Is psychology a sexist discipline? Reflections on The Patient Gloria

In 1964, Gloria Szymanski was recruited by her therapist, Everett Shostrom, to take part in a series of films demonstrating psychotherapy. Shostrom also recruited three leading psychotherapists: Carl Rogers, creator of ‘person-centred therapy’ (widely known as ‘counselling’), Fritz Perls, creator of ‘Gestalt therapy’ and Albert Ellis, creator of ‘Rational Emotive Behaviour Therapy’. Shostrom told Szymanski the videos would be used solely for education purposes. He lied. He later turned the videos into a motion picture, ‘Three Approaches to Psychotherapy’ which was shown in cinemas and on TV. You can still watch it on YouTube today. Szymanski took legal action, but it was unsuccessful.

Last week, I went to see “The Patient Gloria” at Traverse Theatre; a production based on the videos and Szymanski’s experiences. The play combined re-interpretations of the therapy scenes with narration, music and dancing. It took a highly sceptical view of the therapies, highlighting each therapist’s stereotyped interactions with Szymanski (“Rogers is paternal, Perls aggressive and Ellis is predatory”, an information sheet handed out before the play explained). Gina Moxley played all three therapists and also narrated the play, comparing her own experiences of harassment and negative treatment by men with Szymanski’s experiences at the hands of Shostrom and the therapists.

The Patient Gloria

The play was, I think, intended to provoke thought about gender issues; about relationships between men and women and how the ill-treatment of women is often overlooked. As a Clinical Psychologist, my thoughts moved in a slightly different direction. Mainly I was struck by one thing: all three therapists in The Patient Gloria were men. They were therapists I was familiar with, though not the ones who created Cognitive Behaviour Therapy, the psychological approach I use. No: that therapy was created by another man, Aaron Tim Beck. In fact the more I reflected, the more I realised that male views have had a disproportionate impact on the field of psychology. I found this most troubling because psychology is a female-dominated discipline: 80% of undergraduates and around 85% of Clinical Psychologists are women. I began to wonder: is psychology sexist, and is the discipline disproportionately influenced by male views?

In brief: yes

A quick look at the statistics concerning men and women in education and academic psychology would suggest this is the case. While around 80% of psychology undergraduates and Master’s students are women, this drops to 69% at PhD level. It drops further to 63% at Lecturer level and then to 33% at Professor level*. I also did an analysis of the male:female ratio of heads of psychology departments at Russell Group universities (for my advanced spreadsheet, see below). Similar with the ratio of Professors, this suggested that only 36% Of current UK psychology department heads are women. This pattern is a classic version of the “leaky pipeline”: women seem to get lost along the career progression trajectory, until only a minority remain in the most senior positions.

psychology heads of school

No bias in education and training

To be clear, there does not appear to be any bias at the point of enrolling students into educational courses. For example, with undergraduates, females tend to be slightly more successful than males at the application stage, and this has been attributed to females achieving higher grades overall. Similarly, for psychology graduates seeking to enrol onto a competitive Clinical Psychology Doctorate programme, the statistics show no evidence of an anti-female gender bias.

A complex picture

So, when and how do women get lost along the way? The Athena Swan Charter was created in 2005 to address issues of gender inequality in higher education, and academic schools now monitor and report their action on gender equality in order to gain awards (Bronze, Silver, Gold). Some of these reports are available online, and show that the issues are not straightforward. As the School of Psychology at the University of Birmingham reported in their Athena Swan Silver Application, they have tended to receive far more applications for professorial positions from men than women. In fact, over a 3-year period, they reported receiving 3 applications from women, compared with 29 from men.

Part of a wider academic problem?

One possibility is that the inequalities seen in psychology are part of a wider gender bias in academic outcome indicators. For example, an analysis of grants submitted to the Gates Foundation found that those led by women were 16% less likely to get funded than those led by men. Furthermore, where grants are awarded to women, they tend to be for smaller amounts of money. An analysis of funding awarded by the Engineering and Physical Sciences Research Council (EPSRC) found that on average, grants awarded to women were 40% smaller than those awarded to men. There is also some evidence to suggest that research papers written by women are less likely to be accepted by journals.

Part of a wider societal problem?

Another possibility is that the gender patterns present in psychology careers simply reflect patterns present in wider society. For example, an analysis of the Foreign and Commonwealth Office found that women were overly represented in junior grades; only 30% of employees in senior management were women. Furthermore, those women who were employed in senior management earned on average 6.5% less than men in the same category of job. Nationwide, the hourly wage gender pay gap for full-time employees has been estimated to stand at around 8.6%. About 40% of the pay gap between men and women is unexplained, indicating that it could be due to bias.

What has all of this got to do with Gloria Szymanski?

The three approaches to psychotherapy demonstrated in The Patient Gloria involved four prominent men: Carl Rogers; Fritz Perls, Albert Ellis and the instigator, Everett Shostrom. All men benefited in having their ideas broadcast worldwide, gaining international recognition for their work. Szymanski, the only woman in the equation, paid a high price for their gain. Her personal views and experiences were laid bare for public dissection. Furthermore, none of this was necessary. I have made several successful videos on YouTube which aim to demonstrate therapeutic techniques; these have been viewed over a million times and are now used by healthcare organisations and universities internationally. Crucially, none of these has sought to demonstrate therapy with a real patient. ALL of the demonstration videos have used actors. Contrary to the concept behind the Gloria videos: most people can’t tell. If you don’t believe me, just read the number of comments underneath where someone is asking if the clients are real. So the question I am left with is: if the gender balance of leading psychologists was more equal, would Szymanski have suffered in the way that she did? Furthermore: would the videos have been created and promoted, at all?

 

The Patient Gloria is showing at Traverse Theatre in Edinburgh until August 25th.

 

*I have taken these statistics from the Athena Swan Gold application submitted by the School of Psychology at Queen’s University Belfast. While the report said it took the figures from 2014-15 HESA data, I was unable to locate the original data online, and so have relied upon second-hand reporting of these.

Healthcare workforce crisis: Why are so many staff leaving the NHS?

The NHS has a healthcare workforce crisis. It is estimated that 40,000 nursing and midwifery posts currently stand vacant – enough to fill Hong Kong Stadium. Furthermore, 68% of junior doctors report that staffing gaps occur often, which they suggest sometimes put patients’ safety at risk. To try and plug these gaps, there has been a focus on upping recruitment, with strategies aimed at funding training places in the UK and attracting more staff from overseas. However, it has been suggested that rather than being a problem of poor recruitment, the crisis is primarily driven by too many staff leaving. A quick look at the data supports this view: around 200,000 staff have left their NHS jobs every year since 2011, adding up to a combined total of 1.6 million over 8 years. Why is this? Here I explore the NHS dataset on ‘why staff leave’ to try and understand this problem.

The dataset

The data on ‘why staff leave’ has been recorded in a consistent manner since 2011/2012 and is available to download in a single excel file. There are 38 categories, ranