preg4

nancy (DiCenso, Guyatt, Willan & Griffith, 2002). Other systematic reviews have evaluated the effectiveness of theorydriven interventions, such as those informed by the theory of planned behaviour (Hardeman, Johnston, Johnston, Bonetti, Wareham & Kinmouth, 2002), or interventions based on stage theories of behaviour change (Riemsma, Pattenden, Bridle, Sowden, Mather, Watt & Walker, 2002), whilst other reviews have informatively evaluated theory-driven interventions for specific health behaviours, such as stage-based interventions for promoting smoking cessation (Riemsma, Pattenden, Bridle, Sowden, Mather, Watt & Walker, 2003). When the need for a systematic review has been identified (i.e. when there is uncertainty concerning the effects of an intervention), an appropriate question must be formulated. Formulating an appropriate question requires a clear statement concerning such criteria as the type of intervention to be evaluated, the population, condition and outcome(s) of interest, e.g. how effective are stage-based interventions for promoting smoking cessation? The type of intervention (stagebased), the condition (smoking) and outcome of interest (smoking cessation) are all detailed within the review question. The population criteria was not specified, but could have been limited to, for example, adolescents, e.g. promoting smoking cessation among adolescents? A well-formulated question serves to focus the review and facilitate the identification of relevant primary studies, as well as making the review findings more meaningful. Locating relevant research Once an appropriate review question has been formulated, it is important to identify all evidence relevant to the question. An unrepresentative sample of primary studies included in a systematic review is a major threat to the validity of the review.

Systematic reviews in health psychology

It is important that substantial efforts are made to locate all relevant research, both published and unpublished. In practice this is often inadequately performed. The first step should be an exploration of electronic databases, which should not be limited to one or even two databases. Research relevant to health psychology can be found distinctively on databases dedicated to psychology, such as PsychInfo, as well as such databases as CINAHL, EMBASE, ERIC, MEDLINE, NTIS, and the Social Science Citation Index. Moreover, patient groups are increasingly developing condition-specific databases, which may contain additional useful information. Although all of these databases may contain unique references to relevant research, seldom do researchers attempt to identify research for review purposes by searching multiple databases. Electronic searching should be supplemented by handsearching of relevant journals, as well as searching the bibliographies of articles retrieved for the review, both of which have been shown to increase the inclusiveness of research relevant to the review (Dickersin, Scherer & Lefebvre, 1994). Identification of unpublished or grey literature is important as publication bias, the selective reporting of research based on the strength or the direction of results, has been well documented (Dickersin, Min & Meinert, 1992; Easterbrook, Berlin, Gopalan, & Matthews, 1991; Stern & Simes, 1997). Although handsearching of bibliographic details of published research will facilitate identification of unpublished research, additional strategies can be used. There are databases dedicated to referencing unpublished research, such as Conference Papers Index, Dissertation Abstracts and, in particular, the System for Information on Grey Literature in Europe (SIGLE). Another useful strategy for identifying unpublished research is direct contact with authors.

The review should report the search strategy employed, including details of electronic databases (e.g. names, search dates, search terms, etc.), handsearching, and contact with authors. Failure to report adequately the search strategy prevents the reader from determining the thoroughness of attempts to locate all relevant research. Once searches have been completed, it is necessary to determine the relevance of studies to the review. Inclusion criteria should be drawn directly from the review question, and relate to such factors as participants (e.g. adolescents), interventions (e.g. behavioural), condition (e.g. obesity) and outcomes (weight loss). Inclusion criteria may also be limited by study design (e.g. randomised controlled trials). Critical appraisal The studies included in a review will vary in terms of methodological rigour, thus making quality assessment important. Many reviews in health psychology fail to take account of the quality of the research to which they refer, and from which they draw their conclusions. This is important because studies of lower methodological quality tend to report more beneficial intervention effects than studies of higher quality, and that exclusion of poorer quality studies from meta-analyses often leads to substantial changes in treatment effects (Egger, Juni, Bartlett, Holstein & Sterne, 2003). Critical appraisal allows reviewers to grade studies according to the reliability of their results, thus enabling them to be given appropriate weight in the synthesis and when drawing conclusions. Studies of high methodological quality are likely to be least biased; bias in this context refers to the extent to which the observed intervention effects are due to factors other than the named intervention. Critical appraisal of included studies allows for results and conclusions to be interpreted in relation to the quality evidence. 5

Christopher Bridle

Many reviews grade studies into a hierarchy determined by design, with systematic reviews first, followed by randomised controlled trials (RCTs), followed by controlled trials without randomisation, followed by cohort studies, and so on. In this way reviewers attempt to take account of study quality by restricting study inclusion criteria, to, for example, RCTs. However, use of a hierarchy of evidence is a very crude method of ensuring quality, not least because there will be much quality variation among trials of the same design. Ideally the quality of included studies should be assessed systematically against predefined criteria. There are numerous published checklists available to assess the methodological quality of different study designs and, for RCTs for example, common criteria include whether an appropriate method of randomisation was employed, whether outcome assessment was blinded, the completeness of followup, and whether drop-outs, withdrawals, and missing data were adequately explained and appropriately handled in the analysis, e.g. intention-to-treat analysis. The criteria used in quality assessment should be clearly reported, thus maintaining the transparency and reproducibility of the review. Data extraction Data extraction refers to the process of systematically recording important study details, usually into structured tables. Extracted data should include information on study design, sample size per condition, participant characteristics, description of the intervention, setting, outcome measures, follow-up, attrition, results, and author conclusions. A comprehensive approach to data extraction is important because it provides, for both the reviewer and the reader, a snap shot of all of the key features concerning all of the included studies, and can be usefully used as a reference source, as well as 6

providing an easy format for exploring potential sources of heterogeneity (discussed below). In addition, it allows the reader to make a judgement of the appropriateness of the authors decisions to include particular studies in the review. Study synthesis Study synthesis refers to the process of combining the studies included in the review. The aims of study synthesis are threefold: (1) to determine, where it is meaningful to do so, an estimate of the effect of the intervention, (2) to establish whether the effect approximates across different studies, and, if not, (3) to investigate differences in intervention effectiveness, i.e. sources of heterogeneity. In broad terms, these aims can be achieved through a qualitative (narrative) or quantitative (statistical) synthesis. The first step of study synthesis is to determine which method of synthesis is appropriate. Decisions concerning which method of synthesis to employ are influenced by several factors. Use of a statistical method, or quantitative synthesis, is likely to be inappropriate if data are very sparse, when necessary data are unavailable, or when there is much heterogeneity between studies. Heterogeneity between studies may be indicated when participants are very different, when delivery of interventions differ, when different outcome measures are employed, or when differences in study quality exist. Under these circumstances a narrative or qualitative synthesis is more meaningful and more useful for exploring how differences between studies relate to effectiveness. Unfortunately systematic reviews appear to be bound inexorably in peoples minds with the concept of meta-analysis. This is problematic because whilst it is always desirable to systematically review a body of research, it may sometimes be inappropriate and misleading to combine results statistically. Compare for example meta-analyses of RCTs and observational

Systematic reviews in health psychology

studies. With a set of high quality RCTs, which examine the same intervention in comparable participant groups, each study will provide an unbiased estimate of the same intervention effect. Under these conditions, any variability between trials can be attributed to random variation and the meta-analysis will provide an equally unbiased and more precise estimate of the intervention effect (Egger, Ebrahim & Davey-Smith, 2002). A very different situation occurs in the context of observational studies, such as case-control, cross-sectional or cohort studies. The effects of confounding and bias associated with observational studies may produce estimates of associations that deviate from true causal effects beyond that which can be attributed to chance. Combining statistically studies under these conditions may thus produce artificially precise and biased estimates of associations (Egger, Schneider & DaveySmith, 1998). Decisions concerning what method of synthesis to employ rest with the reviewer, but the reasoning underlying that decision should be explained and justified so that the reader is able to make a judgement about the appropriateness of the method. Careful consideration concerning method of synthesis is necessary. Once studies have been combined, it is important to determine to what extent studies are similar in terms of intervention effect. If differences exist, it is important to investigate potential sources of heterogeneity. In systematic reviews where a meta-analysis is conducted, a formal statistical test of heterogeneity can be performed, such as chi-square, likelihood ratios, and ANOVA. These tests have low statistical power for detecting differences unless a large number of studies are included in the meta-analysis (Thompson, 1994). If statistical heterogeneity is not detected, it is still important for reviewers to examine the results for evidence of any non-random differences. Differences

between studies can also be investigated by sub-group analysis, sensitivity analysis or regression models. Potential sources of heterogeneity that may influence intervention effects include, among others, participant characteristics, setting in which the intervention is delivered, and methodological quality. For reviews that employ a narrative synthesis, reviewers may investigate potential sources of heterogeneity by grouping studies within the narrative according to the same differences as examined in quantitative synthesis, e.g. studies recruiting children discussed separately from studies recruiting adults. Sensible investigation of sources of heterogeneity increases both the scientific and applied relevance of review findings. Conclusions and implications Once included studies have been synthesised and appropriately examined for potential sources of heterogeneity, the findings need to be discussed in relation to the evidence. Discussion of the results will need to take account of such factors as quality, heterogeneity, the potential for bias and chance, as well as the applicability of findings. Whilst the reviewers expression of judgement, experience and expertise are not precluded entirely by the rigour of systematic reviews, such potentially subjective processes are reduced in impact and made more explicit. Conclusions, therefore, should reflect a balanced and impartial summary of the findings with appropriate consideration given to any flaws in the evidence. A well conducted systematic review on a topic characterised by empirical uncertainty will necessarily generate implications for both practice and research. These should be highlighted and, where possible, discussed separately. Given that systematic reviews focus almost exclusively on health interventions, there will inevitably be implications for practice, though the extent to which implications can be discussed in terms of 7

Christopher Bridle

recommendations for change in health practices will depend on the reliability of the evidence, as determined by such issues as quality and heterogeneity. In providing an unbiased and critically assessed summary of all the available evidence relevant to a particular topic, systematic reviews offer a unique opportunity to identify implications for future research. Although the precise implications will vary according to the review topic, three broad issues dominate. The first concerns whether sufficient evidence exists. Having conducted comprehensive literature searches and identified few relevant studies, systematic reviews can justifiably recommend the need for additional research. The second issue reflects the fact that specific gaps in research may exist in an otherwise reasonably well investigated area. For example, in a recent review examining stage-based interventions for smoking cessation (Riemsma et al., 2003), 23 RCTs were identified, yet only one trial examined intervention effectiveness in adolescents (Pallonen, Velicer, Prochaska, Rossi, Bellis & Tsoh, 1998). Clearly, although in terms of quantity there is a fairly sufficient evidence base, a specific gap exists in terms of this participant group. Careful examination of study characteristics often reveals specific and potentially important gaps in the research literature. The final issue concerns quality. Simply put, the strength with which review conclusions can be made is dependent upon the quality of studies included in the review. Identifying a lack of high quality studies in a particular field is itself an important finding. However, one particular advantage that systematic reviews have over other pieces of research is that, precisely because included studies are critically appraised within the review process, specific recommendations can be made, highlighting the need for studies to be designed with an a priori need to 8

satisfy specific quality criteria. Rather than making an ambiguous reference to a need for good quality research, reviewers are able to specify a need for studies that, for example, employ appropriate randomisation procedures, conceal treatment allocation, blind participants and outcome assessors, specify participant inclusion criteria, and/or studies that conduct intention-to-treat analysis. Such recommendations strengthen existing areas of weakness. By identifying both gaps and areas of weakness in the evidence base, systematic reviews can be used to strengthen bids for research funding.

The review process

Although not strictly a key component of a systematic review, the way in which the review is conducted is important and merits explanation. Given that a key aim of systematic reviews is to reduce the potential for bias, it is important that two or more reviewers are involved in the reviews conduct. The need for at least two reviewers is especially important when selecting studies for inclusion from all studies identified through the searches, the critical appraisal of included studies, and the extraction of relevant data. Regarding study selection and critical appraisal, the process should be completed independently by at least two reviewers who compare their results and resolve discrepancies through discussion or referral to a third reviewer. Because there is limited potential for bias, the process of data extraction can be completed by one reviewer and checked for accuracy by another. Systematic reviews should report how many reviewers were involved in the process, whether the process was independent, and how discrepancies were resolved, thus enabling the reader to determine the potential for bias in the review process.

Systematic reviews in health psychology

Assessing the quality of systematic reviews

Systematic reviews top the hierarchy of evidence, reflecting the fact that, when conducted well, they provide the best estimate of intervention effect. However, caution must be taken before accepting the findings of any systematic review because, like other pieces of research, systematic reviews can be conducted poorly. Although there are different checklists of criteria to be used in the quality assessment of systematic reviews, all refer to the key components outlined above. Thus the quality of a systematic review can be assessed by asking a series of questions. Was the question well defined in terms of intervention, participants, condition, and outcomes? Was a comprehensive literature search undertaken? Was the methodological quality of included studies critically appraised? Is sufficient information provided about important characteristics of included studies? Was an appropriate method of synthesis employed? Were sources of heterogeneity investigated? Do conclusions accurately reflect the presented evidence? Was the review process free from bias? And so on. Answers to these questions will help to not only assess the quality of a systematic review, but also determine the extent to which a review, which authors may describe as systematic, actually employs systematic review methodology.

Some controversies and solutions

Although systematic reviews use explicit, reproducible methods, and are widely regarded as topping the hierarchy of evidence, some controversy surrounds their conduct. For example, systematic reviews have been criticised for relying too heavily on the use of RCTs, at the neglect of other study designs that may contribute to our understanding. RCTs are typically given preference in systematic reviews because they offer the best, or

least biased, evidence regarding the effects of an intervention. In a very clear demonstration of the superiority of the RCT, Deekes, DAmico, Sakarovitch and Altman (2000) cleverly constructed randomised and non-randomised comparisons from the same dataset, and concluded that non-randomised designs introduce serious and unpredictable biases that can lead to both over- and under-estimates of intervention effectiveness. Other study designs may offer insights, but the reliability of their results is clearly limited given their increased potential for bias. If RCTs exist there seems little utility in including trials of weaker design. This does not necessarily preclude the inclusion of other study designs, but reasons for doing so must be clearly explained and justified, and they should be treated separately in both the analysis and discussion. Another issue concerns the necessity and resultant implications of conducting a thorough literature search. Specifically, a recent study found that trials that are difficult to locate tend to be of lower methodological quality, which raises the possibility that rather than reducing bias through extensive literature searches, such searching may introduce bias into the review through the inclusion of methodologically weak trials (Egger, Juni, Bartlett, Holstein & Sterne 2003). Under these circumstances, it seems most appropriate to suggest that a comprehensive literature search should be undertaken but, after critical appraisal of included studies, greater emphasis should be given to studies of better quality in the synthesis, discussion and conclusions. Thus quality assessment and the examination of quality as a potential source of heterogeneity are especially important. Studies within health psychology are very often assessed as methodologically poor, regardless of the method used for critical appraisal. If one rejects the notion that health psychology researchers fail to 9

Christopher Bridle

produce methodologically rigorous research, then two explanations seem more or less plausible. It is true, for example, that intervention studies within health psychology present unique challenges in their design and conduct, yet this seems unlikely to account sufficiently for the poor quality of studies. A more plausible explanation is that poor methodological quality may be an artefact of poor or insufficient reporting, as opposed to poor conduct. As health psychology studies are increasingly being evaluated for the purpose of informing national and international health care decisions, it is important that this research is regarded and appraised as being reliable, e.g. of high methodological quality. Improving the quality of reporting will serve to enhance the perceived status of research within health psychology from the perspectives of national health care decision making bodies, such as the National Institute of Clinical Excellence, as well as independent assessors of health care interventions, such as the Centre for Reviews and Dissemination at the University of York. One way to address this issue is to engage in an active programme to develop reporting guidelines for studies in health psychology, similar to the Consolidation Standard for Reporting Trials (CONSORT) (Altman, Schultz & Moher, 2001). These guidelines highlight the need to routinely report specific aspects of methodology, such as method of randomisation, which is very rarely reported in the context of behavioural interventions. Such guidelines are necessary to facilitate increases in the assessed quality of health psychology intervention research, and will be useful for not only researchers involved in systematic reviewing, but also for editors of, and referees for, health psychology journals. Health psychology journals, or perhaps more accurately, journal editors, have not yet committed to the important move 10

towards systematising the review process. This is surprising, since in many other domains of health research guidelines for conducting reviews are well documented, and editors of journals actively encourage their submission. In contrast, health psychology journals fail to provide an agreed set of instructions to authors on the specific components of review articles they aim to publish. In this regard health psychology lags behind the related research communities in public health and biomedicine.

Conclusions
Systematic reviews are typically conducted to assess the effects of an intervention where uncertainty exists. By using explicit, reproducible methods to identify, evaluate and synthesise evidence, systematic reviews employ a scientific rather than subjective approach to summarising what is known on a particular topic. This method of research synthesis serves to minimise inaccuracies resulting from bias and thus provides more reliable evidence. For this reason systematic reviews are widely regarded as toping the hierarchy of evidence. Good quality systematic reviews are systematic in their attempts to identify all relevant studies, to individually assess the quality of included studies, to use appropriate methods of synthesis, and to draw conclusions that directly reflect the nature of the available evidence. Systematic reviews thus achieve two goals: they provide a methodological assessment of a particular field and, depending on the status of the former, the relative effectiveness of a specific intervention. Systematic reviews thus serve to focus and direct methodologically superior research and provide evidence-based answers to empirical questions. Health psychology would benefit from the use of systematic review methodology.

Systematic reviews in health psychology

References
Altman, D.G., Schultz, K.F. & Moher, D. (2001). The revised CONSORT statement for reporting randomised trials: Exploration and elaboration. Annals of Internal Medicine, 134, 663694. Bridle, C., Palmer, S., Bagnall, A.M., Duffy, S. & Riemsma, R. (In press). A rapid and systematic review of the clinical and cost effectiveness of newer drugs for treatment of mania associated with bipolar affective disorder. Health Technology Assessment. Bridle, C., OMeara, S., Wilson, P. and Kleijnen, J. (2002). Homeopathy. Effective Health Care, 7(2), 112. Bridle, C., OMeara, S., Wilson, P., Rogers, M. & Kleijnen, J. (2002). The prevention and treatment of childhood obesity. Effective Health Care, 7(6), 112. CRD Report 4. (2001). Undertaking Systematic Reviews of Research on Effectiveness: CRDs Guidelines for Carrying Out or Commissioning Reviews. (2nd ed.). http://www.york.ac.uk/inst/crd Deekes, J.J., DAmico, R., Sakarovitch, C. & Altman, D.G. (2000). How big are the biases associated with non-randomised designs used in evaluations of health care interventions? An empirical investigation. Third Oxford Symposium on Systematic Reviews. Institute of Health Sciences, University of Oxford. DiCenso, A., Guyatt, G., Willan, A. & Griffith, L. (2002). Interventions to reduce unintended pregnancies among adolescents: Systematic review of randomised controlled trials. British Medical Journal, 324, 14261435. Dickersin, K., Min, Y.I. & Meinert, C.L. (1992). Factors influencing publication of research results. Follow-up of applications submitted to two institutional review boards. Journal of the American Medical Association, 267, 374378. Dickersin, K., Scherer, R. & Lefebvre, C. (1994). Identifying relevant studies for

systematic reviews. British Medical Journal, 309, 12861291. Easterbrook, P.J., Berlin, J.A., Gopalan, R. & Matthews, D.R. (1991). Publication bias in clinical research. Lancet, 337, 867872. Egger, M., Ebrahim, S. & Davey-Smith, G. (2002). Where now for meta-analysis? International Journal of Epidemiology, 31, 15. Egger, M., Juni, P., Bartlett, C., Holstein, F. & Sterne, J. (2003). How important are comprehensive literature searches and the assessment of trial quality in systematic reviews? Empirical study. Health Technology Assessment, 7(1). Egger, M., Schneider, M. & Davey-Smith, G. (1998). Spurius precision? Metaanalysis of observational studies. British Medical Journal, 316, 140145. Hardeman, W., Johnston, M., Johnston, D.W., Bonetti, D., Wareham, N.J. & Kinmouth, A.LO. (2002). Applications of the theory of planned behaviour change interventions: A systematic review. Psychology and Health, 17(2), 123158. Pallonen, U.E., Velicer, W.F., Prochaska, J.O., Rossi, J.S., Bellis, J.M. & Tsoh, J.Y. (1998). Computer-based smoking cessation interventions in adolescents: Description, feasibility, and six-month follow-up findings. Substance Use and Misuse, 33, 935965. Riemsma, R.P., Pattenden, J., Bridle, C., Sowden, A.J., Mather, L., Watt, I.S. & Walker, A. (2002). A systematic review of the effectiveness of interventions based on a stages of change approach to promote individual behaviour change in health care settings. Health Technology Assessment, 6(24). Riemsma, R.P., Pattenden, J., Bridle, C., Sowden, A.J., Mather, L., Watt, I.S. & Walker, A. (2003). Systematic review of the effectiveness of stage based interventions to promote smoking cessation. British Medical Journal, 326, 11751182.

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Stern, J.M., and Simes, R.J. (1997). Publication bias: Evidence of delayed publication in a cohort study of clinical research projects. British Medical Journal, 315, 640645. Thompson, S.G. (1994). Systematic reviews: Why sources of heterogeneity in met-analysis should be investigated. British Medical Journal, 309, 13511355.

Correspondence
Dr Christopher Bridle School of Counselling and Health Psychology, University of the West of England, Bristol BS16 2JP UK. E-mail: Christopher.Bridle@uwe.ac.uk

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Individual Article

Putting pain to paper: A qualitative study of chronic pain patients experiences of using a two-week self-report pain diary
Katie Reid1, John Asbury1, Raymond MacDonald2 & Michael Serpell1
Academic Department of Anaesthesia, Gartnaval Hospital, Glasgow, 2Department of Psychology, Caledonian University, Glasgow.
Research aimed at examining the progression of chronic illness has promoted a rise in the use of self-report patient diaries. Diaries serve as a multifunctional tool from which to examine physical, mental and behavioural processes over time in the home context. Recent research by the first author sought to examine the sensory, cognitive and affective experience of chronic pain through the use of two-week patient diaries. This type of research necessitates a commitment from participants in terms of their time and willingness to reflect on their current chronic pain status. As part of the pilot stage of this study, qualitative feedback was drawn from a chronic pain sample concerning their views about the value of keeping such a diary. Participants gave feedback relevant to the design and content of the diary. In addition they provided information about their experiences of using the diary and the adopted functions that it served. approximately three months. The practice of measuring and assessing chronic pain has proven to be one of the hardest methodological tasks facing health professionals with an interest in this area. Single rating scales such as traditional intensity based self report measures remain prevalent in clinical practice and research but the limitations of their use are well documented (for full discussion, see Williams, Davies, & Chadury, 2000). The multidimensional nature of the pain experience and the need to reflect this in the methodological tools that we use has stimulated interest into less conventional methods for data collection and assessment. Monitoring change and stability in physical, mental and behavioural processes over time has opened up new possibilities for the progressive nature of health and illness to be examined (for a review, see Reid, Asbury, MacDonald & Serpell, 2003). The use of patient pain diaries is one method that has gained in popularity as a treatment aid and research tool (for recent examples see Peters et al., 2000; Jamison et al., 2002) Gathering clinical and or experiential self-report data in this repeated, time ordered fashion has maximised the opportunity for the temporal nature of health and illness to be addressed. In the context 13
1

Introduction
Chronic pain is a complex condition that can restrict the capability of the physical body and also threaten psychological well-being. The International Association for the Study of Pain (ISAP, 1994) defines chronic pain as pain that has persisted beyond normal tissue healing time following injury and disease. This is

Katie Reid, John Asbury, Raymond MacDonald & Michael Serpell

of chronic pain, the use of patient pain diaries has delivered much needed information about perceived pain, disability and psychological adaptation on a day-byday, week-by-week and in some cases month-by-month time scale. The time investment made by the participant and the opportunity for increased ownership in the data collection process characterises the keeping of a diary. Participants have been involved in daily monitoring of pain intensity, disability and medication for up to six months (McGorry, Webster, Snook & Hsiang, 2000). However, little research focus has been directed at examining participants own views about the perceived efficacy and personal benefits and costs of being asked to invest their time in such a way. This article highlights some of the descriptive, conceptual and experiential feedback that was generated through interviews with a sample of chronic pain patients who were asked to keep a twoweek record of their chronic pain. The participants were asked to comment on measurement features specific to this study. However, there were also efforts made to obtain more general feedback on the perceived utility, personal rewards and costs of committing to diary based research. This general feedback will provide the main focus for discussion in this article. Why participant feedback was sought 1. There is a lack of any formal research which has presented a qualitative account of participants attitudes towards the value of keeping a home based diary (either for personal use, part of treatment regime or for research purposes) 2. What does this feedback tell us about the implicit, experiential nature of keeping a pain diary? 3. Obtaining participant feedback can be used to ascertain the content validity of the measurement tool. Did the diary 14

cover aspects of the pain experience deemed relevant by the sufferers themselves? 4. Participant feedback can be used to inform changes to the design and content of the proceeding main diary study. Participants and setting The qualitative work presented here forms part of a small pilot study that was carried out with a sample of chronic pain sufferers attending an out-patients pain clinic at Gartnavel Hospital, Glasgow. The participants were all involved in the main pilot study in which they were asked to record the occurrence of their chronic pain on a number of variables over a 14-day period. A total of 26 patients agreed to participate in the pilot diary study. Upon completion of the pilot study 14 diaries were returned (two male, 12 female, mean age 48 years). This was a convenience sample and those who provided feedback varied in relation to the site of chronic pain (predominately back pain) and chronic pain history (63 per cent had endured their pain for over five years). Feedback concerning the use of the diary was obtained from 19 out of the 26 patients. Materials and procedure Overview of pain diary The pain diary was highly structured in design. A questionnaire layout was used to allow patients to give responses to a number of continuous pain variables over the allotted diary duration (once per day x 14 days). The pain variables that were recorded by the participants included sensory perceptions of intensity and cognitive perceptions of predictability/ controllability. The patients were also encouraged to note down how their pain had affected them for each day (how it made you feel, how it impacted on your day). This represented a chance for the

Putting pain to paper

patients to qualitatively report their pain outside the boundaries of the structured diary format. Evaluating the diary: Method of feedback Efforts were made to contact the participants roughly half-way through completion of the diary. By this time most of the participants had become familiar with the diary and were in a position to provide some feedback concerning its use. Feedback was gathered through the use of interviews guided by a semi-structured questionnaire schedule that explored the diary in terms of its practicality, validity and psychological benefit/cost (see Table 1). The preferred method used by the researcher to elicit responses was through telephone contact as this facilitated a rich set of answers. However, if no telephone contact was made then the interview schedule was used as a postal questionnaire or sent via e-mail. During the telephone interviews, the researcher kept a detailed written record of the responses provided by the participants. The accuracy of the written transcription was maintained by informing the participant to speak at a moderate pace, allowing the

researcher to keep up with a written account. The content of the transcribed account was verbally repeated back to the participant so they could ascertain the accuracy of the researchers written account. Following the completed telephone interview, the researcher engaged in reflexive note-taking activity where key issues relating to the interview context and content were highlighted. The interview schedule was not considered to be prescriptive and served as an aid to promote discussion in the first instance. If the participant raised other relevant issues then these were given equal priority and were explored during the interview and incorporated into the analysis. Feedback evaluations were provided by 19 out of 26 of the participants. Some attrition was evident when efforts were made to telephone the participants. A total of 15 telephone interviews were conducted, these interviews lasted between five and 30 minutes. The remaining evaluations were sought by post (N=3) and e-mail (N=1). Analysing the feedback responses The methodological principles of grounded theory were used to inform the analytical procedure (for full analytical method, see

Table 1: Semi-structured questionnaire used for feedback interviews. Interview Schedule for Diary Evaluation a. Q.1 Q.2 Q.3 b. Q.4 Q.5 c. Q.6 Ease of use Have you found diary easy to use? How long did it take you to fill in each night? Were there any questions in the diary that caused you problems? Representative of pain Were there any questions that you would have liked added to the diary? Do you think that this two-week diary accurately reflected the pain that you suffer (prompt: need for diary to be longer or shorter?). Psychological impact of keeping a daily diary Did filling in the diary affect you in any way (prompt: thoughts you had when completing the diary, negative thoughts/positive thoughts?).

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Katie Reid, John Asbury, Raymond MacDonald & Michael Serpell

Glaser & Strauss, 1967). An open coding procedure was followed where each transcript was read (and re-read) in order to identify and describe areas of meaning and possible markers to an implicit belief system. The reflexive notes taken by the research were also used to inform the coding procedure. Relevant passages, words or phrases that seemed to signify areas of practical and or conceptual significance were highlighted and given an open code. Through comparison across transcripts, some of the open codes were developed into higher order thematic categories. Results There were three core thematic categories in which the different forms of feedback could be considered. These broad themes were: 1. Diagnostic and personal characteristics of the diary respondent; 2. The adopted value of the pain diary; 3. The perceived psychological affect of keeping a pain diary.

1. Diagnostic and personal characteristics of the diary respondents

The chronic pain sample used in this study represented a heterogeneous population in terms of the site, source and temporal characteristics of the pain. These factors influenced the participants own perceived suitability as diary candidates. The participant below does not consider herself to be a good candidate for this type of research and discloses that she felt that she needed more pain to provide the researcher with more data. I have had a good fortnight, having only one day of bad pain, the previous fortnight was very different, four days of unbroken constant pain I was almost wishing I had a bad day for you. My pain is so peculiar a diary may not capture this. (012: Chronic facial pain) 16

However for some participants, having more pain or more importantly, multiple pains, was a source of confusion for them when it came to filling out the pain diary. At the pilot stage the diary did not include a question related to the existence of multiple pains. I have lots of pains in different places, so the diary is very full, quite complex (010: Lower back pain and multiple referred areas) Questions could be more specific on areas of back and where the pain spreads to. (025: Lower back pain and referred areas) These multiple pains, symptoms of fatigue and reduced activity were sometimes due to the presence of an additional health condition such as diabetes, asthma and MS. Participants reported that it is difficult to isolate one pain and say that it is caused by one factor. Both the participants who had these additional chronic illnesses subsequently withdrew from the study. As an MS sufferer I feel the diary is very difficult to fill in meaningfully while I suffer this. (013: Lower back pain and MS) I find that some days my diabetes and asthma can make me feel worse, its not all the pain, its not all to do with my back. (021: Lower back pain, diabetes and asthma) The distinction between acute pain and chronic pain was highlighted as an important consideration when accurately reporting pain. Evidence of critical incidents, where participants experienced acute pain following an everyday injury could artificially elevate the pain rating scores specific to the chronic pain that the participant experienced. I have recently fallen, you may want to include an any falls, knocks, bangs today option in the diary. (019: Lower back pain)

Putting pain to paper

2. The adopted value of the pain diary

The participants were informed, as per standard ethical instruction, that their involvement in this study may not be of direct benefit to themselves but could benefit others. However, many of the participants found that they could identify ways in which they had utilised the diary for their own gain. i Tool for gaining knowledge Some participants wrote of a desire to use the diary to try and demystify their pain in terms of exposing previously hidden triggers and possible patterns to their pain experience. This activity was not successful for all participants. It (the diary) may have helped me see a pattern to the headaches that I have been unable to see before, e.g. time of day and impact of physical activity. (017: Chronic headache pain) It was surprising as some days I realised that I didnt have pain where I had previously. (010: Lower back pain) I can see differences in what I do within a day that effects my pain, I wasnt aware of them before. (006: Neck & shoulder pain) I did try to use the information. I was writing to identify patterns, triggers but failed to find any I was not already aware of. (024: Lower back pain) ii Communication aid Describing pain to others is an intrinsically difficult activity. Participants were provided with a free space at the end of each days structured diary to note any thoughts, feelings or experiences that characterised their pain that day. Communicating their pain through unrestricted means was noted as an important design feature of the diary. The content of these qualitative entries provided rich data to include as part of the overall diary analysis.

I liked the idea of putting personal thoughts at the end of the diary. (015: Groin and leg pain) I liked the bit at the end, my chance to note anything the diary had missed. (006: Neck and shoulder pain) Disclosing pain was an important activity for some participants. For one participant, the method by which disclosure occurred was not of primary importance. Communicating the experience of pain through the inanimate pages of a diary allowed the participant to gain a sense of relief but also protected her family from the every day facts of her pain. The diary well. Its not someone but something to talk to. It is difficult trying to hide my pain from my family. (015: Groin and leg pain) One participant wrote that the diary could serve as a useful device to facilitate doctor-patient communication especially in circumstances where the relationship was perceived as strained. It (the diary) would have been an excellent thing to use at the beginning for initial consultation. It might have helped me get on correct treatment sooner. Some of the doctors seen at the pain clinic can be difficult to talk to and the diary could prove a helpful gobetween. (015: Groin and leg pain) iii Consolidating memory for pain Memory for pain has been shown to be vulnerable to error (for review see Erskine, Morley & Pearce, 1990). Participants seemed intrinsically aware that their memory may not be accurate. This admission led many participants to see the diary as a useful way to consolidate memory and monitor change without requiring retrospective recall. A diary like this would have been of great helpas one tends to forget or muddle days and extent of pain. (015: Groin and leg pain)

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Katie Reid, John Asbury, Raymond MacDonald & Michael Serpell

The pain diary did show that I had bad days and good days, pain ranging from a score of four to eight. (014: Left foot pain)

3. The perceived psychological affect of keeping a pain diary.

Those participants who found personal use for the diary either through knowledge gathering, communication and or memory consolidation maximised the opportunity for a greater sense of psychological affect than those who considered purely in terms of a research exercise. One participant who used the diary as a method for hidden disclosure found a sense of relief in its use. You try and hide it from your nearest and dearest, by writing it down its a real relief probably wasnt meant that way. (015: Groin and leg pain) The diary served as a useful way around the problems associated with reporting retrospective memory for pain. However for some, filling in the diary did facilitated a sense of negative reflection about how much life has changed since the emergence of the chronic pain. It (the diary) made me stop and look at my life my pain came about through something that shouldnt have happened. It showed me how much my life has changed. (026: Abdominal pain) The diary gives me an opportunity to reflect about whats been happening. (009: Abdominal pain) Most of the participants reported that using the pain diary exercise did increase their awareness about their pain. Of those participants who successfully filled in the diaries, few reported that this increased awareness led to increased distress. It (the diary) didnt upset me, but it did make me think more of the pain. (022: Abdominal pain) It (the diary) made me more aware of the pain, since I usually try to put it out of my mind. (024: Lower back pain) 18

The diary made me even more aware of the pain, also it was a useful, positive activity. (025: Lower back pain) It is important to note that the attrition rate was 46 per cent in this pilot. Twelve participants withdrew before the completion of the 14-day diary. Reasons for withdrawal were established for eight participants. These included the presence of secondary illnesses that confounded the experience of chronic pain, including acute injury (N=4), lack of time (N=3) and avoidance at focusing on pain (N=1). For some, the experience living with chronic pain was an all-consuming, fulltime burden. There was simply no time left to monitor its progression over two weeks. I am having to think about my pain and attend doctors every week. I dont want to think about it anymore. (003: Lower back pain)

Discussion
Embarking on research that utilises patient self-report diaries as a data collection tool is a demanding task for both researcher and participant. However, there is significant research value associated with this type of time ordered and context dependent data. This small piece of pilot research demonstrates that those who completed the pain diary found it a worthwhile activity. Important feedback was given concerning factors that the participants felt had limited their contribution to the diary study and increased the chance of withdrawal. Those participants with complex chronic health status such as those with impinging secondary illnesses and those with multiple pains found the pain diary entries difficult to document accurately. It is important to note that the researcher was equally interested in those participants who did not experience pain every day of the diary. However for one participant there was an inferred motivation to exhibit some pain in order to represent the previous month where her pain had come more frequently.

Putting pain to paper

The experiential feedback gained from the interviews illustrated that many of the participants had adopted their own use for the diary. The diary study signified more than just a data collection exercise for the participants. Participants reported that the diary could be used as a tool for gaining knowledge about their condition and also as a communication device to aid in self-reflection and promote doctorpatient relations. Many participants in the study reported that keeping the pain diary was not an emotionally neutral exercise. Some participants disclosed that logging the diary entries served as a reminder of how life had changed since developing their chronic pain. For others, the diary keeping promoted a sense of relief where there could be an unburdening of the pain experience within the pages of the diary instead of onto family members. Participants bring their own attitudes and beliefs to the research process. The participants in this sample had important comments to make regarding the design and utility of the pain diaries. In addition they reaffirmed the importance of acknowledging that the research process should not be assumed to be a neutral activity in which participants are engaged in. Researchers working in health care professions have an obligation to understand the affective impact that keeping a self-report diary can have on participants.

International Association for the Study of Pain (1994). Classification of Chronic Pain (2nd ed.) Merskey, H. & Bodguk, N. (Eds.). Seattle, W.A.: ISAP Press. Jamison, R.N., Gracely, R.H., Raymond, S.A., Levine, J.G., Marino, B., Herrmann, T.J. et al. (2002). Comparative study of electronic vs. paper VAS ratings: A randomised crossover trial using healthy volunteers. Pain, 99(12), 341347. McGorry, R.W., Webster, B.S., Snook, S.H. & Hsiang, S.M. (2000). The relation between pain intensity, disability, and the episodic nature of chronic and recurrent low back pain. Spine, 25(7), 834840. Peters, M.L., Sorbi, M.J., Kruise, D.A., Kerssens, J.J., Verhaak, P.F.M. & Bensing, J.M., (2000). Electronic diary assessment of pain, disability and psychological adaptation in patients differing in duration of pain. Pain, 84(23), 181192. Reid, K., Asbury, J., MacDonald, R. & Serpell, M. (2003). Dear Diary: Exploring the utility of diaries as a powerful and multi-functional research tool. Health Psychology Update, 12(2), 712. Williams AcdeC., Davies, H.T.O. & Chadury, Y. (2000). Simple pain rating scales hide complex idiosyncratic meanings. Pain, 85, 457463.

Correspondence References
Erskine, A., Morley, S. & Pearce, S. (1990). Memory for Pain: A Review. Pain, 41, 255265. Glaser, B.G. & Strauss, A. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago, IL: Aldine Publishing Co. Katie Reid Research Student Flat 6, 30 Shelley Court Gartnavel Hospital Complex Great Western Road Glasgow G12 0YN. Tel: 0141 531 3717 E-mail : gcl405@clinmed.gla.ac.uk

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Individual Article

Spousal caregiving in Huntingtons Disease: An issue for health psychology

Aimee Aubeeluck
University of Derby.

Overview
DISEASE (HD) is a rare dementia that is genetically inherited as an autosomal dominant trait with complete life-time penetrance. The majority of the HD literature focuses on the patient and those at-risk of inheriting the HD gene within the family, rather than the spousal carer who has been referred to as the forgotten person in the HD family (Kessler, 1993). Research into the experience of the HD spousal carer has established that carers experience a number of unique obstacles within their caregiving role. However, such research is both sparse and limited and there is a clear need to establish methodically the factors that impact upon the HD spousal carers situation and ultimately their quality of life. This article is aimed at giving an overview of HD and family caregiving in HD. The unique burden that is experienced by HD spousal carers will be discussed as will the role of heath psychology in addressing some of the factors that impact upon the lives of these carers. Finally, I will give a brief overview of my postgraduate research, which is aimed at systematically investigating the factors that enhance and compromise the lives of HD spousal carers by utilising the theoretical construct of quality of life (QoL). My exploratory studies have provided evidence that spousal carers of HD patients have specific difficulties in maintaining their QoL whilst continuing in a primary care-giving role. As such, they have prepared the way for the development of a disease-specific QoL

UNTINGTONS

measure for HD carers (HDQoL-C). The objective of the scale will be to quantify the caregiving experience in HD in order to implement and assess therapeutic interventions.

What is Huntingtons Disease?

HD is a chronic progressive disease of the brain that causes movement abnormalities (i.e. chorea and dystonia), cognitive deterioration and affective disturbances (Folstein, 1989). Symptoms begin on average between the ages of 3545 years and can vary widely from person to person. Patients become severely demented, motorially dilapidated, unable to care for themselves and eventually bedridden. There is no cure for HD, with the treatments available being purely palliative or purely experimental and death occurring on average 1517 years after onset (Harper, 1996). HD is a genetic condition inherited as an autosomal dominant trait with complete lifetime penetrance. Therefore, each person whose parent has HD is born with a 50:50 chance of inheriting the gene. The faulty gene is located on the short arm of Chromosome 4 (Gusella et al., 1983). This gene mutation consists of the expansion of a region in which there is a sequence of the 3 nucleotides cytosine, adenine and guanine (CAG) that normally repeats between 11 and 34 times. On HD chromosomes the region expands over 37 times. This expansion of the gene, which produces a protein called Huntingtin, damages the nerve cells in the basal ganglia and cerebral cortex (Aylward et al., 1997).

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Spousal caregiving in Huntingtons Disease

HD is often characterised by progressive involuntary choreiform (dance-like) movements. However, many patients manifest behavioural changes before the onset of the movement disorder. Early symptoms include lack of concentration combined with short-term memory lapses, depression and changes of mood that may lead to aggressive and/or anti-social behaviour as well as slight choreic movements, stumbling and clumsiness (Harper, 1996). Later on in the illness, earlier symptoms become exacerbated and patients often experience other symptoms such as constant involuntary movements, difficulty in speech and swallowing, severe weight loss, emotional changes resulting in a fixed mindset, frustration, mood swings and depression (Quarrell, 1999). Sufferers who experience cognitive changes that result in a loss of drive, initiative and organisational skills may have difficulty concentrating on more than one thing at a time making them appear lazy and uninterested (Martin, 1984). Sometimes these types of behavioural problems cause more difficulties for the sufferer and their carer than the physical deterioration itself as they come to terms with the sufferers change in personality, behaviour and character (Harper, 1996). In the later stages of HD full nursing care is required and secondary illnesses such as pneumonia are often the actual cause of death rather than the disease itself. Moreover, for every HD patient, it is reported that there are another 20 people, including those who are at risk, who suffer the consequences of HD (Hayden et al., 1980). This may be in relation to caregiving, genetic inheritance or the sheer burden that such a devastating disease places upon a family.

Family caregiving in HD
It is generally the immediate family that take on the responsibility of caring for an HD-affected individual. This is partly due to a societal climate that expects families

to shoulder much of the burden of relatives with dementing illnesses (Schooler & Keith, 1993). In addition, this is complicated by the vast range of symptoms (e.g. physical, neurological, psychiatric and genetic) which make HD sit uncomfortably within the structure of both hospital and community based services. Service provision for HD families is therefore often poor and unsuitable and families are mostly burdened with the main responsibility of care (Shakespeare & Anderson, 1993). HD family carers experience many of the issues that you would expect from reading the existing dementia related caregiving literature (e.g. Dura, HaywoodNiler & Kiecot-Glazer, 1990; Solomon & Draine, 1995). For example, Korer and Fitzsimmons (1985) found that the emotional and physical demands that a HD patient places upon their family can make caregiving difficult. Furthermore, lack of finances, often due to either the patient or carer having to give up their job means that there is not enough money to employ extra help to alleviate this situation. Semple (1995) found that HD family carers experience a wide range of emotions as a result of their caregiving role and this has a significant impact on their wellbeing. In addition, Maslach (1981) found the HD family carer role to be physically and mentally demanding with some carers finding their role to be exhausting, frustrating and a seemingly endless commitment. Hans and Koeppen (1980) further argue that HD permeates the entire life of the non-HD spouse (e.g. lifestyle, family responsibility, goals and marital relationships) and they experience continuous trauma. They found that once a diagnosis had been made the husband/wife was often called upon to help in the management of the patient in terms of supervision, moral support, nursing, handling of finances and total responsibility for the home and any children. However, although such issues can be related to caregiving in many types of 21

Aimee Aubeeluck

dementia, there are also a number of other salient factors which demonstrate that HD as a disease imposes a unique burden on family and especially spousal carers. The mood and behavioural changes associated with HD can drastically alter family, and especially spousal, relationships. Partners frequently describe the way in which they feel they have ended up married to a different person and maybe not the sort of person they would have chosen. Feelings of regret and anger are very common place and often marriages and other close relationships come under extreme pressure (Waltrowicz et al., 1996). The strain on members of the family is further intensified by the impact of the unique implications stemming from the inherited nature of the disease. Because of the genetic implications, HD repeats itself in successive generations and once a HD patient and their spouse have had children the impact on the family is permanent. Wexler (1979) found that spouses were sometimes unaware of the presence of HD in the family until after they had had children due to the sufferers sense of shame or fear of rejection on disclosure of the disease. Moreover, the availability of a predictive test to identify offspring who are at risk of developing the disease also brings its own problems in terms of the psychosocial impact it has on both the patient and their carer (Sobel & Brookes Cowan, 2000). Often those who are at risk or know they carry the gene are involved in the care of their parents or other members of their family, and are constantly reminded of the reality of HD. It is not uncommon for a person to nurse their parent, then an older sibling and finally succumb to HD themselves, whilst worrying all the time that they have transmitted the disease to their children. Aubeeluck and Buchanan (in preparation) found that HD spousal carers felt compromised in terms of neglected needs, sense of loss, loneliness, and a desire to 22

escape their caregiving role. Furthermore, these caregiving issues were found to be far more tenacious in HD due to the inherited nature of the illness coupled with the prolonged disease process. As such, family carers experienced a unique sense of chronic burden in their caregiving role. Hayden et al. (1980) further established that in HD, the non-HD spouse has unique concerns and needs in terms of chronic isolation. They found that the anti-social behaviour associated with HD might cause social embarrassment to the carer and rejection by friends. They also suggested that whilst the patient receives most of the attention, it is often the nonHD spouse who needs the most consideration in order to cope with his/her problems. Certainly it could be argued that within the literature, focus has been placed on affected individuals and those who are at risk rather than on the family carers (Folstein, 1989). However, issues surrounding HD and caregiving were highlighted by Davenport and Muncy as early as 1916 when they noted the psychosocial impact that HD has on both the patients and carers lives. However, the extant literature is very sparse with few prominent papers discussing the impact of HD on the family carer (e.g. Hans & Gilmore, 1968; Telscher & Davies, 1972, Hayden et al., 1980; Flicker, 1992; Semple, 1995). Williams et al. (2000) also make reference to the lack of available literature and relevant service provision for HD sufferers and their families and Kessler (1993) goes as far as to refer to HD carers as the forgotten persons in the HD family. To some extent, it is not surprising that there is relatively little psychological literature on HD and caregiving. HD is a rare disease with prevalence being 10 per 100,000 (Quarrell, 1999). Furthermore, due to the complexity of the disease symptomology, it is difficult to establish in which branch of psychology the disease lies.

Spousal caregiving in Huntingtons Disease

Why is spousal caregiving in HD an important issue for health psychology?

From a general perspective, the psychologists role in HD has traditionally been one of assessment, management, evaluation and research into the disease processes and the sufferer themselves rather than the carer. Numerous scales are used to assess the severity of symptoms (e.g. Stroop, 1935 and Wilson (in Nelson, 1976)) which can demonstrate very early changes in attention, ability to learn and so on, enabling diagnosis often prior to the onset of chorea. These are clearly useful in preparing control and experimental groups in research but, are of less practical value to the sufferer themselves and their family. Therefore, HD affected families may experience a lack of expertise and specialism from health professionals on practical aspects such as therapeutic interventions, advice on genetic counselling or continuity of care. As with many diseases where there is no cure, focus is quite rightly and obviously placed upon finding a successful treatment. Since the discovery of the Huntintin gene (Gusella et al., 1983) patient care has changed quite dramatically in terms of both searching for a cure and developing more appropriate and specialised care facilities. However, carer issues still appear to be the same with current literature highlighting problems that were raised in the 1920s. It is, therefore, clearly important to put resources into establishing ways of alleviating the carer burden in HD by successfully addressing carers needs. With the general remit of health psychology being to promote and maintain well-being via the application of psychological models and theories, the issue of caregiving in HD is undoubtedly an area in which the health psychologist can have an impact. For example, through the practical application of theory such as

designing self-care programs, using therapeutic interventions or by advocating carers views on service quality. However, with health care purchasers increasingly being expected to allocate resources on the basis of the evidence of the effectiveness of health care interventions, lack of systematic research poses a huge problem. Therefore, one of the most pressing issues is the generation of quality research with which to test theories and interventions for HD family caregivers.

How does my research fit in?

My postgraduate research, which is supervised by Dr. Heather Buchanan at the University of Derby, is aimed at establishing the factors that enhance and compromise the lives of HD caregivers by utilising the theoretical construct of quality of life (QoL). Since the 1960s, QoL has been emerging as a useful outcome measure by which to judge the efficacy of psychological interventions (Rapley, 2003). Previous to this, health outcome indicators traditionally included information on avoidable mortality, survival rates, symptom relief, pain and physical and biomedical markers of recovery. However, using QoL as a measure of outcome focuses on the impact of a condition or situation on the individuals emotional and physical functioning and lifestyle. Therefore, QoL indicators can help to answer the question of whether an intervention leads to an increase in wellbeing by providing a more client-led baseline against which the effects of the intervention can be evaluated (Bowling, 2001). With this in mind, my long-term aim is to develop a disease-specific measure that will bring together theoretical constructs and practical application to produce a user-friendly QoL measurement for HD family carers that could be used to implement and assess therapeutic interventions. As has already been noted, there is a lack of psychological literature on the 23

Aimee Aubeeluck

subject of caregiving in HD plus, there is no adequate QoL scale available for use with HD carers due to the unique and disease-specific difficulties they encounter. Therefore, my starting point was to examine the construct of QoL with HD family carers and health care professionals working in the field to investigate whether the construct itself was meaningful and relevant to the HD family carer. As such, opinions on the domains and facets of a well documented and validated multidimensional QoL scale (ComQoL, Cummins, 1997) were investigated for their relevance to the QoL of family carers of HD patients. QoL domains and facets were rated by 20 primary (family) carers and 20 health care professionals using a likert scale. Participants were also asked to make comments in relation to the questionnaire and write down what they felt were the main issues surrounding the QoL of HD family carers and if indeed QoL was a meaningful concept to them. The main findings from this initial exploration established that HD family carers felt that QoL was an important construct to examine in relation to their experiences, but that issues that may be important to the QoL of the general population are not always an issue for carers. Objective indicators such as the amount of personal possessions someone has or having unpaid positions of responsibility were considered mostly irrelevant to HD carers QoL. Furthermore, subjective measures such as whether people outside the family home asked for their help and advice or how satisfied they are with the things they own, were also not deemed important. Highly relevant QoL items included questions such as how often do you sleep well and If you are feeling sad and depressed, how often does someone show they care for you? The health care professionals in the study mostly agreed with the carers that the same issues were relevant/irrelevant in terms of the QoL of 24

the HD family carer. However, carers were found to place a larger focus on their own health than the health care professionals. Carers felt that they needed to keep strong and healthy in order to continue to provide long term care to their affected loved ones. In contrast to this, health care professionals saw a time of illness for the carer as the opportunity for them to take a justified break. Both carers and health care professionals also raised a number of issues in relation to the genetic aspects of HD, professional support systems, advocacy and an overwhelming sense of burden in relation to the caregiving role. With my preliminary investigation confirming that QoL as a concept is relevant to HD family carers, I decided to continue to pursue the area from an exploratory perspective in order to get a more detailed picture of the issues surrounding QoL and caregiving in HD. I therefore decided to utilise a novel approach to research by using a method called Photovoice. Photovoice has traditionally been a process by which people can identify, represent and enhance a specific community through photography (Wang, 1999). However for my research it was used purely in terms of identifying the issues surrounding caregiving in HD. Five HD family carers were provided with disposable cameras and asked to photograph and describe elements of their life in which they felt their QoL was either enhanced or compromised. One-hundredand-nine photographs were generated through this process and using content analysis, were classified into nine themes representing differing aspects of the carer experience in relation to QoL. The themes that emerged were: Care and security; Small pleasures; Loneliness; Escape; Sense of loss, Neglected needs, Support, Lack of time and Daily Hassles. For each photograph, the carer also wrote a sentence or two about why they had taken the picture and what it meant to them,

Spousal caregiving in Huntingtons Disease

allowing for tentative latent inferences to be made with regards to each photo and ultimately each theme. From this exploratory investigation, it was established that caring for a family member with HD seemed to impose a unique and difficult burden on the carers life. Although some positive elements emerged, these appeared to be minimal (i.e. small pleasures like having a cigarette or having flowers in the house) when compared to the negative impact that HD has on their lives. We found these informal carers often experienced loneliness, a need to escape and a unique sense of loss while trying to adequately care for their loved ones and maintain some form of QoL for themselves. Such issues are unique for HD spousal carers as there is seemingly no end to their caregiving role. Spouses will often care for generations of their loved ones; caring for their partner, then their children and maybe even grandchildren. As such, each issue appears to be magnified and places a heavy burden upon the carer. The issues raised in the initial study and the themes from the photovoice analysis were then taken to a larger group of HD family and spousal carers for discussion. Six focus groups were conducted to further examine the relevance of QoL especially in terms of the existing domains and facets in the COMQoL-A5 and also additional domains and facets that could be generated from the newly identified issues and themes. The focus groups allowed carers to talk about their experience of living with HD, and engaged them in concept clarification and in proposing items that could be included in a disease-specific questionnaire. The focus groups were also used to clarify participants comprehension of terminology and concepts developed during the preliminary investigations. Through this process, many general issues relating to QoL were identified and confirmed such as lack of time, difficulty

managing finances and stress. However, disease-specific aspects of QoL were also evident such as, lack of specialist support, genetic issues (e.g. survivor guilt) chronic isolation and chronic burden.

Conclusions
The multi-faceted nature of HD, and the subsequent repercussions on the family, make this under-researched area a challenging and compelling one to study. My exploratory investigations have provided further evidence of the impact that HD has on family carers. Moreover, that spousal carers of HD patients have specific difficulties in maintaining their QoL whilst continuing in a primary caregiving role. As such, they have prepared the way for the development of a diseasespecific QoL measure for HD carers (HDQoL-C). This scale is now in the final stages of development and is due to be piloted later on in the year. The objective of the scale will be to quantify the caregiving experience in HD in order to set the most beneficial and cost effective support in place via a self-report questionnaire for primary carers of HD patients. This will continue to be important as carers play such a vital role in the HD support system in both emotional and practical terms.

References
Aylward, E.H., Li Q., Stine, O.C., Ranen, N., Sherr, M., Barta, P.E., Bylsma, F.W., Pearlson, G.D. & Ross, C.A. (1997). Longitudinal change in basal ganglia volume in patients with Huntingtons disease. Neurology 48, 394399 Bowling, A. (2001). Measuring disease. Buckingham: Open University Press. Cummins, R.A. (1997). The Comprehensive Quality of Life Scale (CoMQoL-A5) Manual. Toorak, Deakin University. Dura, J.R., Haywood-Niler, E. & KiecoltGlazer, J.K. (1990). Spousal caregivers of persons with Alzheimers and 25

Aimee Aubeeluck

Parkinsons disease dementia: A preliminary comparison. The Gerontologist, 30, 332336. Flicker, L. 1992 . The effects of caregiving for the demented elderly. Australian Journal on Ageing, 11, 915. Folstein, S.E. (1989). Huntingtons Disease: A disorder of families. London: John Hopkins, University Press. Gusella, J.F., Wexler, N.S., Conneally, P.M. et al. (1983). A polymorphic DNA marker genetically linked to Huntingtons Disease. Nature, 306, 234238. Hans, M.B. & Gilmore, T.H. (1968). Social aspects of Huntingtons Chorea. British Journal of Psychiatry, 114, 9398. Hans, M.B. & Koeppen, A.H. (1980). Huntingtons Chorea: Its impact on the spouse. Journal of Nervous and Mental Disorders, 168, 209214. Harper, P.S. (1996). Major problems in neurology: Huntingtons Disease. London: W.B. Saunders Company Ltd. Hayden, M.R., Ehrlich, R., Parker, H. & Ferera, S.J. (1980). Social perspectives in Huntingtons Chorea. South African Medical Journal, 58, 201203 Kessler, S. (1993). Forgotten persons in the Huntington Disease family. American Journal of Medical Genetics, 48, 145150. Korer, J. & Fitzsimmons, J.S. (1985). The effect of Huntingtons Chorea on family life. British Journal of Social Work, 15, 581597. Martin, J.B. (1984). Huntingtons Disease: New approaches to an old problem. Neurology, 34, 10591072. Maslach, C. (1981). Burnout: The cost of caring. New York: Prentice Hall Nelson, H. (1976). A modified card sorting test sensitive of frontal lobe defects. Cortex, 12, 313324. Quarrell, O. (1999). Huntingtons Disease: The facts. New York: Oxford University Press. 26

Rapley, M. (2003). Quality of life research: A critical introduction. London: Sage. Schooler, N.R. & Keith, S.J. (1993). The clinical research base for the treatment of schzophrenia. Psychopharmacology Bulletin, 29, 431446. Semple, O.D. (1995). The experiences of family members of persons with Huntingtons Disease. Perspectives, 19, 410. Shakespeare, J. & Anderson, J. (1993). Huntingtons Disease falling through the net. Health Trends (England), 25(1), 1923. Sobel, S.K. & Brookes Cowan, D. (2000). Impact of genetic testing for Huntingtons Disease on the family system. American Journal of Medical Genetics, 90, 4959. Solomon, P. & Draine, J. (1995). Subjective burden among family members of mentally ill adults: Relation to stress, adaptation and coping. American Journal of Orthopsychiatry, 65(3), 419427. Stroop, J. (1935). Studies of interference in serial verbal reactions. Journal of Experimental Psychology, 18, 624643. Telscher, B. & Davies, B. (1972). Medical and social problems of Huntingtons Disease. Medical Journal of Australia, 1, 307311. Wang, C.C. (1999). Photovioce: A participatory action research strategy applied to womens health. Journal of Womens Health, 8, 185192. Waltrowilcz, W., Ames, D., McKenzie, S. & Flicker, L. (1996). Burden and stress on relatives informal carers of dementia sufferers in psychogeriatric nursing homes. Australian Journal on Ageing, 15, 115118. Wexler, N.S. (1979). Genetic Russian Roulette. The experience of being at risk for Huntingtons Disease. In S. Kesler (Ed.), Genetic counselling: Psychological dimensions (pp.199220). New York: Academic Press.

Spousal caregiving in Huntingtons Disease

Williams, J.K., Schutte, D.L., Holkup, P.A., Evers, C. & Muilenburg, A. (2000). Psychosocial Impact of Predictive Testing for Huntingtons Disease on Support Persons. American Journal of Medical Genetics (Neuropsychiatric Genetics), 96, 353359.

Correspondence
Aimee Aubeeluck Centre for Psychological Research in Health and Cognition, School of Education, Health and Science, University of Derby, Western Road, Mickleover DE3 9GX. E-mail: a.aubeeluck@derby.ac.uk

27

Individual Article

What can multidimensional scaling and facet theory offer health psychology?
Simon R. Cooper1 & Ian Donald2
1

Liverpool John Moores University & 2University of Liverpool.

Introduction
health psychology is that health-related behaviours can be predicted and ultimately understood. Social cognitive models such as the theory of planned behaviour (TPB; Ajzen, 1991) have done much to advance this understanding. The TPB proposes that health behaviours are determined by intentions. In turn, intentions are underpinned by attitudes, subjective norms, and perceived behavioural control (PBC), which are themselves a function of behavioural, normative and control beliefs. While the predictive validity of the model is well documented (see, for example, Godin & Kok, 1996, for a meta-analysis), less research has examined the convergent and discriminant validity of the models components. This is an important oversight and gap in the research since the distinction between attitude, subjective norm and PBC occupies a central role in the model. If this distinction is shown to be invalid, then the form of the model would have to be questioned. This paper describes research in progress concerned with the structure of the TPB. Using a facet design and analytic approach (see Borg & Shye, 1995), the research explores the convergent and discriminant validity of the models components and aims to provide a theory-driven rationale for extending the model.

Structural representations of the TPB

ASSUMPTION OF

CENTRAL

The majority of research examining the structure of the TPB has used one form or another of factor analysis (e.g. principal components, principal axis). The procedure has been used to examine whether one component of the model can be distinguished from another (e.g. Trafimow & Duran, 1998), or from additional constructs (e.g. Sheeran & Orbell, 1999). Typically, this research supports the independence of the different measures. At the same time, however, little information is provided about the overall structure of the model. Model estimation procedures such as path analysis or structural equation modelling have yielded some information about the structure of the TPB (van den Putte & Hoogstraten, 1997). However, as a test of the model they remain incomplete since the presumed determinants of the constructs tend not to be assessed (Vallerand, Deshaies, Cuerrier, Pelletier & Mongeau, 1992). While structural equation modelling is generally preferred to path analysis, the procedure is also open to criticism. As de Leeuw (1991) notes, the stability of the resulting solutions will be doubtful and the usefulness of the detailed aspects of the fitted model even more so (p.243). The extent to which these procedures have clarified the structure of the TPB has also been questioned (van den Putte & Hoogstraten, 1997). Employing alternative analytical procedures may, therefore, yield new insights into the structure of the model. Multidimensional scaling (MDS) is one

28

What can multidimensional scaling and facet theory

approach with considerable potential that can be employed with this aim in mind.

Multidimensional scaling (MDS)

All MDS procedures have essentially the same purpose. This is to represent relationships in a dataset as points in space with the aim of making aspects of the data that may be obscured in the original matrix more apparent. One of the most frequently used and productive forms of MDS is the non-metric model, often referred to as smallest space analysis (SSA-I; Lingoes, 1973).1 MDS has several potential advantages over factor analysis. It does not assume that the data are distributed as multivariate normal or that the relationships are linear. This is important, as there is a growing number of studies which suggest that many aspects of peoples experience cannot be adequately portrayed using linear dimensions (e.g. Donald & Cooper, 2001; Maraun, 1997). Moreover, MDS can fit or model a domain within a smaller number of dimensions than other procedures. It is, therefore, capable of more parsimonious modelling. A further reason why MDS is useful is in its ability to uncover topological similarities across diverse kinds of material. That is, by deriving its output from the rank rather than the magnitude of correlation coefficients, the procedure tends to yield similar spaces even with different correlation matrices or variation in variable samples. Thus, employing MDS is more likely to yield a general structural model of the TPB rather than behaviour or population specific ones.

this, including preference analysis, property fitting and canonical regression. This variety of interpretation methods underlines a potential difficulty with MDS, which is that unless relatively simple configurations of points are evident, interpretation of the resultant plots can be problematic and little more than exploratory. The method used here, which has resulted in the discovery of structural laws in a variety of domains, is to interpret plots according to principles derived from Facet Theory (see Borg & Shye, 1995). The method, known as regional partitioning, involves introducing boundary curves on the plot to form regions. The distinction between any number of constructs is, therefore, empirically validated if separate regions on the plot exist for them. The advantage of using Facet Theory in conjunction with MDS and regional interpretation is that facet theory requires the a priori specification of the components of the domain, their content and the classification of each variable or item in relation to the components or facets. At the most basic level the use of Facet Theory clearly guides the interpretation of MDS output. The approach does have a number of other advantages that go beyond the scope of the present discussion (Donald, 1995). In relation to the TPB, support for the convergent and discriminant validity of intention, attitude, subjective norm and PBC, and hence the structural form of the model, would be obtained if the regions of the MDS corresponded to the components of the model.

Interpreting MDS spaces

A major challenge in using MDS is how the resulting plots can be interpreted. A number of methods exist to assist in
1

SSA-I of the TPB: An example using cannabis and ecstasy use

In a recent study, SSA-Is were performed on the TPB measures in relation to cannabis and ecstasy use. The structural

SSA-I rank orders association coefficients between pairs of variables and represents the items as points in a co-ordinate free n-dimensional Euclidean space, such that the rank of the distances between the points is the inverse of the rank of the inter-item association coefficients. Thus, the closer two points are in the space, the higher their positive association or greater their similarity.

29

Simon R. Cooper & Ian Donald

models that emerged were highly consistent with the theoretical structure of the TPB (see Ajzen, 1991, p.182). For each behaviour, the model could be summarised by a radex-like structure, which showed the relations between intention, its proximal and distal determinants. Intention was central to the structure, as befits its status as the dependent variable in the model, the direct measures were close to the origin, and the belief-based measures were in the periphery of the space. Regardless of measurement format, attitude, subjective norm, and PBC were qualitatively differentiated. Moreover, it was also the case that measures of attitude, subjective norm and PBC were more strongly related to their antecedent beliefs than to other beliefs. The partitioning, therefore, provided clear evidence for the convergent and discriminant and validity of the TPBs components.

An idealised representation of this structure, known as a cylindrex, is presented in Figure 1. The structure indicates that while beliefs, attitudes and intentions to use cannabis are independent of beliefs, attitudes and intentions to use ecstasy, the relationships between the components are consistent. In other words, the constructs are not seen as isolated variables as indicated by some analytic procedures but form an organised system that operates at two levels.

Directions for future research

In an often-cited quotation, Ajzen (1991, p.199) indicated that further variables could be added to the model providing they contribute additional variance in intention after controlling for the theorys components. Given the parsimony of the TPB, it is perhaps unsurprising that a variety of variables predict intention and/or behaviour

Figure 1: Structural representation of the TPB.

30

What can multidimensional scaling and facet theory

over and above the effects of attitude, subjective norm and PBC (see Conner & Armitage, 1998, for a review). Even allowing for the non-trivial effects observed in some studies, the amount of variance engendered by additional variables provides only one criterion for their inclusion in the model. Frequently, however, it has been treated as the sole criterion. Using the approach advocated here, future research concerning the interrelationships of additional variables to the existing components of the TPB would be desirable in order to identify the key factors impacting on health behaviours. This process would be facilitated by the powerful combination of MDS and facet theory.

References
Ajzen, I. (1991). The theory of planned behaviour. Organizational Behaviour and Human Decision Processes, 50, 179211. Borg, I. & Shye, S. (1995). Facet theory: Form and content. London: Sage. Conner, M. & Armitage, C.J. (1998). Extending the theory of planned behaviour: A review and avenues for future research. Journal of Applied Social Psychology, 28, 14291464. de Leeuw, J. (1991). Data modelling and theory construction. In J.J. Hox & J. DeJong-Gierveld (Eds.), Operationalisation and research strategy (pp.229246). Amsterdam: Swets & Zeitlinger. Donald, I. (1995). Facet theory: Defining research domains. In G.M. Breakwell, S. Hammond & C. Fife-Schaw (Eds.), Research methods in psychology (1st ed.) (pp.116137). London: Sage. Donald, I. & Cooper, S.R. (2001). A facet approach to extending the normative component of the theory of reasoned action. British Journal of Social Psychology, 40, 599621.

Godin, G. & Kok, G. (1996). The theory of planned behaviour: A review of its applications to health-related behaviours. American Journal of Health Promotion, 11, 8798. Lingoes, J.C. (1973). The GuttmanLingoes Non-metric Program Series. Ann Arbor, MI: Mathesis. Maraun, M.D. (1997). Appearance and reality: Is the big five the structure of trait descriptors? Personality and Individual Differences, 22, 629647. Sheeran, P. & Orbell, S. (1999). Augmenting the theory of planned behaviour: Roles for anticipated regret and descriptive norms. Journal of Applied Social Psychology, 29, 21072142. Trafimow, D. & Duran, A. (1998). Some tests of the distinction between attitude and perceived behavioural control. British Journal of Social Psychology, 37, 114. Vallerand, R.J., Deshaies, P., Cuerrier, J.P., Pelletier, L.G. & Mongeau, C. (1992). Ajzen and Fishbeins theory of reasoned action as applied to moral behaviour: A confirmatory analysis. Journal of Personality and Social Psychology, 62, 98109. van den Putte, B. & Hoogstraten, J. (1997). Applying structural equation modelling in the context of the theory of reasoned action: Some problems and solutions. Structural Equation Modelling, 4, 320337.

Correspondence
Simon Cooper School of Psychology, Liverpool John Moores University, Henry Cotton Campus, 1521 Webster Street, Liverpool L3 2ET. Tel: 0151 231 4150 E-mail: s.r.cooper@livjm.ac.uk

31

Individual Article

Dental anxiety and oral health promotion

Sara Cox, Katie Clarke & Tom Cox
Insitute of Work, Health & Organisations, University of Nottingham.

Background
much research into the effective management of dental care and of related oral health promotion. A concern in itself, the failure to maintain good oral health has been linked to other health problems. The presence of gum disease, for example, has been linked to the occurrence of heart disease (Jansson, Lavstedt & Frithiof, 2002), while on the positive side, the conduct of regular dental check-ups has been linked to the early detection of cancers of the mouth (Hagglin, Hakeberg, Ahlqwist, Sullivan & Berggren, 2000). It is clear from the available research that many people hold negative attitudes to dental treatment, and, as a result, delay or avoid such treatment (Stouthard & Hoogstraten, 1990). Dental anxiety is a particular challenge (e.g. Rao, Sequeire & Peter, 1997; Gordon, Dionne & Snyder, 1998; Kaakko et al., 1998; Locker, Thomson & Poulton, 2001). So far, most attempts at changing attitudes to treatment and in promoting oral health have had limited success (Brown, 1994) and it is widely recognised that a deeper understanding of dental anxiety is important for the management of dental care and for oral health promotion (Freeman, 1999).

HERE HAS BEEN

Dental anxiety
Dental anxiety has been defined as feelings of fear, tension and panic related to the anticipation of or exposure to dental treatment taken in its broadest possible meaning and context (Freeman, 1999). Many existing studies have focused on the prevalence of dental anxiety and on rela32

tionships among such anxiety, patients previous attendance for treatment and their behaviour during treatment including their interactions with the dentist (Peretz, Katz & Eldad, 1999; Milgrom, Mancel, King & Weinstein, 1995). What the literature does not do convincingly is address the question of how such fear arises and why it persists. Research by the authors has addressed these two issues. The authors research has contributed to the description of the nature, sources and effects of dental anxiety in young adults and explored the possibility of age and sex differences in the expression of such anxiety. It has also discussed the role of dentist-patient interactions and learned behaviour focussing on the role of the young persons mother in the aetiology of their anxiety. The authors data is consistent with and offers an integration of much of what has gone before. It described dental anxiety as an experience in terms of heightened report of stress and of arousal (using the stress arousal checklist: Cox & Mackay, 1985) and identified particular sources of anxiety in a number of dental procedures such as drilling, injections and in anticipation of pain. The authors argued, on the basis of their qualitative data, that dental anxiety was often communicated to the young people by their mothers and then reinforced by their interactions with their dentists. Ten per cent of the sample said that the dentists manner made them feel fearful. The interview data suggested that the negative aspects of the dentists

Dental anxiety and oral health promotion

manner focused on a failure to communicate with and involve the patient in their treatment. There was a tendency to treat patients as if they were not there or not important. Seventy-two per cent of all patients reported that they went to the dentist because they know that they ought to go regularly, and only 17 per cent reported attending because of problems with their teeth. However in the anxious group, the figures showed a markedly different profile: 60 per cent and 31.6 per cent respectively. The interview data also suggested that young people had been influenced by a developmental environment in which they had been exposed to their mothers fears of dental treatment and by the overt manifestations of those fears. This is consistent with the findings of both Klingberg, Berggren, Carlsson and Noren (1995) and Astrom and Jakobsen (1996). Astrom and Jakobsen (1996) argued that parents function as strong social models for the development of several different aspects of dental behaviour. In the same vein, others report that parental rationalisations for scheduling childrens dental appointments are influenced by their own visits to the dentist particularly when those visits were symptom-driven rather than routine check-ups (Thomson, Stewart, Carter & Spencer, 1996).

Towards a model of dental anxiety

These data, and similar data in the scientific literature, have been used by the authors to suggest a working model of dental anxiety that might be usefully applied in the promotion of oral health. The model suggests that dental anxiety is a learnt behaviour maintained by partial reinforcement deriving from negative interactions with dentists. The learning process is essentially social in nature and the origin of the learning is to be found in the young persons exposure to their mothers anxieties and rationalisations about oral health and dental treat-

ment. The anticipation and experience of pain is particularly important in this respect. Anxiety in the young person may be detected by the dentist. In turn, they may experience heightened anxiety over the prospect of treating an anxious patient. A positive feedback loop may thus be established in which the unsatisfactory experience of the treatment situation reinforces negative attitudes in both patient and dentist. Such a model is not new in essence but the authors research has added useful detail. The model allows a number of suggestions as to future research and oral health promotion. Two examples are presented here. First, in terms of research, there should be a significant correlation between the experiences of anxiety by dentist and patient, and either should predict the future experience and behaviour of the other party in the treatment situation. Equally, maternal anxiety should predict dental anxiety in young people, and the mothers awareness of and sensitivity to pain should correlate with both. Second, oral health promotion should target mothers (and young women as potential mothers) and attempt to confront their anxiety and fears of dental treatment either directly or by managing their fear of pain. The evaluation of such oral health promotion should not only be cast in terms of the immediate effects on those mothers and young women but also in terms of the level of dental anxiety of their off-spring. A longitudinal study of some magnitude is indicated.

Conclusions
Although there is much research on dental health care and oral health promotion, insufficient is known about dental anxiety. However, a working model can be suggested and should be exploited in terms of research and oral health promotion.

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Sara Cox, Katie Clarke & Tom Cox

References
Astrom, A.N. & Jakobsen, R. (1996). The effects of parental dental-health behaviour on that of their adolescent offspring. Acta Odontologica Scandinavica, 54, 235241. Brown, L.F. (1994). Research in dental health education and health promotion: A review of the literature. Health Education Quarterly, 121, 83102. Cox, T & Mackay, C.J. (1985). The measurement of self-reported stress and arousal. British Journal of Psychology, 76, 183186. Freeman, R. (1999). Barriers to accessing dental care: Patient factors. British Dental Journal, 187, 141144. Gordon, S., Dionne, R. & Snyder, J. (1998). Dental fear and anxiety as a barrier to accessing oral health care among patients with special health care needs. Special Care in Dentistry, 18, 8892. Hagglin, C., Hakeberg, M., Ahlqwist, M., Sullivan, M. & Berggren, U. (2000). Factors associated with dental anxiety and attendance in middle-aged and elderly women. Community Dentistry and Oral Epidemiology, 28, 451460. Jansson, L., Lavstedt, S. & Frithiof, L. (2002). Relationship between oral health and mortality rate. Journal of Clinical Periodontology, 29, 10291034. Kaakko, T., Milgrom, P., Coldwell, S.E., Getz, T., Weinstein, P. & Ramsay, D.S. (1998). Dental fear among university employees: implications for dental education. Journal of Dental Education, 62, 415420. Klingberg, G., Berggren, U., Carlsson, S.G. & Noren, J.G. (1995). Child dental fear: Cause-related factors and clinical effects. European Journal of Oral Sciences, 103, 405412.

Locker, D., Thomson, W.M. & Poulton, R. (2001). Psychological disorder, conditioning experiences and the onset of dental anxiety in early adulthood. Journal of Dental Research, 80, 15881592. Milgrom, P., Mancel, L., King, B. & Weinstein, P. (1995). Origins of childhood dental fear. Behaviour Research and Therapy, 33, 313319. Peretz, B., Katz, J. & Eldad, A. (1999). Behaviour of big and small communities dental phobic residents. Journal of the Brazilian Dental Association, 10, 2328. Rao, A., Sequeire, P.S. & Peter, S. (1997). Characteristics of dental fear amongst dental and medical students. Indian Journal of Dental Research, 8, 111114. Stouthard, M. & Hoogstraten, J. (1990). Prevalence of dental anxiety in the Netherlands. Community Dentistry and Oral Epidemiology, 18, 139142. Thomson, W.M., Stewart, J. F., Carter, K.D. & Spencer, A.J. (1996). Dental anxiety among Australians. International Dental Journal, 46, 320324.

Correspondence
Dr Sara Cox Institute of Work, Health & Organisations, University of Nottingham, William Lee Building 8, Nottingham Science & Technology Park, University Boulevard, Nottingham NG7 2RQ. E-mail: sara.cox@nottingham.ac.uk

34

Individual Article

Testing implementation intentions in the field: Is non-intentional non-adherence really a problem?

Cath Jackson, Rebecca Lawton & Mark Conner
University of Leeds.

TO NON-ADHERENCE prescribed medication continues to be a significant issue (Royal Pharmaceutical Society of Great Britain [RPSGB], 1997). Research suggests that patients take, on average, only 50 per cent of drugs prescribed and this level of nonadherence is evident regardless of disease, symptom, regimen and age group (Schaffer & Yoon, 2001). Clearly large numbers of patients are taking less medication than necessary for effective results. Moreover, the costs associated with non-adherence, apart from prolongation of suffering, include additional prescriptions, further visits to the doctor, absence from work and even unnecessary hospitalisation (RPSGB, 1997). The aim of this research was to test the efficacy of implementation intentions (Gollwitzer, 1993) to promote adherence to medication prescribed for coronary heart disease (CHD) (Study 1) and adherence to antibiotics (Study 2). Implementation intentions specify exactly when and where a behaviour will be performed (e.g. I will take my tablet before I brush my teeth before bed, in the bathroom). As such, implementation intentions address the problem of non-intentional non-adherence, rather than intentional non-adherence.

ATIENTS

Study 1: Promoting adherence to medication for CHD

Taking CHD medication is important because CHD is one of the biggest killers in the UK and the treatments are undoubtedly beneficial (Department of

Health [DOH], 2000a). Forty participants were recruited to a pilot study. All participants were attending secondary prevention CHD clinics in general practice and were taking at least one medication for CHD. They were randomly assigned to a control group or an intervention group. For the purposes of the study participants were asked to report on their most recently prescribed medication. Selfreported adherence was measured at recruitment and over the telephone at 7, 28 and 90 days follow-up. We used two measures: the Medicine Adherence Report Scale (MARS5, Horne, personal communication) and two open-ended questions (e.g. how many times have you taken this medication at a different time in the last month? What was the reason for this?). Self-reported adherence at recruitment using MARS5 was 24.95 (SD = 0.22) of a maximum possible score of 25. The openended approach to exploring adherence prompted 73 per cent of participants to admit to sometimes missing a dose or taking medication at a different time. However, further probing revealed the frequency of this non-adherence to be low. This pattern of results was consistent across the three follow-up time points and across groups. The high adherence at recruitment presented problems for this intervention study. Indeed, the main study did not run, as it appeared that an intervention to improve adherence to CHD medications was not necessary for these participants.

35

Cath Jackson, Rebecca Lawton & Mark Conner

Study 2: Promoting adherence to antibiotics

The appropriate use of antibiotics is currently a priority for the NHS, particularly in primary care. Inappropriate use, especially the high level of patients not completing the course of treatment, is a factor in the increasing level of resistance to antibiotics (DOH, 2000b). A total of 250 participants presenting to a participating pharmacy with a prescription for an antibiotic were recruited to this study. They were randomly assigned to a control group or an intervention group. Self-reported adherence to the antibiotics was assessed over the telephone at the end of the prescribed course. We used two measures: a pill count and the open-ended questions used in the first study. The mean number of pills remaining at the end of the course was 1.15 (SD = 3.02). Two-thirds of the participants who reported pills remaining stated that they were still taking the antibiotics. The open-ended questions prompted 87 per cent of participants to admit to sometimes missing a dose or taking medication at a different time. However, once again, further questioning revealed the frequency of this non-adherence to be low. There were no differences between groups on either measure.

have regular contact; and with patients taking antibiotics who do not participate in research projects. This obviously has implications for interventions designed to increase adherence to medication. Future research could usefully explore innovative methods of recruiting these at-risk groups to this type of intervention study. Despite these setbacks we are now working with practice nurses in general practice to increase the fruit and vegetable consumption amongst 120 CHD patients. At last we have found a behaviour where even those agreeing to participate in our research are performing badly and where our intervention can be appropriately tested.

References
Department of Health (2000a). National Service Framework: Coronary Heart Disease. London: HMSO Publications Centre. Department of Health (2000b). UK Antimicrobial Resistance Strategy and Action Plan. London: HMSO Publications Centre. Gollwitzer, P.M. (1993). The role of intentions. In W. Stroebe & M. Hewstone (Eds.), European review of social psychology. Chichester: Wiley. Haynes, R.B., McDonald, H., Garg, A.X. & Montague, P. (2003). Interventions for helping people to follow prescriptions for medications. The Cochrane Library, 2, CD000011. Horne, R. University of Brighton, personal communication. Reid, L.D. & Christensen, D.B. (1988). A psychosocial perspective in the explanation of patients drug-taking behaviour. Social Science and Medicine, 27, 277285. Royal Pharmaceutical Society of Great Britain (1997). From compliance to concordance. Achieving shared goals in medicine taking. London: Royal Pharmaceutical Society and Marck Sharpe and Dohme.

Is non-intentional nonadherence really the problem?

At the outset of this research we considered that there was a true non-adherence with medication problem to be tackled (Haynes, McDonald, Garg & Montague, 2003). Previous studies using self-report measures of adherence have identified such a problem. For example, Reid and Christensen (1988) assessed self-reported adherence to antibiotics over the telephone and recorded 38 per cent adherence. If we believe the self-reports of adherence obtained in our two studies, the conclusion must be that the problem of non-adherence exists amongst CHD patients with whom practice nurses do not 36

Testing implementation intentions in the field

Schaffer, S.D. & Yoon, S.L. (2001). Evidence-based methods to enhance medication adherence. Nurse Practitioner, 26, 4452.

Correspondence
Dr Cath Jackson School of Psychology, University of Leeds, Leeds LS2 9JT. Tel: +44 (0) 113 343 5734 E-mail: psccj@leeds.ac.uk

Acknowledgements
We would like to acknowledge the contribution of Professor Jose Closs, Dr Peter Knapp, Dr Catherine Lowe and Professor Theo Raynor, who were collaborators on this research.

37

Individual Article

Getting together to prevent falling in older people: A multidisciplinary and a multinational approach
Maggie Donovan-Hall & Lucy Yardley
Department of Psychology, University of Southampton.

ALLING IS A major health concern in later life, with more than one in four people over 69 years falling each year (Tinetti & Speechely, 1989). In some cases the consequences can be brutal, with falling being among the leading causes of death in older people (Baker & Harvery, 1985; Tinetti, 1995). It is often found that older people fail to regain full mobility and function after a serious injury (Todd et al., 1995) and have an increased likelihood of falling a second time. Psychological stress is also associated with falling, with fear of falling (FoF) being the most common fear among older people (Howland et al., 1998). The need for research and interventions to prevent falling and address the psychological distress related to falling and FoF is clear, however, previous research and intervention attempts have had limited success. This may be due to previous research focusing on single isolated factors of falling, as opposed to investigating all aspects and adopting a multidimensional approach. The Prevention of Falls Network Europe (PROFANE ) is a project bringing together scientists and clinicians from diverse fields to co-ordinate research and practice in all areas of falling. This multidisciplinary multinational team of professionals will work within four main work packages. The work involved will focus on collating previous and current research and presenting guidelines for future research, identifying those at risk of falling and developing self-help

approaches, identifying and developing state of the art balance assessment tools, and attempting to understand the psychosocial processes related to all aspects of falling. As health psychologists our work within PROFANE involves trying to understand the psychosocial factors related to many different aspects of falling. We will be investigating what motivates older people to initiate and maintain behaviours that will reduce their risk of falling. This will enable interventions to be designed that identify older peoples beliefs, attitudes and perceived risk with regard to falling. Furthermore, we are interested in understanding the psychological mechanisms related to FoF. This will also involve examining the impact that programmes have on fears related to falling and whether better methods to reduce such fears can be integrated within the programmes. As PROFANE promotes a multidisciplinary approach bringing all heads together, we are interested in making contact with other academics and health professionals who are working within this field. If you have previously or are currently carrying out research investigating psychosocial factors related to the prevention of falling and FoF, please contact Maggie Donovan-Hall.

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Getting together to prevent falling in older people

References:
Baker, S.P. & Harvey, A.H. (1985). Fall injuries in the elderly. Clinical Geriatric Medicine, 1, 501215. Howland, J., Lachman, M.E., Peterson, E.W., Cole, J., Kasten, L. & Jetter, A. (1998). Covariates of fear of falling and associated activity curtailment. The Gerontologist, 38, 549555. Tineti, M.E. & Speechley, M. (1989). Prevention of falls among the elderly. New England Journal of Medicine, 320, 10551059. Tineti, M.E. (1995). Falls. In Hazzzard, W.R., Bierman, E.L., Blass, J.P., Ettinger, W.H. & Halter, J.B. (Eds), Principles of geriatric medicine and gerontology (3rd ed.). New York: McGraw-Hill. Todd, C., Freeman, C., CamilleriFerrante, C., Palmer, C., Hyder, A., Laxton, C., Parker, M. & Rushton, N. (1995). Differences in mortality after fracture of hip: The East Anglian Audit. British Medical Journal, 210, 904908.

Correspondence
Maggie Donovan-Hall School of Psychology, University of Southampton, Highfield, Southampton SO17 1BJ. E-mail: mh699@soton.ac.uk.

39

Individual Article

The BPS Stage 1 qualification in health psychology

James Elander
Department of Psychology, London Metropolitan University.

Introduction

BRITISH PSYCHOLOGICAL SOCIETY (BPS) offered for the first time a Stage 1 qualification in health psychology, in the form of a written examination with four papers, plus a research dissertation. The qualification provides an alternative to completing an accredited MSc course for psychologists who wish to achieve Stage 1 of the requirements for Chartered Health Psychologist status. This article describes the form of the qualification, the procedure, and some important aspects of the regulations.
N

2003

THE

psychology (Board of Examiners in Health Psychology (BEHP), 2001, p.4). Note that the qualification is not normally available to individuals who have failed a postgraduate health psychology course.

The knowledge requirement

To obtain the qualification, candidates must demonstrate their knowledge and understanding of a syllabus identical to the core curriculum covered by accredited MSc courses in health psychology. The syllabus is assessed by four three-hour examination papers, plus a research dissertation from which exemptions can be sought by candidates who hold, or are enrolled for, PhD or other postgraduate research degrees involving substantial health psychology research. The four examination papers divide the syllabus into four areas: health-related behaviour, illness and health care delivery, research and development, and context and related areas. Three of the papers require conventional essay-style answers, and one requires more structured answers, based on a choice of case studies. The 2003 examination papers, provided in Appendix 1, are probably the simplest guide to the subject matter of the qualification, but candidates should be aware that: Questions will be set to sample the range of topics covered in the syllabus. Papers will seek to examine the breadth of the syllabus and candidates are notified that they are expected to be able to draw on the full range of their knowledge in all papers Familiarity with recent psychological research and theory is expected.

The purpose of the Stage 1 qualification

The Stage 1 qualification is designed to allow individuals with postgraduate research degrees in health psychology, and Chartered Psychologists transferring laterally from other areas of psychology, to progress towards Chartered Health Psychologist status. It provides an alternative to completion of an accredited postgraduate training course for individuals with advanced knowledge of health psychology.

Eligibility
The regulations require applicants to: i. be Graduate Members of the British Psychological Society who hold the Graduate Basis for Registration (GBR), and either ii. hold or be enrolled for a postgraduate research degree relevant to health psychology or iii. be Chartered Psychologists seeking a lateral transfer from another area of 40

The BPS Stage 1 qualification in health psychology

Candidates should also be conversant with relevant knowledge and practice of related disciplines (BEHP, 2001, pp.78). The standard is equivalent to BPSaccredited postgraduate courses in health psychology. The current assessment criteria are provided in Appendix 2. These allow for the qualification to be awarded with merit and distinction, based on aggregated performance across the four papers and the research dissertation.

The process
The qualification is offered annually, and failed candidates are not normally allowed to re-register, so potential candidates are advised to consider the requirements carefully before registering. Registration and dissertation exemption forms are available from the BPS, and these should be submitted by 1 November. Candidates submitting a dissertation should do so by 1 December. The written examinations are held in February, and oral dissertation examinations are held in the spring.

The research dissertation

The dissertation consists of a written report of original, empirical health psychology research, up to 15,000 words in length, assessed by oral examination. Details of the requirements are given in the regulations (BEHP, 2001, p.11). The research must be supervised and must have received appropriate ethical approval, but the dissertation must not have been submitted for another qualification. Candidates who already hold a research degree, such as a PhD, may be exempted from the dissertation if they can show that their research is relevant to health psychology, conforms to ethical standards, is appropriately supervised, and meets the requirements for the Stage 1 research dissertation. Candidates seeking exemption from the dissertation should make their exemption application at the same time as registering for the Stage 1 qualification. Candidates can apply for exemption, and sit the written examination, before they have been awarded the research degree that is the basis for their exemption, but the Stage 1 qualification will not be awarded until that research degree has been awarded.

References
Board of Examiners in Health Psychology (BEHP) (2001). Regulations for the Qualification in Health Psychology (Stage 1). Leicester: British Psychological Society (http://www.bps.org.uk/documents/ qualshealthstage1.pdf)

Acknowledgements
James Elander is the Chief Examiner of the BPS Board of Examiners in Health Psychology. Many thanks to Helen Clark, Denise Keen, and all of the Board of Examiners, especially Sara Cox, Vivien Swanson, Susan Michie and Marcus Munaf, the 2003 Stage 1 examiners.

Correspondence
For enquiries about the Stage 1 qualification other than to register as a candidate, contact James Elander, Department of Psychology, London Metropolitan University, London E1 7NT. Tel: 020 7320 1073. E-mail: j.elander@londonmet.ac.uk. For information about registering for the Stage 1 qualification, contact Denise Keen, BPS Board of Examiners in Health Psychology, BPS, Leicester LEI 7DR. Tel: 0116 252 9512. E-mail: denkee@bps.org.uk.

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James Elander

Appendix 1: The 2003 examination papers.

Paper 1: Health-related behaviour: Cognitions and individual differences. Three hours. Answer one question from each section. You should not base more than one answer on the same core material. SECTION 1: HEALTH-RELATED BEHAVIOUR 1. Health beliefs predict health behaviours. Discuss with reference to two key theoretical models in health psychology. Discuss the influence of social and cultural factors on health-related behaviour. To what extent does psychology enable us to understand the processes of health and illness and what are the limitations of a purely psychological approach?

2.

3.

SECTION 2: HEALTH-RELATED COGNITIONS 4. Discuss the extent to which control is important in the maintenance of health behaviours. Why might a person engage in risky behaviours, e.g. smoking or alcohol abuse? Evaluate the contribution that psychology has made to our understanding of pain and the perception of pain.

5.

6.

SECTION 3: INDIVIDUAL DIFFERENCES, HEALTH AND ILLNESS 7. To what extent does the belief that we can succeed at something we want to do impact on our health behaviours? What is the role of individual differences in understanding health and illness?

8.

42

The BPS Stage 1 qualification in health psychology

Paper 2: Psychological processes in illness and health care delivery. Three hours. Answer three questions, each from different sections of the paper. You should not base more than one answer on the same core material. SECTION 1: STRESS, HEALTH AND ILLNESS 1. Stress has a major role to play in the development and course of illness. Discuss this statement with reference to either: (a) cancer or (b) coronary heart disease. How useful is the concept of social support in understanding the relationship between stress and illness?

2.

SECTION 2: CHRONIC ILLNESS/DISABILITY 3. The impact of pain is to a large extent determined by individual coping styles and strategies. Discuss. What do you understand by the term quality of life? What interventions could be implemented by a health psychologist to improve the quality of life of people with a chronic illness such as diabetes or asthma?

4.

SECTION 3: HEALTH CARE CONTEXTS 5. 6. What factors might influence patients adherence to medical treatment? Health screening is a waste of time. Give arguments for and against this statement.

SECTION 4: LIFESPAN, GENDER AND CROSS-CULTURAL PERSPECTIVES IN HEALTH PSYCHOLOGY 7. How do health behaviours change across the lifespan? What implications does this have for health psychology? What impact do cultural differences have on illness behaviours and health care delivery?

8.

43

James Elander

Paper 3: Research and development in health psychology. Three hours. Answer all the questions in relation to one of the four case studies. SECTION 1: APPLICATIONS OF HEALTH PSYCHOLOGY 1. What additional information will you require before writing the protocol for the evaluation? (5 marks) Outline the steps you would take in preparing your protocol. (10 marks) What problems can you foresee in undertaking the evaluation? (5 marks) Outline the main outcomes of the evaluation. (5 marks)

2. 3. 4.

SECTION 2: RESEARCH METHODS 5. Which theory or theories would you draw on, and how would they inform the evaluation? (10 marks) Outline the design for the evaluation study, and describe the method that will be used for the data analysis. (10 marks) What are the main strengths and weaknesses of the study design and research methods that are proposed? (5 marks)

6.

7.

SECTION 3: MEASUREMENT ISSUES 8. What psychological constructs or processes would you measure that are related to the intervention outcomes, and why? (10 marks) What criteria would you use in deciding which specific measures to use or develop? (15 marks)

9.

SECTION 4: PROFESSIONAL ISSUES 10. How could you involve different health professionals in the intervention? (5 marks) 11. What legal, ethical and professional issues will need to be incorporated in the intervention? (5 marks) 12. The local research ethics committee is known to be particularly rigorous in its examination of applications and to have members who are suspicious of psychological studies. What aspects of the protocol for the evaluation would you expect the committee to pay closest attention to, and how will you allay those concerns? (15 marks)

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The BPS Stage 1 qualification in health psychology

Case studies for Paper 3: Research and development in health psychology. Case Study 1 Two Primary Care Trusts are co-operating in launching a new smoking cessation service, to be run by community pharmacists. It will be a five-session course, run on site in pharmacies by pharmacists who have undergone training by local smoking cessation advisors. The pharmacists will be able to prescribe Nicotine Replacement Therapy and Zyban and will provide sessions of about 15 minutes each. This new service will be promoted within primary care and community pharmacy settings. You have been asked to evaluate the effectiveness of the service. Case Study 2 A new role is being developed within primary care of Public Health Assistant (PHA), to be based in community settings, with the aim of helping people who may have had little contact with health services to improve their health. Targeted outcomes are screening and immunisation uptake, and achieving change in health behaviours such as activity levels, diet and smoking. Five PHAs are to be appointed in one locality as a pilot, and you have been asked to evaluate their role and the health needs and plans of the people they make contact with. Case Study 3 High levels of absenteeism have been identified amongst domestic staff of an NHS Trust, and there is a view that this may be related to their isolation at work and stress levels caused by factors at work and outside (e.g. low pay, long hours, family commitments). You have been asked to design and evaluate an intervention to reduce absenteeism in this staff group. Case Study 4 Current treatment for patients with HIV involves a combination of drugs, many of which have unpleasant side effects. Treatment is demanding and difficult, and patients willingness and ability to adhere to the medication regime is an important influence on treatment outcome. At one treatment centre the multidisciplinary care team is being extended with the addition of a health psychologist whose role will be to support and promote treatment adherence. You have been asked to evaluate this new part of the service.

45

James Elander

Paper 4: Context and related areas. Three hours. Answer one question from each section. You should not base more than one answer on the same core material. SECTION 1: CONTEXT AND PERSPECTIVES IN HEALTH PSYCHOLOGY 1. What are the limitations of current models within health psychology? What role can multidisciplinary approaches play in tackling these limitations? How could social and cultural influences form a more central part of health psychology research and practice?

2.

SECTION 2: EPIDEMIOLOGY OF HEALTH AND ILLNESS 3. What factors contribute to the association between social class and health? How might this association be explained? Gender differences in morbidity and mortality are socially constructed. Discuss with reference to psychological theories. Health promotion targets have identified priorities for tackling health inequalities. What contribution can health psychology make in these priority areas?

4.

5.

SECTION 3: BIOLOGICAL MECHANISMS OF HEALTH AND DISEASE 6. Discuss the main methodological and conceptual problems in psychoneuroimmunology research. Critically evaluate the insights that genetic research can offer into the aetiology of physical illness. Type A research has hindered, more than advanced, health psychology research into the mechanisms of coronary heart disease. Discuss.

7.

8.

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The BPS Stage 1 qualification in health psychology

Appendix 2: The assessment criteria.

Assessment criteria for examination answers in Papers 1, 2 and 4. The level of knowledge expected by the examiners is equivalent to that required on a postgraduate course of study. Familiarity with recent psychological research and theory is expected. Candidates should also be conversant with relevant knowledge and practice of related disciplines. (BEHP, 2001, p.8) Grade band Distinction (70100%) Criteria

Synthesis of material to answer the question in novel or authoritative way. Evidence of very wide-ranging and/or impressively detailed knowledge of HP research and theory. Integration of core HP material with information about related disciplines. Insightful or authoritative evaluations of theory and research. Extremely well organised answers whose structure reflects the development of argument. Professional academic writing style, with good use of language and cogent, fluent expression of ideas. Use of appropriate material to provide an answer to the question. Evidence of sound knowledge of core HP theory and research, including some recent and/or non-core and/or wide-ranging material. Evidence of ability to relate HP material to information about related disciplines. At least some sound evaluation of theory and research. Material organised in a sensible, logical way. Reasonable to good academic writing style with appropriate use of language and comprehensible, grammatical expression of ideas. Irrelevant or inappropriate material used in attempt to answer the question, or the question is not properly addressed. Evidence of significant misunderstandings or limitations of knowledge or awareness of core HP theory and research. Very limited awareness or knowledge of related disciplines, or mistaken understandings of role of HP in those contexts. Little evaluation provided or unsound attempts at evaluation of theory and research. Disorganised or badly structured answers. Poor writing style with unclear or incoherent expression of ideas.

Pass (5069%)

Fail (less than 50%)

Note: These criteria are intended to provide descriptions of typical performance at the mid-point of each grade band, but the grade bands are broad and the criteria may be demonstrated to different degrees, so not all of the criteria need always be met to award a grade in that band (i.e. high performance on one aspect may compensate for poor performance on another). Some criteria may be treated as more important than others depending on the paper and the question (e.g. awareness of related disciplines may be more important in paper 4).

47

James Elander

Assessment criteria for examination answers in Paper 3. The level of knowledge expected by the examiners is equivalent to that required on a postgraduate course of study. Familiarity with recent psychological research and theory is expected. Candidates should also be conversant with relevant knowledge and practice of related disciplines (BEHP, 2001, p.8) Grade band Distinction (70-100%) Criteria

Authoritative, insightful understanding of strengths and weaknesses of different research methods. Evidence of insights into statistical concepts in relation to HP research. Ability to make complex balances and/or trade-offs between HP research and practice issues and legal, ethical, professional and other issues. Insightful, innovative or wide-ranging grasp of concepts in research, e.g. validity, reliability, control, artefact, change, process, outcome, including at least some advanced research concepts (e.g. mediation/moderation, latency effects). Innovative and/or authoritative ability to relate HP theory to research and/or practice. Creative or insightful contextualisation of health psychology research and practice. Clear understanding of key strengths and weaknesses of different research methods. Evidence of sound understanding of core statistical concepts in relation to HP research. Ability to balance HP research and practice issues against legal, ethical, professional and other issues in sound, sensible way. Understanding of key concepts in research (e.g. validity, reliability, control, artefact, change, process, outcome). Evidence of ability to relate HP theory to research and/or practice. Ability to place HP research and practice in meaningful context. Limited or mistaken understandings of strengths and weaknesses of different research methods. Little awareness of statistical issues in relation to research. Limited awareness or knowledge of legal, ethical, professional and other issues in relation to health psychology research and practice. Limited or mistaken understandings of key research concepts (e.g. validity, reliability, control, artefact, change, process, outcome). Little or mistaken understanding of links between HP theory and research or practice. Little evidence of ability to contextualise HP research and practice.

Pass (50-69%)

Fail (less than 50%)

Note: These criteria are intended to provide descriptions of typical performance at the mid-point of each grade band, but the grade bands are broad and the criteria may be demonstrated to different degrees. Not all of the criteria are relevant to each question, and some may be especially relevant for certain questions.

48

Individual Article

Stage 2 training: How do we acquire and demonstrate competence in consultancy?

Sandra Horn
School of Psychology, University of Southampton.

S A CO-ORDINATOR of one of the new Stage 2 programmes, supervision plans and how the demonstration of the core competences can best be facilitated have been exercising my mind of late. I am guessing that I am probably not alone in that respect. Our current Stage 2 trainees are undertaking jobs and/or programmes of study in which it will be no problem for them to acquire and demonstrate competence in generic professional skills, in research, in teaching and in disseminating psychological knowledge. The broad range of other optional competences means that few will experience difficulties in finding appropriate opportunities to demonstrate those areas of knowledge and skill. Most of the trainees are in research jobs, so all the research competences, some of the generic professional, legal and ethical competences and those concerned with dissemination of psychological knowledge can be attained as normal parts of their work. We can provide them with medical students, nurses, midwives, other health care professionalsin-training, undergraduate and postgraduate psychologists on whom to demonstrate their teaching skills. The acquisition and demonstration of competence in consultancy is, however, another kettle of flounders. Such opportunities as there are to undertake consultancy in academic institutions and the NHS are few, and are, rightly, the preserve of senior and experienced people. Where and how are appropriate placements to be had? In the interests of opening the debate and encouraging the sharing of thoughts,

issues and ideas, here are some we have had.

1. Consultancy is essentially applied research with knobs on

There are differences in details of how research and consultancy are conducted, as the description of the units of competence shows, but the only major differences are: i. the nature of the consultancy contract; ii. the way that meetings are documented. These are not difficult issues; it is the habit of working in a particular way that our trainees need to learn. We have employed a freelance management consultant to run a workshop with the stage 2 trainees on negotiating and drawing up contracts, so that they become familiar with the language and procedures and what must be included. The article by Marcus Munaf in the January 2003 Health Psychology Update is also very useful and will be required reading for our trainees. On the other hand, we are also encouraging Stage 2 trainees to set and circulate agendas for research supervision meetings, and take minutes, so that they become comfortable with conducting and documenting meetings in that particular way. This blurs the differences between research and consultancy meetings in a way that, we hope, can only be to the benefit of both and should enable trainees to move confidently between one paradigm and the other. 49

Sandra Horn

2. Many people need someone to carry out a piece of consultancy

Informal contact with local health and social care providers has identified a number of potential projects. A family drop-in centre needs a formal evaluation of their work in order to make an effective application for funding; a GP practice wants to set up a Smokestop programme and evaluate its impact and cost-effectiveness; a counselling service wants the data it has collected collated, analysed and presented as a report there is no shortage of need, if you go out and look for it. Not everyone knows that it is consultancy they need in order to make sense of some data or perform an evaluation, however, so we have designed and produced a flier to distribute to health care centres and practices to announce our service.

4. What about money?

As the consultants are trainees, it may seem appropriate to offer the consultancy for free, but trainees are under supervision by experienced colleagues, and are expected to provide a professional product, so we think it is reasonable to ask if there are funds available. If there are no funds, it still might be worth taking the opportunity to do the work for its own intrinsic value to the trainee, but theres no harm in asking.

5. Theoretical considerations
Stage 2 health psychologists in training are required to write a case study demonstrating the application of one or more theories of consultancy. So far, these have proved to be elusive beasts. We think they may be living under assumed names, or perhaps they dont exist at all. Theories relating to behaviour change, behaviour in groups/teams, communication, social cognition, etc., may all be used as the basis on which a piece of consultancy is framed, but they are mainstream psychology or health psychology theories, not theories of consultancy. Unless, of course, someone out there knows different We would like to be part of an information/good ideas exchange system with other departments in the process of setting up Stage 2 programmes, and with lone supervisors who are also facing these issues.

3. Fitting trainees into existing organisations

We have a local Help for Health consultancy and they are only too delighted to offer trainees office space and resources to carry out small-scale projects or parts of projects under supervision of staff members there. It took one phone call to ask if they would consider it. It counts as a placement, and, therefore, must conform to the Universitys requirements mostly health and safety for students on placement, but that has not proved to be problematic. There is no fee/pay for the trainees, but they will get excellent experience and networking opportunities.

Correspondence
Sandra Horn School of Psychology, University of Southampton, Highfield, Sounthampton SO17 1BJ. E-mail: S.A.Horn@soton.ac.uk

50

Individual Article

Stalkers and their victims: Some psychological implications

Mike Berry & Sarah Rockliff
Department of Psychology and Speech Pathology, Manchester Metropolitan University. Introduction
(1997) ESTIMATED THAT one in 12 Americans will be stalked in their lifetime. Public misperception of stalking has serious implications for reporting rates, the development of awareness, and treatment interventions, which we argue results in feelings of isolation and confusion being felt by ordinary stalking victims. Star stalking such as Mark Chapmans stalking and killing of John Lennon reinforces the misperception that only celebrities are victims. The reality is the victim is much more likely to be Ms./Mr./Mrs Average. The aim of this paper is to identify some of the psychological implications for victims of stalking based upon both treating and advising victims and providing psychological input for offenders. In England and Wales, Anti-Stalking legislation is defined under the Protection from Harassment Act (1997), as a person must not pursue a course of conduct (a) which amounts to harassment of another, and (b) which he knows or ought to know amounts to harassment of the other. This differs from the original definition of erotomania, a delusional belief that an individual is passionately loved by another, usually of a higher status, who is unable to publicly acknowledge this love (De Clrambault, 1922). It was originally thought to affect females, but it is now recognised in males also. Health professions and academics are at particular risk. Homosexual erotomania is just starting to find its way into the literature. Hall (1998) identified four categories of stalkers, based on their relationship to the victim, with 57 per cent as Prior Sexual Intimates (post-intimate relationship), 34 per cent as Prior Acquaintances, six per cent Strangers who stalked and three per cent unknown. Mullen, Path and Purcell (2000) define five sub-types of stalkers, namely; Intimacy Seekers (pursue relationships with people who they are in love with), Rejected Stalkers (pursue ex-partners or other prior intimates), Resentful Stalkers (harbour a desire for retribution against the victim), Predatory Stalkers (who wants a sense of power over the victims, while planning to attack them); and Incompetent Suitors (individuals lacking adequate social skills to forge a relationship).

JADEN

Some case examples

Tracey Morgan was a naval civilian in November 1992, who was stalked for six years by a colleague Bristow, resulting in 20 court cases including several imprisonments for him. Eventually, in 2001, Bristow was given a life sentence (with a seven years tariff) for having tried to kill another victim. A contrasting example involved a male who married a local woman but because of his violence, she left him. He stalked her for some time before becoming involved in another relationship. Unfortunately, this marriage also broke up and after a gap of several years he then started to stalk his first wife, who subsequently became ill because of his attentions.

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Mike Berry & Sarah Rockliff

Psychological implication of being a stalking victim

In the authors experience, many victims shared a number of characteristics, including a tendency to think that: a. They must be the only person being stalked, because they are ordinary citizens rather than a celebrity. b. It must be their fault! Many victims believe that they have perhaps inadvertently encouraged the stalker. c. The stalker will give up eventually; it would appear that some stalking victims often tolerate their situation for years before complaining. d. The stalking would cease if only they talked or met with the stalker. A worrying number of victims had tried to meet their stalker with the intentions of making it clear that they do not want the stalkers attentionsunaware of the concept of intermittent reinforcement. e. That the severity of the problem will be underestimated, all of which can result in physical health problems.

Consequences
Victims are likely to suffer from any of the following depending upon the circumstances of their case: increased anxiety, depression, social isolation, agoraphobia, irrational guilt, self doubts; increased usage of drugs, medication, alcohol as stressors leading to physical ill health. They often complain of a lack of control over their lives and feel anxious that the legal system will not take them seriously. Many feel pressure to sort it out with stalker (if known). Anxiety and stress Many victims are anxious they wont be believed. There is often a problem of proving some stalkers actions, e.g. it is difficult for a victim to prove that they have been followed down the street, or received phone calls if not recorded. We actually advise they record incidents carefully. 52

Some victims do not know how to explain being stalked to their significant others. Such problems are further fuelled by the nature of many stalking offences, as they often involve seemingly innocent gestures such as buying flowers for the victim. Initially, there seems little to complain about when a person receives flowers from an admirer. Whilst victims are acutely aware of the motives behind the flowers, it can be difficult to make others understand this. Many physical gestures, i.e. flowers, champagne, phone calls, may not be regarded as serious but can be psychologically damaging! Many of these things can lead a victim to question their reaction to the stalking, perhaps convincing themselves that they are over-reacting. Some victims may even begin to question their own sanity. There is a desperate need for partners, family, friends, and the police to believe them. Berry and Rockliff (in press) show that the police are likely to be understanding and were amenable to the victims complaints and this should be perceived as a positive finding to encourage victims to report their problem. However, by reporting the problem, and being believed, a victim can face a new anxiety; that of having to face her stalker (for example in court), or angering him by reporting him and thus heightening the problem. Because of the obsessional nature of the stalker, the victim can also become embroiled in the obsessional routine, as it begins to dominate their lives. For some victims an increased sense of anger forces them to fight back! Social isolation Many victims express feelings of extreme isolation, as they often keep the problem to themselves, which can increase their levels of distress, and cause difficulties later, when questions are asked as to why the incidents were not reported to the police. In many cases, social isolation can

Stalkers and their victims

increase further as the victim is often afraid to go out, or trust others as a result of the stalkers actions, or simply be embarrassed about going out, if the stalker has a habit of turning up at events or places where the victim goes. Break-up of relationship is a major consequence, as is trusting lovers in new relationships. If the stalker is an expartner, it can cause feelings of jealousy with a new partner, or even cause them to become suspicious of the victim, believing them to be encouraging the stalker. It can have serious effects on victims, on family relationships and increase employment problems. In many cases, it is the stress of the everyday intrusion and resulting distress that partners, families and friends cannot cope with. Victims often have a fear of embarrassment at family or other social gatherings. For some victims they become so distrustful of people that they actually become agoraphobic because of high anxiety of being possibly followed. Clearly, social isolation, which results in loss of fundamental support networks, can intensify the psychological implications for the victim. Characteristics of stalkers The major characteristic is the level of obsessionality they have with their victims as it can take up literally most of their waking hours. This can have devasting effects on their employment patterns and ironically their own families, who in turn become secondary victims of stalking. Some will justify their behaviour and even contact the victims colleagues informing them of their victims deteriorating mental health (rationalising their own role in the process). Management of the stalker Legal measures can be taken to prevent the stalker from targeting the victim, including injunction orders, prison or

Special Hospital. However, a longer-term solution is needed, which is where psychological intervention becomes of relevance. An important consideration is whether the behaviour displayed is a clinically recognised pathology, the result of an existing underlying mental disorder or represents the entirety of the clinical picture. For some, preventing access to their victims, by imprisonment or restraining orders is questionable. Imprisonment does not prevent the stalker from continuing stalking, as s/he can continue by phone or letter from within the prison. Under the Mental Health Act, in-patients can be prevented from contacting a victim but not in the prison system unless it is a clause of the perpetrators sentence. In addition, if a conviction has been secured against the perpetrator, then feelings of anger and resentment towards the victim may become heightened and the behaviour may actually escalate. Furthermore, when a restraining order or injunction has been imposed, it may prevent the stalker from targeting the original victim but it does not address the underlying behaviour, unless engaged in treatment. Psychotropic medication may be relevant in some stalking cases, for controlling anger and impulsivity. Therapists treating offenders need to be aware of the negative effects of the stalkers behaviour for they may be subjected to threats, abuse, attempts at bribery, from some stalkers because they have blocked access to the stalkers victims. Psychological treatment In some ways the treatment for the victim and the offender are quite similar but with different outcomes. Psychological treatment could include Cognitive Behavioural Therapy (CBT) to identify and challenge negative thought patterns. For Incompetent Suitors, Social Skills 53

Mike Berry & Sarah Rockliff

Training may be beneficial. Additionally, it is argued that a significant proportion of stalking behaviour occurs because the stalker is socially isolated and thus needs to hold on to past or non-existent relationships. SST may enable some stalkers to develop stable social networks and improve their perception of the victims situation by more accurate interpretation of social cues. Furthermore, enhanced social skills can serve to aid victim empathy. Anger is an important antecedent of violent behaviour. The anger-aggression relationship is a complex one. Not every stalking case leads to violence. However, much stalking is clearly motivated through anger, particularly in cases where the perpetrator has been rejected by the victim. Where the perpetrator seeks to instil fear or inflict harm, rather than establish a relationship with the victim, the use of anger control is appropriate, where the offender is motivated for treatment. Anger Management can reduce arousal levels in revenge-seeking stalkers, which can lead to a reduction of stalking. Enhanced Thinking Skills is widely used to identify and address the thought processes underpinning criminal behaviour. For some victims/offenders, psychodynamic therapy might be of value if it was readily available in the system, although the literature is devoid of any successful evaluations. Some victims argue that the law is weighted to the offender rather than the victim. We disagree. The legal system is aware of the problems; for example, the Victim Advisory Panel is now advising Home Secretary. However, Morgan makes a powerful point that if it was a physical problem, victims would get sympathy but not for psychological symptoms as she

argued you cant have bandages around your brain. False victimisation Each year of a number of individuals, make false allocations of being stalked for reasons including attention-seeking behaviour, misuse of the Act against neighbours or work colleagues. In addition, there are cases of individuals who are clearly suffering from delusional ideas, paranoia or simply cases of mistaken identification that make them complain to the authorities1 they also need treatment.

Conclusions
There has been a blurring of boundaries between domestic violence and stalking. Victims of harassment by ex-partners have been included in studies, which we argue that this could be described as relationship breakdown and often relate to rejection and jealousy about their former relationship(s) or the victims potential/ actual relationship with someone else. This has implications for treatment. There is an argument for using the behavioural term of harassment to describe this type of behaviour, compared to the generalised use of the term stalking. Although many people will have heard of stalking and have some expectations of victims and perpetrators, it is currently not fully understood especially by the victims. We would argue that there is a need to educate the victims to reduce the Celebrity status, to take control over their lives, not to destroy evidence, record incidents and to talk about their situation. We need to obtain a clearer picture of stalking harassment in the UK and fund specialist treatment for victims, stalkers and their families. Victims will often require psychotherapy and extended

Interested readers are referred to Path et al. (1999), 'Stalking: False Claims of Victimisation', Brit. J. Psych., 174, 170172, and much of the literature concerning Munchausens Syndrome.

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Stalkers and their victims

follow-up, to overcome the stress associated with the trauma of being stalked; as well as input for physical health factors arising from the stalking. One worrying thought is that the phenomenon will increase with the advent of cyberstalking and mobile-stalking! Management of victims has long-term psychological implications for us all.

References
Berry, M.J. & Rockliff, S.H. (in press). Perceptions of police officers to stalking: Some comments on an underreported phenomenon. Forensic Update. De Clrambault, G. (1922). Psychoses Passionelles. Paris: Universitaires de France Hall. D. (1998). The victims of stalking. In R. Meloy. (Ed.), Psychology of stalking: Clinical and forensic perspective. London: Academic Press. Morgan, T. (2003). BBC Radio 4, 10 March.

Mullen, P.E., Path, M. & Purcell, R. (2000). Stalking. The Psychologist 13(9), 454459. Sheridan, L. & Davies, G.M. (2001). What is stalking? The match between legislation and public perception. Legal and Criminological Psychology, 6, 317. Tjaden, P. (1997). The crime of stalking: How big is the problem? U.S Department of Justice, National Institute of Justice: Washington.

Correspondence
Mike Berry or Sarah Rockliff Department of Psychology and Speech Pathology, Manchester Metropolitan University, Elizabeth Gaskell Campus, Hathersage Road, Manchester M13 OJA. E-mail: m.berry@MMU.ac.uk sarah_rockliff@yahoo.com

55

Individual Article

Some characteristics of 7289 cases of rape and sexual assault seen at St. Marys Sexual Assault Referral Centre since 1986*
Iain McLean1 & Val Balding2
Academic Unit of Obstetrics & Gynaecology and Reproductive Healthcare, the University of Manchester & 2Independent research consultant and PhD Candidate, University of Manchester.
St. Marys Centre was the first sexual assault referral centre in the UK, offering co-ordinated forensic medical, counselling and other aftercare services for people who have experienced rape and sexual assault in Greater Manchester. Conducting forensic medical examinations in dedicated accommodation at a hospital rather than a police station, and incorporating counselling provision, is considered by the Centre to be essential in minimising the potential effects of rape trauma syndrome. Characteristics of 7289 cases seen at the Centre from October 1986 to the end of December 2001 are presented to demonstrate the scale and nature of sexual assault as witnessed by a specialist service in a large and mainly urban area of the United Kingdom. syndrome (e.g. Burgess & Holmstrom, 1974; Holmstrom & Burgess, 1975) describes a form of post-traumatic stress syndrome particular to rape and sexual assault. The four stages of this syndrome contain a variety of possible symptoms, such as fears/phobias, anxiety, guilt, numbness, disorganisation, and flashbacks. The expressed emotional response can vary between and within individuals, and often in opposition to the stereotypical response expected by society. Given the especially traumatic nature of these violent crimes, and their complex personal, inter-personal, social, medical, and legal consequences, there is great benefit in integrating counselling and other support services with the forensic medical examination conducted in police cases. St. Marys Centre was the first one-stop SARC in the UK, conducting forensic medical examinations to collect evidence for police investigations and possible prosecutions, by female staff in dedicated accommodation. The provision of counselling, plus screening for sexually transmitted infections (STIs) and practical support with criminal justice system consequences, are combined in the service.
1

Introduction
This paper briefly describes a sexual assault referral centre in Manchester, rape trauma syndrome, and some characteristics of its large client group. The information presented here, collated from 7289 cases seen at the Centre since 1986, provides a strong empirical basis on which health service providers can build sexual assault support systems. Rape trauma

*A presentation based on this paper will be made at the Forensic Health Psychology Conference at Manchester Metropolitan University, 8 November, 2003.

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Some characteristics of 7289 cases of rape and sexual assault

The social stigma (Mackey et al., 1992) and the poor conviction rate for such crimes (HMCPSI/IC, 2002) may compound the trauma of the sexual assault, and deter people from reporting the assault and/or seeking assistance for their physical or mental health. As St. Marys Centre sees self- as well as policereferred cases, its client group is more representative of those in society that have been raped or otherwise sexually assaulted, although many incidents will always remain hidden.

Description of the Centre

St. Marys Centre was established in 1986 in partnership with Greater Manchester Police (GMP) and the health authorities in central Manchester. The provision of co-ordinated forensic, counselling, and medical aftercare services was unique in the UK for several years. The Centre is available to adults who have been raped or sexually assaulted as adults, usually on the one occasion, and usually by a nonfamily member, as opposed to cases of ongoing or historical child sexual abuse. However, adult is defined more by competence to consent to the forensic medical examination than by age, and serially assaulted individuals (as in cases of domestic violence) are seen. Clients must be resident in the region of Greater Manchester or have been assaulted therein, due to the funding from GMP. In 2001 the regions population was 2,499,441: 1,291,040 female, and 1,208,401 male (Office for National Statistics, 2002). Self-referred clients can access any and all services at the Centre so that not reporting to the police is not a barrier to support. An adult reporting rape or sexual assault to GMP will be offered the services of St. Marys Centre. The forensic medical examination is conducted at the Centre within St. Marys Hospital in Manchester rather than a police station, by one of a rota of about 12 female, forensically-

trained doctors. The police and client are met at the Centre by the on-call Crisis Worker (CW), also female from a rota of about 10. The CW is key in providing comfort and support, and liaising with the police and examiner on behalf of the client. As a neutral agent in a supportive environment, the CW is crucial to helping the client counter the initial shock of the assault and further distress of dealing with the police and examination. She will later inform the client of the other services available at the Centre. CWs are responsible for maintaining the cleanliness of the examination suite to protect evidential integrity and chaperone the client during the examination. The Centres three counsellors participate in the CW rota, the rest being other types of health care workers or with relevant past experience. The purpose of the forensic medical examination is to collect evidence from the body, ultimately for use in a prosecution, following standard protocols. Evidence might include the presence of injuries, swabs and other samples, and occasionally photographs. The clients informed and signed consent must be given for different aspects of the examination. If the client declines to consent to any aspect, such as the taking of photographs, then that is struck out on the forensic medical examination form. The medical examination also enables any medical consequences of the assault to be identified and dealt with, and reassures where no serious or permanent injury has been sustained. Records and samples are handed to the police, who send samples for analysis. All aspects of the record of the examination are available to the court, if so ordered. Confidential medical information recorded at the time of the examination, subsequent STI screening, and counselling records will not be disclosed unless ordered by a judge. These records are only made available in part, with the Crown Prosecution Service mediating. The examination proceeds similarly for self57

Iain McLean & Val Balding

referrals with any samples taken stored at the Centre should the client later wish to report to the police. Reporting to the police is the clients decision, and the Centre will not do so without his/her consent. Where child protection issues are involved then the Centre has a responsibility in accordance with Trust policy. In a police case the client will give a statement to the police. A lengthy process, this may revive thoughts and feelings the client may have been trying to repress. The Centres Support Worker (SW) is available to clients to facilitate the statement at a suitable time and place, and accompanies the client during what can be a difficult process. The SW facilitates contact with the police and court, explains the procedures and accompanies the client when attending court. This new role is intended to lessen the distress of involvement with the criminal justice system, in which the complainant is only a witness. Residents of Greater Manchester may also attend for counselling long after they were assaulted, again without any requirement to report to the police. There is no time limit set on the process, and clients significant others can also receive counselling. Group work is not conducted, essentially because of the potential of contaminating court testimony.

Discussion of results
Referral St. Marys Centre saw 7289 cases of alleged sexual assault in its first 15 years, 4766 (65.4 per cent) were police-referrals. This comprised 6922 individual clients, 6653 of whom attended once, 207 attended for two separate incidents, 41 for three, 11 for four, 7 for five, and 3 for six. The 2000 British Crime Survey (BCS) (Myhill & Allen, 2002) estimated 61,000 females were raped in 1999 whereas the police recorded 7707 incidents (about 12 per cent). Two-hundred-and-ninety-eight female rape cases were seen at St. Marys in 1999, 0.5 per cent of the estimated national total. The 204 police-referred female rape cases formed 2.6 per cent of the UK total of recorded incidents. Only 18 per cent of respondents in the BCS had reported to the police. Gender 6977 (95.7 per cent) were female and 312 (4.3 per cent) male. Most research gives male figures of between five and 10 per cent (Scarce, 1997). However, in recent years the proportion at St. Marys has risen (to 8.2 per cent in 2001), probably due to increased reporting, in line with a general increase of reported male rape in England and Wales (Povey, 2001). A greater proportion of female clients reported to the police than male, with 65.8 per cent of all female clients and 55.4 per cent of all male clients being police referrals. Age The mean age was 26 years, but notably the mode was 17 (range three to 93). Even this is older than some studies, e.g. the 2000 BCS cited the 16 to 19 age group as at most risk from sexual assault (Myhill & Allen, 2002) and a study of 418 cases of sexual assault in Paris in 1998 produced a mean age of 15.9 years and a median of 14 (Grossin et al., 2003).

Method
A new computer database of St. Marys Centre clients records began in 2002. A survey of key aspects of rape and sexual assault was conducted by calculating totals for the 7289 cases from the inception of the service from October 1986 to 31 December, 2001. The apparently large number of unknowns in some of the data is in part due to the information being unknown to clients, perhaps because of unconsciousness during some or all of the assault. For clients attending sometime after the incident for counselling rather than an examination, details such as weapon and force may not be recorded. 58

Some characteristics of 7289 cases of rape and sexual assault

Ethnicity 5116 (70.2 per cent) cases were White, 97 (1.3 per cent) were Black, 106 (1.4 per cent) were Asian, 19 (0.3 per cent) were of dual heritage or other ethnic origin, and 1,951 (26.8 per cent) unrecorded. The 1991 Census found the proportions of these groups in Greater Manchester to be 94.1 per cent, 1.3 per cent, 4.1 per cent, and 0.5 per cent respectively (Office for National Statistics, 1991). The small figures for ethnic minorities and the large number of unknowns make drawing conclusions about assault rate and service take-up difficult. Assailants In 2754 (37.8 per cent) cases the alleged assailant was a stranger (including assailants met for the first time within 24 hours before the attack who could not be traced). Present or former partners accounted for 1078 (14.8 per cent) cases. For more details see Table 1. The incidence of stranger assaults in the BCS (Myhill & Allen, 2002) was eight per cent overall, but 36 per cent for cases reported to the police. This latter is more in line with our finding and is similar to the Haven (a SARC in London), which reported 32 per cent of cases seen there from May 2000 to May 2001 recorded as stranger assaults (Kerr et al., 2003).

A large proportion of unreported assaults may be caused by partners, which could further inhibit reporting. Current and expartners make up 56 per cent of assailants in the BCS (34 per cent for reported cases, Myhill & Allen, 2002) but 14.5 per cent at St. Marys. 5533 (75.9 per cent) cases involved sexual assault by a single assailant (although others may have been complicit in its commission), 460 (6.3 per cent) involved two assailants, 182 (2.5 per cent) three, 134 (1.8 per cent) four or more, and in 980 (13.4 per cent) cases this was unknown. Assault type Rape (including anal) was the largest assault type at 4005 (69.7 per cent) cases, followed by 1102 (19.2 per cent) cases of indecent assault (including object or digital penetration of vagina or anus), and attempted rape at 272 (4.7 per cent) cases. These figures exclude unknowns, which constitute 1544 cases. More details of sexual assault types are presented in Table 2. Weapons and violence A weapon was claimed to have been present in the assault in 596 (8.2 per cent) cases, and additional physical assault other than the sexual assault was perpetrated in 3013 (41.3 per cent) cases.

Table 1: Relationship between client and perpetrator in 7289 cases of sexual assault seen at St. Marys Centre between October 1986 and the end of December 2001. Relationship Stranger Stranger (met but could not trace) Acquaintance (over 24 hours) Present partner Previous partner Family member Not known Total Total 2065 689 2267 647 431 296 894 7289 % 28.3 9.4 31.1 8.9 5.9 4.1 12.3 100.0 59

Iain McLean & Val Balding

Table 2: Assault types in 7289 cases of sexual assault seen at St. Marys Centre between October 1986 and the end of December 2001. Assault type Rape and anal rape Attempted rape Indecent assault Threat of sexual assault/sexual harassment Non-sexual violence Not known Total
*Figures rounded to nearest 0.1 per cent.

Total 400 272 1102 127 239 1544 7289

% 54.9 3.7 15.1 1.7 3.3 21.2 *99.9

The Haven sample reported the use of a weapon in 11 per cent of cases, and additional force in 50 per cent (Kerr et al., 2003). These differences may be due to recording practices, local crime patterns, and changes over time. Injuries Forensic examination occurred in 4688 (64.3 per cent) cases, however genital injuries data entry for the whole of this period was not complete at the time of writing. A test sample of data (January 1988 to December 1992) showed genital injuries in 182 (16.8 per cent) of the 1081 cases that were examined. One-hundredand-nineteen (65.4 per cent) of these had injuries to the vaginal area, and 63 (34.6 per cent) to the anal area. A review of genital injury literature found a range of about 10 per cent to 70 per cent of women alleging rape presented with genital injures (Lincoln, 2001), whilst an earlier review by Geist (1988) calculated a representative rate of just over 15 per cent. A specific, detailed research project on injuries is underway at the Centre. Counselling and STI screening 4317 (59.2 per cent) of all clients had counselling at the Centre, with 1804 of these attending more than one session. 15,123 counselling sessions were conducted from 1986 to the end of 2001. 60

1304 clients have used the STI clinic, which started in 1992. Age, gender, and referral source for clients using these services is similar to the general client group profile.

Conclusion
Comparison with other studies is difficult because of the variability of populations and assaults. However, similarities between Manchester, London and the national police figures indicate that the characteristics described here may be similar to those found in other British cities. The establishment of St. Marys model SARCs nationally will involve the integration of different health care professionals with law enforcement agencies. It is the experience of existing SARCs that this co-operation produces a strong dynamic improving the execution of justice and ensuring the best support and health outcomes for clients.

References
Burgess, A. & Holmstrom, L. (1974). Rape trauma syndrome. American Journal of Psychiatry, 131, 981987. Forensic Science Service, the Association of Police Surgeons, and the Association of Chief Police Officers (2000). Guidelines for the collection of samples. Glasgow: The Association of Police Surgeons.

Some characteristics of 7289 cases of rape and sexual assault

Geist, R. (1988). Sexually-related trauma. Emergency Medicine Clinics of North America, 6(3), 439466. Grossin, C., Sibille, I., de la Grandmaison, G., Banasr, A., Vrion, F. & Durigon, M. (2003). Analysis of 418 cases of sexual assault. Forensic Science International, 131, 125130. Holmstrom, L. & Burgess, A. (1975). Assessing trauma in the rape victim. American Journal of Nursing, 75(8), 12881291. HMCPSI/IC (2002). A report on the joint inspection into the investigation and prosecution of cases involving allegations of rape. London: HM Crown Prosecution Service Inspectorate and HM Inspectorate of Constabulary. Kerr, E., Cottee, C., Chowdhury, R., Jawad, R. & Welch, J. (2003). The Haven: A pilot referral centre in London for cases of serious sexual assault. BJOG: An International Journal of Obstetrics and Gynaecology, 110, 267271. Lincoln, C. (2001). Genital injury: Is it significant? A review of the literature. Medicine, Science and the Law, 41, 206216. Mackey, T., Sereika, S.M., Weissfeld, L.A., Hacker, S.S., Zender, J.F. & Heard, S.L. (1992). Factors associated with long-term depressive symptoms of sexual assault victims. Archives of Psychiatric Nursing, 6(1), 1025.

Myhill, A. & Allen, J. (2002). Rape and sexual assault of women: The extent and nature of the problem. Home Office Research Study 237. London: Home Office Research, Development and Statistics Directorate. Office for National Statistics (1991). Census: Small area statistics and local base statistics [computer file]. ESRC/JISC Census Programme, Census Dissemination Unit, University of Manchester. Office for National Statistics (2002). Census 2001: First Results on Population for England and Wales. London: The Stationery Office. Povey, D. (2001). Recorded crime: England and Wales, 12 months to March 2001. Home Office Statistical Bulletin 12/01. London: Home Office Research, Development and Statistics Directorate. Scarce, M. (1997). Male on male rape: The hidden toll of stigma and shame. New York: Insight.

Correspondence
Iain McLean St. Marys Sexual Assault Referral Centre, St. Marys Hospital, Hathersage Road, Manchester M13 0JH. Tel: 0161 276 6515 Fax: 0161 276 6691 E-mail: iain.mclean@cmmc.nhs.uk

61

Individual Article

A career in mental health promotion

Tonja Schmidt
South West London and St. Georges Mental Health NHS Trust.

Background
one-in-four people likely to experience a mental health problem at some point during their lives (Goldberg, 1991), there is clearly a need to raise awareness of and try to improve the mental health of the population. Mental health promotion is a relatively new branch of health promotion. It was first formally recognised by the government in the Department of Health white paper Saving Lives: Our Healthier Nation (1999). That document described how promoting good mental health is relevant to everyone schools, workplaces, neighbourhoods should all play their part in improving mental health (Department of Health (1999), para. 8.10). In the same year the National Service Framework for mental health was published and included mental health promotion as the first of its seven standards. For the first time health authorities, trusts and local authorities were required to promote mental health for all and to reduce the discrimination experienced by people with mental health problems (Department of Health, 2001, p.10).

ITH

AN

ESTIMATED

Many factors influence positive mental health. For example, living in a run-down area with high crime and poor transport can lead to fear, isolation and subsequently increased risk of mental health problems such as depression. By contrast, having good access to amenities, healthcare and a strong network of family and friends improves resilience and so promotes mental health. Factors such as individual personality and coping skills as well as the physical, social and economic contexts in which people live, all play a role. Promoting mental health means looking at how all these factors can be influenced to improve the lives of individuals and communities.

What does the work involve?

Working in mental health promotion is very varied. The basic aims of the job, that is, to promote mental health for all and to reduce the stigma around mental health problems, are outlined in the National Service Framework. These aims need to be translated into a local strategy, based on local needs. This involves working closely with local authority, education, primary care and the community partners, and also importantly with partners in the voluntary sector. To give you more of a flavour, here are some concrete examples of work that has been going on in South West London. The Merton Mental Health Promotion worker spends two days a week at the local council in an advisory capacity, working in partnership with key council officers towards integrating mental health promotion into their policy and practices. For example, Environmental Services determine transport and green spaces for the general

What is mental health promotion?

Mental health promotion is essentially concerned with how individuals, families, organisations and communities feel, the factors which influence how they feel and the impact that this has on overall health and well-being (Friedli, 2000). In the same way that being physically healthy can help to prevent physical illness, having positive mental health can help to prevent mental health problems.

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A career in mental health promotion

public. Their work, therefore, impacts on peoples mental health, because having nearby access to public transport may help to avoid older people becoming isolated in their homes, and access to open spaces increases opportunity for relaxation and physical activity. The mental health promotion worker might share their expertise with head of department and support staff to implement any action decided upon. This work, and that from other departments, is brought together to form a strategic document, which will guide the mental health promoting activities of the local authority in future years. Because the council provides services for people all over the borough, working at this strategic level increases the area over which mental health promotion has an impact. In Wandsworth, mental health promoting adult education courses are available free of charge to the local community. These include topics such as stress management, anger management and relationship skills and are provided in partnership with the local college. In Sutton, a project was set up in a deprived estate to provide residents with activities to promote well being in a supportive atmosphere. The mental health promotion worker was involved in setting up this project from scratch, and work included project planning, funding applications, organising the launch, and the creation of publicity materials. A highlight in all three boroughs is World Mental Health Day. Held on 10 October each year, this day is an opportunity to get local organisations working together to raise awareness of mental health. The mental health promotion workers play a key role, co-ordinating borough-wide activities often linked with national and sometimes international events.

health or behavioural science is asked for, preferably with a further qualification in health psychology, health promotion or the equivalent experience. It is now also possible to get a postgraduate qualification in mental health promotion from Kingston University. Personal characteristics essential to the job are that you enjoy working with people and are comfortable working across a variety of settings. It is essential to be versatile, have good communication skills and determination. Knowledge of research methods, including qualitative and quantitative approaches is likely to be useful. In some trusts, personal experience of a mental health problem is also seen as a distinct advantage. Jobs are advertised in the usual places, The Guardian, BPS careers supplement, jobs.ac.uk, primary care trust or mental health trust websites. Also look out for general health promotion posts which include an element of mental health promotion. Expect an interview and be aware you may be asked to give a presentation but dont worry, you will be warned at least a few days in advance!

Career progression
As this is a relatively new field, career progression is not yet clearly defined. Once you are a mental health promotion specialist or advisor the next step can be to move to a more general management role within the PCT. It may also be possible to do some extra training and branch out into public health, community development or more strategic work. In general though, the breadth of experience gained in the job will stand anyone in good stead when seeking employment. For those who come from a health psychology background, many of the skills and activities used in mental health promotion cover the core competencies required to fulfil Stage 2 of the route to becoming a Chartered Health Psychologist.

How do I get a job in the field?

Every job will be different but here are a few guidelines. Usually a first degree in a

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Tonja Schmidt

Why go in to mental health promotion?

If you are excited by working with people at all levels and across organisations to make lasting changes to peoples well being this job is for you!

References
Department of Health (1999). Saving Lives: Our Healthier Nation (1999a). Department of Health Publications. Department of Health (2001). Making it happen A guide to delivering mental health promotion. Department of Health Publications.

Friedli, L. (2000). Mental health promotion: Rethinking the evidence base. The Mental Health Review, 5(3), 1518. Goldberg (1991). Filters to care-model. In R. Jenkins & S. Griffiths (Eds). Indicators for mental health in the population. The Stationery Office Books.

Correspondence
Tonja Schmidt South West London and St. Georges Mental Health NHS Trust.

THE BRITISH PSYCHOLOGICAL SOCIETY ANNUAL CONFERENCE

IMPERIAL COLLEGE LONDON

15 17 April 2004
CALL FOR SUBMISSIONS Submissions are invited on any area of psychology as well as those particularly related to the Conference themes; Positive Psychology, Creativity and Innovation, and Perception. Guidelines are available on the Society website (www.bps.org.uk) or from the Leicester office on 0116 252 9555 or e-mail conferences@bps.org.uk. Deadline date is Monday 20 October 2003.

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A profile of health psychology

A profile of health psychology at Queen Margaret University College (QMUC)

Jane Turnbull & Joyce Willock
School of Social Sciences, Media and Communication, Queen Margaret University College.

1875 QUEEN MARGARET was founded as a small institution specialising in preparing students for work in the areas of health and nutrition. Now with University status and seeking University title, these continue to be areas of excellence, while QMUC has expanded to include, for example, Social Sciences, Tourism and Hospitality, and the full range of Allied Health Professions (see The Times Higher Education rating and the Award of the Queens Anniversary prize for University College achievements). Following a recent reorganisation, Psychology is a designated Subject Area within the School of Social Sciences, Media and Communication, which is part of the Faculty of Health and Social Sciences. The University College is planning to move from its currently outgrown and outdated site to a new state of the art campus in 20062007, located on a greenfield site on the eastern edge of the City of Edinburgh. The new site will provide easier access to transport links and facilities than the current location permits. Issues of access, environmental sustainability, inclusivity, multi-professional working and of course increasing use of electronic resources in learning and teaching will influence the ultimate design and layout, for which plans are well-developed, with academic staff input at every stage. Psychology staff are looking forward to the much closer relationships with colleagues in the Allied
N

Health Professions and their client groups that the new site will promote. The new campus is situated close to the Royal Infirmary of Edinburgh and staff will be able to liaise more closely with colleagues there. We have three undergraduate awards accredited by the BPS, one of which, BSc (Hons) Health Psychology, is the only one of its kind in Scotland. Currently we are also the only Scottish HE Institution whose Health Psychology MSc is accredited by the BPS as conferring Stage 1 Chartered Health Psychologist status; further work is underway to be able to offer Stage 2 training from 2004. There are 13 members of staff in Psychology, of whom five are Chartered Health Psychologists.

Research and consultancy

Health Psychology is a relatively new discipline within the University College and staff interests have focused particularly in two areas, stress and chronic illness/impairment, within a strong theoretical framework. Dr Joyce Willock, the Course Director for the MSc Health Psychology, is currently acting as a consultant on a large project measuring stress in farmers in the drylands of Australia with Curtin University. She visits Norway regularly to run workshops on farming stress and on improving communication for the Tine Dairy Company. Dr Willock has also recently conducted two qualitative 65

Jane Turnbull & Joyce Willock

studies; the first looked at the different perceptions women have of their treatment for prolonged menstrual bleeding and the second at preference for different types of treatment for endometrial bleeding; both were investigating cultural and personality effects. She has published research findings in, for example, the European Journal of Personality, The Journal of Vocational Behaviour and Stress and Work. With Dr Turnbull she is currently preparing a book on Selected Readings in Health Psychology, with input from contributors to the MSc course including Professors Ian Deary, Marion Hetherington and John McLeod. Dr Willock is a member of the Steering Committee charged with setting up the Division of Health Psychology: Scotland, necessary to consider the implications of Scotlands legal system and issues consequent on the devolution of health and education matters to the Scottish Executive. Michele Hipwell continues her research into stress and the student population, having recently completed her PhD thesis and become a Stage 2 trainer. She is in the process of becoming a qualified Cognitive Behaviour therapist, and will be able to impart a greater understanding of the practical skills required in this form of therapy to our Masters students. Dr Julie Hepworths research interests lie in qualitative methods, theories and methods in psychology, and psychosocial aspects of chronic illness, in particular hepatitis C, type 2 diabetes, eating disorders and cancer. Her current research focus also includes the development of the sub-discipline of public health psychology, global health issues, and public involvement in decision-making about research participation. Recent publications include those in Social Science & Medicine on womens decision-making, the special edition of the Journal of Health Psychology on public health psychology due for publication in November this year, 66

and The Social Construction of Anorexia Nervosa (Sage Publications, London). She is currently preparing an application for funding a collaborative project with Maggies Centre to examine the psychological adjustment of people living with cancer and of their carers. A Chartered Health Psychologist of long and distinguished standing, Dr Patricia Kerr has over a number of years undertaken extensive work in the application of psychology to audiological theory and practice in rehabilitation, and also to physical and sensory disability. Her recent research, in conjunction with members from the WHO ICIDH UK collaborating centre, has focussed on applied hearing loss and hearing impairment, and has explored the role positive experiences of these conditions play in the lives of affected people. In the course of this work, Dr Kerr and her colleagues have developed a framework for application of the International Classification of Impairments, Disability and Handicap (ICIDH-2) to auditory rehabilitation. She has published extensively in, for example, The International Journal of Audiology and The Journal of Applied Research in Disabilities, and has co-authored a book (Living with Hearing Loss) to be published by Whurr in 2004. Dr Kerri McPherson has obtained funding to continue her research into the aetiology of obesity following the completion of her PhD on the psychological correlates of overweight in men. She will be examining the role of restraint as a predictor of breakfast eating in relationship to body weight in conjunction with the members of staff in Dietetics and Nutrition here at Queen Margaret University College. Reports of her research to date have been published in Journal of Mens Health and The Nutrition Bulletin. She has recently been awarded funding by the Royal Society of Edinburgh to host a multidisciplinary research workshop which aims to identify

A profile of health psychology

gaps in our knowledge of obesity that require urgent research attention. The research interests of several other members of staff overlap with the general area of health psychology. For example, Dr Vivienne Chisholms research interests have included theoretically-driven work looking at general developmental processes as well as applied research with atypically developing children. In children with Down syndrome, this research has concerned a longitudinal study of mother-child attachment relations and childrens integration into mainstream schools. Current research includes an investigation of maternal techniques for promoting cooperation with the treatment regime in young children with diabetes, funded by the Chief Scientist Office. This project entails the application of conceptual frameworks taken from the Developmental Psychology literature and a multi-method assessment protocol based on measures from medicine, psychology and dietetics. Dr Chisholm plans to extend this research through an investigation of childrens management of diabetes in the peer environment. These research projects are conducted in collaboration with colleagues from the University of Toronto, the University of Edinburgh and the Royal Hospital for Sick Children, Edinburgh. Dr Chisholms papers have been published in child development journals (Social Development, Monographs of the Society for Child Development) as well as journals which specialise in health-related issues (e.g. British Journal of Medical Psychology, British Journal of Health Psychology). Dr Chris McVitties research interests lie in the social construction of ageing and its influence on health, particularly in the study of discourse and the social psychology of communication. These include the issue of social exclusion and its consequences for members of disadvantaged groups; the negotiation of

threatened identities, and the social construction of age and its consequences for older workers and jobseekers. Other interests include quality of life for older people and the effects of gender on health and health-care provision. Dr Jane Turnbull continues with a longitudinal study of factors pertaining to maintenance of successful weight loss in women, is considering an updated edition of her book (The Good Diet Guide) and preparing to co-author another with Dr Willock as described above. Dr Stuart Wilson is in the early stages of a study examining nurses intuitive decision-making regarding patients. He will be looking at whether patterns present in previous experience may unconsciously facilitate decisions made by nurses regarding patient needs. Members of staff supervise MSc and PhD research in these and related areas. We have close links with colleagues in the University of Edinburgh, Royal Hospital for Sick Children, Royal Edinburgh Hospital (Psychiatric), Royal Infirmary, University of Glasgow, University of Newcastle, University of New South Wales, Curtin University and the University of Toronto.

Training
Our first intake of MSc students in September 2001 consisted of 13 full-time and two part-time students; this grew to our maximum, 24 FTE, for 20022003, and applications are holding steady for the coming year. The original accreditation went well; the report of a more recent visit (2003) noted with approval the high level of support staff gave students, particularly those with Special Needs, and accreditation was granted for a further five years. The course is run using a number of different techniques. For example, a Virtual Learning Environment (WebCT) is used to produce exercises and information sources for students. This year we are 67

Jane Turnbull & Joyce Willock

moving forward to have a WebCT resource for every module, and investigating the greater use of groups of virtual seminars and group interaction. One module, Public Health Psychology, uses problem-based learning (PBL), which the students initially find very challenging but we believe truly fosters independent learning and thinking. As a consequence of our success with PBL we are investigating its use in other health psychology modules to facilitate students reasoning skills and links with practice. Staff and students have been particularly fortunate in that eminent theoreticians and researchers of health psychology from across the UK have contributed their time to our seminar programmes, sharing their recent thoughts and findings, exciting enthusiasm and a deeper understanding of the subject in the students. Specific new resources in hardware, software and test instrumentation have been allocated to the course, which will widen even further the variety already noted by the External Examiner of Masters thesis topics we can offer. Most of the students who have graduated from the course have found fulfilling employment in their chosen fields, and remain in touch with us. We very much hope that our colleagues in NHS Education Scotland continue to move towards equivalence of all applied psychologists in NHS Scotland, including Health Psychologists, which initiative QMUC staff have fully supported, and which will offer even more opportunities. Meanwhile, we are equally proud of our

International Students, whose meteoric career successes since graduation demonstrate recognition of the usefulness and relevance of the health psychology they have learned to the future of developing countries. Our plans for the future are to run an accredited work-based DPhil and PhD in Applied Psychology and to offer opportunities to work towards Stage 2 of Chartered status, as mentioned above. Several members of staff have been trained by the BPS as supervisors for Stage 2. Subject to approval by the University College and the BPS it is hoped to be able to offer this programme from next year- many of our MSc graduates are keen to start as soon as possible. We are pleased to have been asked to host the next BPS Division of Health Psychology Conference in Edinburgh. The Conference venue is in the heart of the City of Edinburgh, under the shadow of an extinct volcano and in sight of the Castle. It will take place from 811 September 2004. The theme is Health Psychology: Positive Perspectives and we are delighted that Professors Jim Prochaska, Ed Diener and Lucy Yardley have agreed to be keynote speakers. Please visit the website at http://dhpconf2004 for more details.

Correspondence
Dr Jane Turnbull School of Social Sciences, Media and Communication, Queen Margaret University College, Edinburgh. E-mail: JTurnbull@QMUC.ac.uk

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A profile of health psychology

A profile of health psychology at University College London

Lynn B. Myers
Unit of Health Psychology, Centre for Behavioural and Social Sciences in Medicine, University College London. Unit of Health Psychology
Stan Newman, Professor of Health Psychology. He has a multitude of research interests and is principal investigator on all studies in themes 1, 2, and 3 and is a collaborator on studies in themes 4 and 5. He is co-director of the MSc in Health Psychology and a deputy director for Stage 2 training. Lynn Myers, Senior Lecturer in Health Psychology. Her research focuses on three main areas: repressive coping style, adherence to treatment and health behaviours. She is principal investigator on all studies in theme 4. She is course director for the MSc in Health Psychology, a deputy director for Stage 2 training and an approved Stage 2 supervisor. James Thompson, Senior Lecturer in Psychology. His research interests include risk perception in breast cancer and prostate cancer and stress and illness. He is programme director for Stage 2 training. Georgina Charlesworth, Lecturer in Psychology. She has a special interest in work with older people and interventions to support family caregivers. She is principal investigator for the BECCA (Befriending and costs of caring) trial, studying the cost-effectiveness of a befriending intervention of family carers of people with dementia. Her research can be found under theme 3. She teaches on the MSc in Health Psychology and is involved with Stage 2 training.

formerly part of the Department of Psychiatry and Behavioural Sciences. It is now one of three units which comprise the newlyformed Centre for Behavioural and Social Sciences in Medicine. The other two units are Medical Anthropology and Medical Sociology. The Director of the Centre and the Unit of Health Psychology is Stan Newman. The Unit is made up of permanent academic staff, research fellows, research assistants, PhD students, MD students, clinical research fellows and honorary research fellows. Sixteen researchers are undertaking PhDs either as research fellows or PhD students. Unit research is divided into a number of themes: Theme 1: Impact of illness, surgery and medical treatments on cognition and the brain. Theme 2: Factors related to adaptation to chronic illness. Theme 3: Interventions in chronic illness. Theme 4: Adherence and health behaviours. Theme 5: Communication between patients and health care professionals. There are currently 45 ongoing studies. More details of these studies can be found on the Centre website: http://www.ucl.ac.uk/medicine/behavioural-social/index.html There are four permanent academic staff who are all chartered psychologists.
HE UNIT WAS

69

Lynn B. Myers

Research fellows tend to work on multiple projects and below are two examples to give a flavour of some of the work they do. Jan Stygall is a Chartered Psychologist and unit co-ordinator and has been a research fellow at the Unit for over 10 years. She has worked on a multitude of studies, research grants and publications. An example of some of her current work includes: a study to detect the incidence of neuropsychological problems associated with heart valve surgery and the neuropsychological impact of different surgical techniques in coronary artery bypass surgery. She has an interest in the impact of religion and is involved in a study which examines religion as a coping mechanism. In addition to her research she teaches on the MSc in Health Psychology and supervises MSc Health Psychology projects. Liz Steeds work as a Chartered Psychologist consists of involvement in a number of projects. One of these was the development and evaluation of a selfmanagement programme for patients with type 2 diabetes. Following on from this project the need to train health care professionals in the use of psychological techniques necessary for facilitating a self-management programme was identified. She has then been involved in developing a training course which aims to teach health care professionals the skills of facilitating groups, problem solving, goal setting, challenging beliefs, etc. A second role is as Trial Manager of a Multi-Centre RCT evaluating the efficacy of two new minimally invasive glucose monitors for use with patients with insulin treated diabetes. She also teaches on the MSc in Health psychology and supervises MSc Health Psychology projects. The Unit attracts a wide variety of funding including MRC, Wellcome, NHS 70

R&D, commercial organisations and charities. As part of the School of Medicine it has very good links with clinical departments both within and outside UCL.

Training in health psychology

MSc in Health Psychology (accredited by the BPS as Stage 1 training towards Chartership) is a University of London degree course run jointly by UCL/Kings. This is the longest running MSc in Health Psychology. It started as a part-time course in 1988 and one of the early students is now a Professor of Health Psychology. The full-time course began in the academic year 19941995 and has been awarded a number of Medical Research Council advanced studentships since that time. For the past three years it has received four MRC studentships. There are three course directors. The main course director, who is also the course organiser, is Lynn Myers. The other two directors are Stan Newman and John Weinman (Kings, Guys campus). The MSc take both full-time and part-time students, equivalent to approximately 15 full-time students and the numbers are kept low to allow small group teaching and to maximise the quality of research dissertation supervision. The emphasis of the course is to provide an excellent background in research, and to highlight this, the majority of students follow a health psychology research career after they complete their MSc. For example, from the 20012002 cohort the first job destinations post-MSc for full-time students were five going on to do funded PhDs and seven taking research assistant posts. Although the majority of graduates stay in research, a minority choose other destinations which have included health promotion, civil service and nursing. Students are encouraged to present and publish their research projects and systematic reviews. Again from the 20012002 cohort, 13 abstracts were

A profile of health psychology

accepted for the Division of Health Psychology Annual Conference 2003. A number of projects have been published in peer-reviewed journals including British Medical Journal, British Journal of Health Psychology, Psychology & Health, Psychology, Health & Medicine, Behavioural Medicine, Heart, Sexually Transmitted Infections, Accident and Emergency Medicine, Progress in Transplantation and International Journal of Obesity. Stage 2 training is being introduced in October 2003 and will be achieved by MPhil/PhD. The Programme Director is James Thompson, working as part of a programme team including deputy directors Stan Newman, Lynn Myers, John Weinman (Kings) and Susan Michie (UCL).

Health Psychology at UCL is not confined to the Centre. In a later issue of Health Psychology Update, health psychology in other UCL departments will be described.

Correspondence
Lynn B. Myers Unit of Health Psychology, Centre for Behavioural and Social Sciences in Medicine, University College London. E-mail: rejulmy@ucl.ac.uk

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Book Reviews

Book Reviews
The Psychology of Eating: From Healthy to Disordered Behaviour J. Ogden Blackwell Publishing, 2003; ISBN 0-631-23374-1; pp.248. Reviewed by Heather Semper
Eating behaviours have been increasingly recognised as a major factor involved in the aetiology, progression and treatment of various illnesses including disorders directly related to eating such as obesity, anorexia nervosa and bulimia nervosa and also indirectly related to diseases such as cancer, diabetes mellitus and coronary heart disease. However, as Ogden eloquently points out, the literature on eating behaviours is vast and tends to be specifically focussed on a single aspect of eating behaviour from an individual perspective. She argues that in order to obtain a comprehensive understanding of diet it is necessary to integrate the research from a range of different disciplinary and theoretical perspectives. The psychology of eating goes someway towards integrating this vast wealth of knowledge and research from a number of disciplines including sociology, psychology, physiology, nutrition and psychiatry and attempts to integrate it into a clear, coherent model of eating behaviours from healthy to disordered. The book has an easy to read format with clear explanations of the concepts to be discussed at the start of each chapter. At the end of each chapter Ogden provides a suggestion for how the themes of each chapter can be combined into an integrated model of eating behaviours and demonstrates how each chapters contents and concepts can be linked together which is further discussed in the final chapter. The book starts with a clear introductory overview of the aims, focus and structure of the book. In addition at the end of the chapter Ogden provides a very useful section of further reading guiding the 72 reader towards pertinent journals, online resources, useful texts, and a list of classic historical texts related to all of the areas covered in the book. Chapter 2 first discusses what exactly constitutes a healthy diet and how this has changed historically from the 19th century. It then goes on to discuss how diet contributes to the aetiology and treatment of illnesses such as coronary heart disease and diseases of the cardiovascular system, various forms of cancer, diabetes mellitus and gallstones and argues that diet plays a major role in the aetiology and treatment of diseases. It then discusses who has a healthy diet from a developmental perspective across cultures first focussing upon children, then young adulthood and then discusses the elderly and concludes that the diet of these age groups are deficient in a number of ways however middle adulthood is omitted from this analysis. Chapter 3 goes on to examine the factors that can explain why we eat what we eat and examines three models of food choice including developmental, cognitive and psycho-physiological theories. Based on the literature, each model is examined and critically evaluated for its relevance and ability to explain food choice. Ogden argues that each of the models has important facets for explaining food choice however the theoretical perspectives fail to adequately address the social context and meaning of food. Therefore, Ogden suggests that it is necessary to integrate these approaches with the meaning of food and the meaning of body size which is the focus of chapters 4 and 5. Chapter 4 discusses and evaluates the social and cultural meaning of food.

Book Reviews

Drawing upon sociological and anthropological literature this chapter explores how research has examined the classification of different types of food by people of many cultures and how food can be part of an individuals identity or cultural identity. Research examining how food can be used to communicate to others a persons internal needs, conflicts and desires and how food is portrayed and linked with sexuality and sexual desire, guilt and pleasure, self-control and denial is examined and discussed. It is argued that food needs to be understood in terms of the social context within which it is consumed in order to fully understand eating behaviours and the meaning of food. Chapter 5 draws upon both quantitative and qualitative research to explore the meanings associated with both body shape and size. It examines how the media represent body shape in relation to both males and females in newspapers, magazines, comics, and on television and shows that there appears to be more emphasis and portrayal of thinness being a positive ideal to achieve for females than for males. The chapter then goes on to investigate why being overweight and/or obese is portrayed and perceived as a negative state in western populations. Chapter 6 examines and defines body dissatisfaction, it then looks at how body dissatisfaction is measured, then goes on to examine who is dissatisfied with their body shape and size and looks at the causes and consequences of body dissatisfaction. Chapter 7 then looks at one of the causes of body dissatisfaction namely dieting. It discusses what dieting is and how dieting has historically arisen as a way of controlling the body and discusses the part that the dieting industry plays in perpetuating dieting behaviours. It then explores the psychological mechanisms underpinning food restriction and overeating and concludes by examining the consequences of dieting and restrained eating.

Chapter 8 and 9 focus upon obesity. In Chapter 8 obesity is first defined, and then how obesity is measured is discussed and the methods of measurement of obesity are critically evaluated. Ogden then goes on to investigate the prevalence, the physiological and psychological causes and consequences of obesity. It then goes on to critically evaluate the research, methods and measurement used to examine obesity. In Chapter 9 the focus is upon the treatment of obesity, dietary interventions and treatment alternatives are examined and evaluated, then prevention of obesity is discussed. Chapters 10 and 11 then look at the other end of the spectrum and focuses upon eating disorders such as anorexia nervosa and bulimia nervosa. Chapter 10 looks at the prevalence, causes, physiological and psychological consequences and complications of both anorexia nervosa and bulimia nervosa. Psychological and physical sequalae of eating disorders are examined and the different theoretical approaches to understanding these disorders are critically evaluated. Chapter 11 discusses how the theories of the aetiology of eating disorders translate into treatment practice and evaluates the successfulness of individual and combined eating disorder treatments. Chapter 12 re-examines the literature reviewed and evaluated in the precious chapters and elicits the common themes that have emerged from the different areas and perspectives. The themes are then synthesised into a coherent comprehensive psychological model of eating behaviour. This model integrates both individual factors such as gender, cognitions and biological factors and social context factors such as social norms and family influences thus Ogden suggests that diet originates from the interface between individual and social factors and is mediated through control, conflict and communication. On the whole the book is clear and wellwritten that is easy to read and 73

Book Reviews

interesting. It provides a very detailed and useful explanation, evaluation and interpretation of a number of theoretical and disciplinary perspectives that have attempted to provide an understanding of the spectrum of eating behaviours. It draws the vast literature together in an understandable and coherent manner and provides an insight into the psychological mechanisms involved in eating behaviours from healthy eating, through food choice, body dissatisfaction and dieting to disordered eating behaviours in obesity,

anorexia and bulimia. Therefore, this book may be of use to undergraduates, postgraduates and researchers from many different disciplines interested in the study of diet, eating, and eating disorders and may hopefully stimulate multi-disciplinary research within the field of eating behaviours. Heather Semper School of Education, Health and Science, Centre for Psychological Research in Health and Cognition, University of Derby.

Congenital Hemiplegia B. Neville & R Goodman MacKeith Press, 2001; ISBN 1-898-68319-0; pp.200. Reviewed by Catherine Smith
This interesting book provides a range of perspectives on congenital hemiplegia, leaving the reader feeling objectively informed. Each of the 15 short chapters has been contributed by different authors, who include Consultant Paediatric Neurologists, a Paediatric Neuroradiologist, and a Clinical and Research Psychologist. Neville and Goodman, themselves a Professor of Paediatric Neurology and Professor of Brain and Behavioural Medicine respectively, also provide contributions. They have brought together worldwide expertise, which adds to the books objectivity. Topics cover aetiology, clinical presentation, physical assessment, management options, and supporting parents of children with congenital hemiplegia, amongst others. Photographs, diagrams, charts and tables clearly illustrate many of the points made, without being overwhelming. The text is a good all round resource, which may appeal to a range of health professionals. Its information and advice is practical, and the editors have managed to cover a wealth of factors. It is probably best described as an ideal guide to the spectrum of issues concerning congenital 74 hemiplegia, from which interested individuals could go on to pursue selected issues in greater depth. Bearing in mind that the editors have prepared this as a resource for the clinician, the more clinically-orientated chapters are very thorough, examining trends in the prevalence of hemiplegia, providing a detailed focus on its neurology/neuropathology/ neuro-radiology, discussing impairments, examination of a child, and gait analysis and abnormalities. It usefully touches upon the child in later life, which Goodman in his introduction recognises as a frequent concern for the family, however, this is only very briefly addressed in the main body of the book, and so perhaps could have been explored further in terms of the long-term prognosis of the condition. Whilst clinically useful, this book alone may not be able to provide what those with more specific interests in some areas are seeking, particularly those which are less-clinical. Chapters relating to what could be termed as more social aspects of the condition could be a disappointment to some readers. Whilst a good chapter on emotional, behavioural and social conse-

Book Reviews

quences is included, other very interesting chapters on educational management, the aforementioned supporting of parents, and on a community-level service for children with congenital hemiplegia, are each as brief as between four and seven pages in length, and left me wanting more, as what they offered was excellent. Despite this, they do provide useful references, and make easier reading for those with a non-clinical background. As I myself have a younger brother with congenital hemiplegia, I have for sometime loosely read around the topic, in the context of many of the physical, educational, social and psychological difficulties

it poses to those with the condition and their families. I feel that whilst much of this book is quite scientific, many of the topics covered would in theory be of interest to the layperson/parents in understanding congenital hemiplegia, in addition to the texts appeal to the health profession. Overall, it is well structured, a valuable evidence-based resource, and would be a good introduction to anyone looking to research aspects of the condition in greater detail. A helpful index is provided. Catherine Smith University of Manchester.

Counselling for Eating Disorders S. Gilbert Sage Publications, 2001; ISBN 0-803-97725-5; pp.187. Reviewed by Erika Borkoles
Sara Gilberts book is a must for all health professionals who work with patients with eating disorders. Her clinical experience and knowledge that she coherently contextualised for the purpose of this book is an invaluable source for practitioners and patients alike. Although the book draws attention to the similarities between people with similar eating disorder types and offers a how to do it stance, she clearly warns practitioners that each clients expression of disorder is individual (p.134). This ethos is followed through the chapters. She urges readers to recognise the complexity of the situation in which eating disorders are treated within the UK and calls for practitioners to collaborate and work together to help patients to recover from their often very problematic and long term illness. In the first two chapters she explores the definitions and causes of eating disorders, recognising that even evidencebased research is often equivocal when classifications are considered. Chapter 1 describes the behaviour, eating habits and physical symptoms of people with disorders of eating. I particularly liked her view on obesity and eating disorders as she addressed the concerns these patients had in the past and still have today. Obese patients without co-morbidities were often dismissed at a primary care level as not having a problem because they did not fit into any previously known category of psychiatric or physical disorder. Sara Gilberts view is that despite a lack of available categories at the classification stage for the obese client, practitioners should recognise the complex motivations of people unable to prevent themselves from abusing their bodies, and that these symptoms needs to be addressed. In Chapter 2, she explored a plethora of hypotheses for the development of eating disorders, including stress induced and comfort eating, family as a source of eating disorder and so forth. From personal experience working in a family therapy setting, I was thrilled to read her 75

Book Reviews

suggestions to use family therapy as a treatment for eating disorders especially at a younger age. It makes sense. In Chapter 3, she introduces the reader to the Cognitive Behavioural Educational Approach to eating disorders. Her definition of what therapy should be like for people with eating disorder is still unique and was very resonant with me. She states that the approach a therapist should take is a behavioural one with psychoeducational and cognitive approaches in helping clients both to monitor and change behaviour and to explore and evaluate their ways of thinking about their eating disorder and the world and experiment with alternatives (p.39). In other words, she advocates that any eating disorder should be tackled by the combination of practical, behavioural and educational approaches and that the therapists role should be both of a teacher and of a listener. She adopts a non-critical therapeutic framework where the therapist is guiding patients by sharing information and operates on an equal footing with them. In Chapter 4, the author is very thorough in describing the essential process of assessing patients before they enter to therapy. She calls for the triangulation of different sources of assessment and provides a very useful and comprehensive list of questionnaires and templates for questioning the client about their attitude to food and dieting; exploring their weight and dieting history; and the situational factors of their illness. In Chapter 5, the author emphasises that all patients with eating disorders have distorted beliefs about what constitutes good nutrition and about

how weight is gained or lost. She rightly calls for the dietitian and the psychological therapy provider to work together so that the patient would receive a coherent and channelled advice from both professionals. In establishing their respective roles, she recognises that the dietitian needs to understand underlying psychological processes and in the same token the therapist should have some basic nutritional knowledge too. In Chapters 7 and 8, the author makes a clear distinction between what cognitive and behavioural techniques are, however, this is only for practical reasons. She warns that the separation of behavioural from cognitive techniques is of course entirely a false one as behaviour is often influenced by cognitions (p.92). In Chapter 9, she discusses how to end the counselling relationship, which is often a difficult process. She provides useful tips for preventing relapse and how to enable patients to continue on strengthening their own progress through therapy. The Appendices are very useful, in particular Appendix 2, a reading list for clients. Overall, in this book Sara Gilbert illustrates her therapeutic work through case studies that are highly informative and practical. This book is very up-to-date, engaging, and extremely insightful about the nature of eating disorders and about the skills that practitioners need to acquire and use to help patients with eating disorders. Highly recommended. Erika Borkoles School of Leisure and Sports Studies, Leeds Metropolitan University.

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Book Reviews

Human Aggression R.G. Geen Open University Press, 2000; ISBN 0-803-97725-5; pp.170. Reviewed by Erika Borkoles
This book attempts to acquaint the reader with the origins of human aggression and its corresponding theoretical framework. However, I feel that the book could be better organised in order to achieve coherence in explaining a very complex behaviour. The book consists of eight chapters. In Chapter 1, the author offers several definitions for aggression and rightly concludes that current definitions supported by research findings are still inadequate. I was surprised that instrumental aggression was somewhat dismissed by the author, when in a sporting context this definition is a very real one (e.g. boxing and knockout). Russell Geen goes on to discuss the nature vs. nurture explanations for aggression and supports previous research findings that in explaining human aggression one has to take account of both heritability and social learning cues. He presents some interesting research findings around inter-male competition. In other words, cited research proposed that mere perception of victory or loss could be sufficient to influence the rise or lowering of testosterone levels within individuals. The author also draws attention to methodological flaws in the study of human aggression and this continues throughout the book. In Chapter 2, Geen explores the circumstances around the provocation of aggression. One of the interesting research findings was that individuals were much more able to cope with their own aggression if they perceived that they are in control of the situation and, therefore, themselves. This chapter struggles to present a coherent story. For example, the General Affective Aggression Theory is discussed and alluded to in Chapter 2, however, its full description only appears in Chapter 3 and there are numerous examples like this throughout the book. Chapter 3 explores the intervening processes in aggression. As an exercise psychologist I found interesting the concept of excitation transfer. A study by Zillman (1972) was cited by the author. Zillman first aroused subjects by an experimental confederate, then half of the subjects were told to do strenuous physical exercise by riding a bicycle, and the other half were told to perform a sedentary task. He found that those who were in the strenuous exercise condition were significantly more angry than those who did a sedentary task. Furthermore, Zillman found that if arousal was perceived as hostile, it influenced aggression far beyond the time at which arousal has dissipated. Indeed this studys findings confirmed other studies findings which called for a caution to use exercise as a therapeutic tool when one is clinically anxious or over aroused because it might make the persons anxiousness/ arousal worse. Again, this chapter too could have benefited from more coherence. For example, how does the alcohol, cognitive processing and aggression section fit with the rest? In Chapter 4, the author revisits the background variables that are discussed previously in Chapter 2. Why not discuss all background variables together? Again on page 67 he talks about the Buss-Perry Aggression Questionnaire but it is not described until much later on. The assessment of aggressiveness section in this chapter could have been a lot more comprehensive and encompassing. It would have been useful to present the mentioned questionnaires in the Appendices. In Chapter 5, Geen extensively discusses violence, however, he fails to make a conceptual distinction between aggression and violence. There is 77

Book Reviews/Books for Review

also very little discussion about the relationship between the two. Chapter 6 concentrates on aggression and entertainment. The spectator aggression at sporting events section could have included more recent studies from the sport and exercise psychology literature. Chapter 7 is the most interesting one for health psychologists since it deals with the relationship between hostility and health. There are some good studies cited here, like Miller et al. (1996) who found that it is likely that hostile people show greater physiological reactivity to stressful situations than less hostile ones. They concluded that the stress and strain on the bodys vital organs promote the risk of developing heart disease. Yet again, the behavioural consequences of aggression could have been more related to the theme

of the first half of this chapter. The final chapter offered an overall schematic explanation of affective aggression, supported by a good diagram on page 139. However, at the end of the chapter the text is again very fragmented. I found this an interesting read. It was essentially a scientific text that was well supported with research evidence. However, overall, the book could have benefited from a clearer organisation of the content, but at the end of each chapter there is a good summary section and a useful suggested reading list. Erika Borkoles School of Leisure and Sports Studies, Leeds Metropolitan University.

Books for Review

HE FOLLOWING BOOKS have been sent to HPU for review. If you would like to review one of these books, please contact Dr Rory OConnor. Also, we particularly welcome reviews of books or multimedia that are not listed here but which would be of interest to health psychologists. Contact: Dr Rory OConnor, Department of Psychology, University of Stirling. E-mail: roryoc@orange.net

Arcinegas, D.B. & Beresford, T.P. (2001). Neuropsychiatry. An Introductory Approach (pp.460). Cambridge University Press. Ballard, K. (2003). Understanding Menopause (pp.144). John Wiley & Sons Ltd. Bancroft, G. & OSullivan, G. (2000). Foundations in Quantitative Business Techniques (pp.341). McGraw-Hill. Bates, T. (1999). Depression: The Common Sense Approach (pp.128). Newleaf. 78

Castle, D.J., McGrath, J. & Kulkarni, J. (2000). Women and Schizophrenia (pp.151). Cambridge University Press. Cooper, H. (2002). The Alphabet of Paradise (pp.144). Darton Longman & Todd. Darnley, S. & Millar, B. (2003). Understanding Irritable Bowel Syndrome (pp.134). John Wiley & Sons Ltd. Davar, B.V. (Ed). (2001). Mental Health from a Gender Perspective (pp.360). Sage Publications Ltd.

Books for Review

Dickenson, D.L. (Ed.) (2002). Ethical Issues in Maternal-Fetal Medicine (pp.366). Cambridge University Press. Dunn, J. (2000). Think Like a Shrink and Keep Yourself Sane (pp.220). Newleaf. Evans, P., Hucklebridge, F. & Clow, A. (2000). Mind, Immunity & Health: The Science of Psychoneuroimmunology (pp.195). Free Association Books. Fernandez-Alvarez, E. & Aicardi, J. (2001). Movement Disorders in Children (pp.272). MacKeith Press. Field, A. (2003). Clinical Psychology (pp.136). Crucial. Forshaw, M. (2002). Essential Health Psychology (pp.242). Arnold. Gafner, G. & Benson, S. (2003). Hypnotic Techniques: For Standard Psychotherapy and Formal Hypnosis (pp.224). Norton. Harris, P. (2002). Designing and Reporting Experiments in Psychology (pp.247). Open University Press. Jason, L.A., Fennell, P.A. & Taylor, R.R. (2003). Handbook of Chronic Fatigue Syndrome (pp.793). John Wiley & Sons Ltd. Joynson, D.H.M. & Wreghitt, T.G. (2001). Toxoplasmosis. A Comprehensive Clincial Guide (pp.410). Cambridge University Press. Kaufman, A.S. & Kaufman, N.L. (2001). Specific Learning Disabilities and Difficulties in Children and Adolescents (pp.240). Cambridge University Press. Kovacs, GT. (2000). Polycystic Ovary Syndrome (pp.240). Cambridge University Press.

Kremer, J., Sheehy, N., Reilly, J., Trew, K. & Muldoon, O. (2003). Applying Social Psychology (pp.256). Palgrave. Leslie, J.C. (2002). Essential Behaviour Analysis (pp.240). Arnold. Marks, D.F. & Yardley, L. (2003). Research Methods for Clinical and Health Psychology (pp.256). Sage Publications Ltd. Memon, A., Vrij, A. & Bull, R. (2003). Psychology and Law (2nd ed.) (pp. 236). John Wiley & Sons Ltd. Nasser, M., Katzman, M. & Gordon, R. (2002). Eating Disorders and Cultures in Transition (pp.224). Brunner-Routledge. Papadopoulos, L. & Walker, C. (2003). Understanding Skin Problems (pp.108). John Wiley & Sons Ltd. Remschmidt, H. (2001). Schizophrenia in Children and Adolescents (pp.324). Cambridge University Press. Remschmidt, H. (2001). Psychotherapy with Children and Adolescents (pp.600). Cambridge University Press. Rose, J. (2002). Sharing Spaces? Prayer and the Counselling Relationship (pp.192). Darton, Longman & Todd Ltd. Rothschild, B. (2003). The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD (pp.224). Norton. Stahl, S.M. (2002). Essential Psychopharmacology of Antipsychotics and Mood Stablizers (pp.160). Cambridge University Press. Tantum, D. (2002). Psychotherapy and Counselling in Practice (pp.334). Cambridge University Press. 79

Books for Review

Tinsley, B.J. (2003). How Children Learn to be Healthy (pp.198). Cambridge University Press. Titman, P. (2003). Understanding Childhood Eczema (pp.120). John Wiley & Sons Ltd. Vingerhoets, J.J.M. & Cornelius, R.R. (2001). Adult Crying. A Biopsychosocial Approach (pp.352). Brunner-Routledge.

Ward, N.G. & Maxmen, J.S. (2002). Psychotropic Drugs: Fast Facts (3rd ed.) (pp.450). Norton. Webster, R.A. (2001). Neurotransmitters, Drugs and Brain Function (pp. 534). John Wiley & Sons Ltd. Wilkinson, S.R. (2003). Coping and Complaining (pp.336). BrunnerRoutledge.

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Forthcoming Events

Forthcoming Events
2003 Until 16 November 2003 Medicine Man: The Forgotten Museum of Henry Wellcome The British Museum, London. Items from Henry Wellcomes medical artefacts collection. Exhibits include 18th century Chinese diagnostic dolls, African masks, birthing chairs, amputation saws, prosthetics, ancient manuscripts and Napoleons toothbrush! Admission free. Website for opening times and related talks: www.thebritishmuseum.ac.uk 1922 October 2003 International Healthy Cities Conference 2003 The Power of Local Action: 15 years Experience Belfast. Themes: Health, sustainability, equity, urban development and community empowerment. Contact: Belfast Healthy Cities: Tel: + 44 28 9032 8811 E-mail: info@belfasthealthycities.com 2324 October 2003 Complementary Therapies and Nursing: Diversity in Practice (Royal College of Nursing Complementary Therapies in Nursing Forum Annual Conference) York. Aim: Explore the integration of CTs into practice. Contact: Vicky Langley, RCN Events, 20 Cavendish Square, London W1G 0RN. Tel: 020 7647 3579 E-mail: comptherapies@rcn.org.uk Website: www.rcn.org.uk 2325 October 2003 3rd International Symposium on Obesity and Hypertension Berlin. Content: Genetics; central and peripheral mechanisms; cardiovascular and metabolic risk; adipose tissue biology; diet, exercise and treatment. Registration deadline: 15 October 2003. Contact: Friedrich C Luft, Max Delbrueck Centre for Molecular Medicine. E-mail: luft@fvk.charite-buch.de Tel: + 49 30 9417 2206 Website: www.iotf.org 2426 October 2003 3rd World Congress in Mens Health (International Society for Mens Health) Vienna. Main topics: Erectile dysfunction and male sexual health; voiding dysfunction; cancer (prevention, diagnosis and treatment); male cardiovascular disease; osteoporosis; mood disorders; from anger to depression; puberty; communication with male patients and mens health: a view from general urology, general practice and general internal medicine. Website: www.univie.ac.at/wcmh/website/ 5 November 2003 Eating Disorders Association Regional Training Day Birmingham. Cost: 120. Online booking form: www.edauk.com E-mail: info@edauk.com 1314 November 2003 Interpersonal Therapy Workshop (British Association for Behavioural and Cognitive Psychotherapies: North West Branch: Two-day workshop: Dominic Lam, Institute of Psychiatry) 81

Forthcoming Events

Heywood, Manchester. Aims: Introduction and overview to IPT treatment methods: key principles of IPT including clinical strategies and techniques. Contact: hildegard.schakel@penninecare.nhs.uk Tel: 01706 754070 Website registration: www.babcp.com/training/ training13register.htm 17 November 2003 Special Interest Group in Oncology and Palliative Care (SIGOPAC) Meeting (Division of Clinical Psychology) Royal Marsden Hospital Education and Conference Centre, Fulham, London. Includes: Presentations on Solution Focused Therapy, introduction to neuro-oncology, and art therapy with people with cancer. Cost: 10 for SIGOPAC members or 15 for non-members (includes lunch). Bookings: Ann Orr, 4th Floor, University Hospital of Hartlepool, Holdforth Road, Hartlepool TS9 2AH. To join SIGOPAC: contact Dr James Brennan, Bristol Haematology & Oncology Centre, Horfield Road, Bristol BS2 8ED. 18 November 2003 Understanding Whitehall and Government: The Health Sector One-day seminar (also available on 11 December 2003) London. Seminar to consider the drivers and implications of government health policy. Cost: 400 plus VAT. Tel: 020 7324 4330 (Neil Stewart Associates) E-mail: info@neilstewartassociates.co.uk Website including registration: www.neilstewartassociates.com

1 December 2003 Eating Disorders Association Regional Training Day Leeds. Cost: 120. Online booking form: www.edauk.com E-mail: info@edauk.com 15 December 2003 Living on the edge: healthcare within the community Royal Society of Medicine, London. Sessions: Where is the gap? Barriers to access. Closing the gap: models of good practice. Contact: RSM Administration: Jennifer Lake. Tel: 020 7290 3919 Website: www.rsm.ac.uk/academ/ 232-edge.htm 2004 January 2004 (date to be confirmed) Short Course in Medical Humanities (Centre for Medical Humanities, UCL) Royal Free and University College London Archway Campus. Workshops based around literature, art and creative writing to explore the arts-medicine interface. Course fee: 295. Contact: Heather Mitchell, Centre for Medical Humanities. Tel: 020 7288 3597 E-mail: heather.mitchell@pcps.ucl.ac.uk Website: www.pcps.ucl.ac.uk/cmh 18 February 2004 Pelvic Dysfunction in Women: Key Advances Royal Society of Medicine, London. Content: Pelvic pain, urinary incontinence, congenital abnormalities and their aftermath, pelvic infection. E-mail: events@rsm.ac.uk Website: www.rsm.ac.uk/academ/ 050-pelvic.htm

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Forthcoming Events

510 March 2004 International Society for Affective Disorders Conference Cancun, Mexico. Register for details: isad@soton.ac.uk Website: www.isad.org.uk 1618 March 2004 MIND Annual Conference Harrogate. Website to register for details: www.mind.org.uk/events/ events_conference.asp 2425 March 2004 Womens Health: An Holistic Approach (RCN Womens Health joint conference and exhibition) York. Contact: Jeanette Staddon, RCN Events, Copse Walk, Cardiff Gate Business Park, Cardiff CF23 8XG. Tel: 029 2054 6493 E-mail: womenshealth@rcn.org.uk Website: www.rcn.org.uk 30 March2 April 2004 The Pain Society Annual Scientific Meeting Manchester. Tel: 020 7631 8870 E-mail: meetings@painsociety.org Website: www.painsociety.org 1517 April 2004 4th European Oncology Nursing Society Spring Convention (Federation of European Cancer Societies) Edinburgh. Themes: Quality of life, new developments in oncology: implications for nursing, carers and family members. Abstract deadline: 15 December 2003. E-mail: EONS4@fecs.be Website: www.fecs.be/conferences/eons4

1922 April 2004 12th UK Annual Public Health Forum (UK Public Health Association) Brighton. E-mail: info@ukpha.org.uk Website to register for details: www.phaworldcongress.com 1619 May 2004 14th International Congress of Psychosomatic Obstetrics and Gynaecology Edinburgh Conference Centre. Topics: Include AIDS, abortion, eating problems, ethics, infertility, menopause, post natal depression and sexual dysfunction. Abstracts for themed paper sessions, free communications (deadline of 3 October 2003) and posters (deadline of 12 January 2004) are invited. Contact: ISPOG2004, Meeting Makers, Jordanhill Campus, 76 Southbrae Drive Glasgow G13 1PP. Tel: + 44 (0)141 434 1500 E-mail: ispog2004@meetingmakers.co.uk or Professor Beth Alder E-mail: e.m.alder@napier.ac.uk Website: www.ispog2004.org 30 May3 June 2004 6th European Congress on Epileptology Vienna. Main topics: New treatment options; epilepsy syndromes; psychiatric implications of treatment, and remission vs refractoriness. Abstract submission deadline: 12 December 2003. Contact: ILAE Congress Secretariat Tel: + 35 31 409 7796 E-mail: vienna@epilepsycongress.org Website: www.epilepsyvienna2004.org

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Forthcoming Events

1215 June 2004 Heart Failure Update 2004: From Hippocrates to Hypotheses Wroclaw, Poland. Content: Pathophysiology, epidemiology, prognosis, management and prevention. Abstract deadline: January 2004. Website: www.escardio.org 58 July 2004 Positive Psychology: 2nd European Conference Lago Maggiore, Italy. New theoretical perspectives and applications of positive psychology in areas including health, education, work, social policy and intercultural relations. Speakers include Martin Seligman, Mihaly Csikszentmihalyi, Felicia Huppert and Ruut Veenhoven. Abstract submission deadline for paper and poster presentations: 15 December 2003. Early registration fees (pre- 28 February 2004): 200 Euro (150 Euro for students). Contact: Andrea Fianco-Manuela Lombardi. Tel: + 39 02 5031 9703 Fax: + 39 02 5031 9705 E-mail: andrea.fianco@unimi.it 69 July 2004 30th British Congress of Obstetrics and Gynaecology SEEC, Glasgow. Website including registration for details: www.bcog2004.co.uk

2024 July 2004 World Congress of Behavioral and Cognitive Therapies Kobe, Japan. Abstract submission deadline for symposia, panels and posters: 18 October 2003. Contact: Professor Yuji Sakano E-mail: WCBCT2004@congre.co.jp

2528 August 2004 8th International Congress of Behavioral Medicine Mainz, Germany. Theme: Integrating social and behavioural sciences with medicine and public health. Website: www.psycho.sowi. uni-mainz.de/abteil/kl/subsites/icbm/ 1823 September 2004 12th World Congress of Psychophysiology: The Olympics of the Brain (International Organisation of Psychophysiology) Thessaloniki, Greece. Abstract submission deadline for symposia, workshops and poster presentations: 25 April 2004. Website with submission guidelines: www.iop-world-org/iop2004

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News of Members

News of Members
In Memory of Dr Stephen Wright (19572003)
Many colleagues will have heard the very sad news of the untimely death of Dr Stephen Wright, Clinical Psychologist, in April 2003. We would firstly like to express, on behalf of the psychology community, our deepest sympathies to Stephens family. The news of Stephens death came as a major shock not only to those of us who knew Stephen well and worked with him but also to colleagues across many different disciplines and geographical boundaries a wide network, the size of which bears testament to Stephens considerable contribution to the fields of clinical health psychology and health care. Stephen completed his clinical psychology training at the University of Leeds in 1991. However, an indication of his excellent contribution to clinical research in later years was that he had already completed his PhD in psychology before then and had started to build up his impressive list of publications. After a brief spell as Lecturer in Health Psychology with Gloucestershire Health Authority, Stephen went on to develop his clinical and research interests in clinical health psychology and worked for several years within the Medical Psychology Department in Leicester. Through his clinical research, membership of various BPS and Health Psychology committees and sitting on the editorial boards of a number of journals, he was at the forefront of developments in health psychology research and teaching in the UK. While Stephen became a very wellrespected applied researcher in health psychology in his own right (Stephen would have chuckled at this unintentional pun!) and often collaborated with some big names in the field of health research, one of our abiding memories of him is of his own sense of modesty and his determination to avoid complacency. He was totally committed to developing high quality research and built up an excellent track record of attracting research funding, completing projects, presenting at conferences and publishing. Stephen took a lead role in research consultancy and supervision for health care workers and research staff across many disciplines. He also successfully supervised numerous student projects from undergraduate level right up to doctoral level. Apart from his legendary technical expertise, one of Stephens strengths was his sheer enthusiasm for applied health research and we know that he willingly put in many extra hours and considerable further work, in his own time, on any project that he was involved with. Stephens talents undoubtedly lay in applied clinical research but he was also a dedicated clinician and it was instructive to observe his meticulous preparation for client work. In many ways he was a true scientist-practitioner who was prepared to innovate. Many people within psychology and other health care fields owe a big debt of gratitude to Stephen for helping them in some way with specific projects and sometimes, with their subsequent careers. He was always willing to help and was a reservoir of useful knowledge, suggestions and resources. Away from psychology, Stephen was a private person but he certainly enjoyed company and was always very warm, welcoming and humorous. He often talked fondly about his family, particularly his parents and, his brother and his family. Stephens modesty extended to his undiscovered football talents his young nephew mentioned that Uncle Stephen had recently beaten him 100 in a game of shoot at the goalkeeper! Stephen was 85

News of Members

also an ardent environmentalist and an enthusiastic cyclist! Never mind the impressive scientific papers Stephen enjoyed mentioning an article in New Cyclist magazine in 1988 entitled Why on earth do we do it? written by him! Stephen will be missed very much and his death is a great loss to clinical health psychology and allied disciplines. To the

authors, Stephen was also a friend as well as a respected colleague. The biggest compliment we can pay Stephen is that through good times and bad he maintained a level-headed approach and continued to have positive faith in life and in others around him. Aftab Laher & Sam Lewis

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WE NEED REFEREES!
Due to an increase in the number of papers and articles submitted to HPU, the editorial team are looking for DHP members who are willing to act as Referees. You would be sent no more than four articles to review each year by e-mail, and you would be asked to return each review within two weeks of us sending a paper to you. If you are interested in becoming a Referee for HPU, then please complete the information requested below: Name: ............................................................................................................................... Address:............................................................................................................................ .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... E-mail: .............................................................................................................................. Telephone number: .......................................................................................................... Please list below the specific area(s) of Health Psychology that you have expertise in, and would be willing to act as a Referee for: .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... Would you consider reviewing papers on more general topics and issues in Health Psychology? .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... Please take the time to send to: Dr Neil Coulson, Centre for Psychological Research in Health and Cognition, University of Derby, Western Road, Mickleover, DE3 9GX. E-mail: n.s.coulson@derby.ac.uk If you have any questions about Refereeing for HPU, please get in touch with Neil or Diana (full contact details are given on the inside back cover).

87

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88

Notes for contributors to Health Psychology Update

Health Psychology Update (HPU) editors invite contributions from all areas of health psychology including experimental and clinical research, the aetiology and management of acute and chronic illness, research into health behaviours and health promotion and psychological aspects of clinical interventions and the health care system. Articles (including extended articles) may provide a broad overview of a particular area or issue, review the literature, include original research, discuss and debate theory, practical or professional problems in health psychology. The editors would also like to encourage the submission of book reviews, short research reports, letters, news of members, work in progress and news of forthcoming events. Guidelines for submission to HPU Empirical articles, extended articles and short research reports should be clearly written as for an educated audience but non-specialist, with non-technical language and aim to engage the interest of the membership at large. Sexist, racist and other discriminatory or devaluing language should be avoided. Articles should be between 8002000 words (excluding references). Extended articles should be between 20004000 words (excluding references) and a maximum of 800 words for brief research reports. All manuscripts should be typed on A4 paper, double-spaced, with complete references (kept to a reasonable minimum). Full bibliographic references should be contained in the list of references at the end of each article (between 1015), listed alphabetically by author, be complete and accurate and in the format used in the British Journal of Health Psychology. Authors are asked to supply a PC-compatible 3.5" disk of the article at the time of submission. Submission of material by e-mail is strongly encouraged. Review Procedures HPU operates a policy of blind peer review by two independent referees for all original articles. Book reviews, material for Research in Brief, letters, conference reports and forthcoming events are not refereed but evaluated by the editors. Submissions should be sent to: Original research, extended articles, letters, news of members: Dr Neil Coulson (Co-ordinating Editor), Centre for Psychological Research in Health and Cognition, University of Derby, Western Road, Mickleover, Derbyshire, DE3 9GX. Tel: +44(0)870 040 7271. E-mail: n.s.coulson@derby.ac.uk Dr Diana Harcourt (Deputy Editor), Centre for Appearance Research, School of Counselling & Health Psychology, University of the West of England, St Matthias Campus, Oldbury Court Road, Fishponds, Bristol, BS16 2JP. Tel: +44(0)117 344 4303. E-mail: Diana2.Harcourt@uwe.ac.uk Brief research reports and work in progress: Dr Daryl OConnor, School of Psychology, University of Leeds, Leeds, LS2 9JT. E-mail: daryloc@psychology.leeds.ac.uk Articles relating to consultancy in health psychology: Dr Marcus Munaf, Cancer Research UK General Practice Research Group, Dept. of Clinical Pharmacology, University of Oxford, Oxford, OX2 6HE. E-mail: marcus.munafo@clinical-pharmacology.oxford.ac.uk Articles relating to the training of health psychologists: Dr Mark Cropley, Dept. of Psychology, University of Surrey, Guildford, Surrey, GU2 7XH. E-mail: mark.cropley@surrey.ac.uk Book Reviews: Dr Rory O Connor, Dept. of Psychology, University of Stirling, Stirling, FK9 4LA. E-mail: roryoc@orange.net Postgraduate Issues: Sarah Christie, Dept. of Psychology, Staffordshire University, Mellor Building, College Road, Stoke-on-Trent, ST4 2DE. E-mail: slc2@staffs.ac.uk Forthcoming events: Pauline Fox, Dept. of Psychology, The Wolfson Institute of Health Sciences, Thames Valley University, St. Marys Road, London, W5 5RF. E-mail: pauline.fox@tvu.ac.uk Dates for submission: For publication in January 2004 issue 24 October 2003. April 2004 issue 23 January 2004; July 2004 issue 23 April 2004; October 2004 issue 23 July 2004

Contents

continued Volume 12 Issue 4

32 Regulars A profile of health psychology at 65 Queen Margaret College University Jane Turnbull & Joyce Willock A profile of health psychology at University College London Lynn B. Myers Book Reviews The Psychology of Eating Heather Semper Congenital Hemiplegia Catherine Smith Counselling for Eating Disorders Erika Borkoles Human Agression Erika Borkoles Books for Review Forthcoming Events News of Members 69

Dental anxiety and oral health promotion Sara Cox, Katie Clarke & Tom Cox Testing implementation intentions in the field: Is non-intentional non-adherence really a problem? Cath Jackson, Rebecca Lawton & Mark Conner

35

Getting together to prevent falling 38 in older people: A multidisciplinary and multinational approach Maggie Donovan-Hall & Lucy Yardley The BPS Stage 1 qualification in health psychology James Elander 40

72 74 75 77 78 81 85

Stage 2 training: How do we 49 acquire and demonstrate competence in consultancy? Sandra Horn Stalkers and their victims: Some psychological implications Mike Berry & Sarah Rockliff 51

Some characteristics of 7289 56 cases of rape and sexual assault seen at St. Marys Sexual Assault Referral Centre since 1986 Iain McLean & Val Balding A career in mental health promotion Tonja Schmidt 62

The British Psychological Society 2003

The British Psychological Society St Andrews House 48 Princess Road East Leicester LE1 7DR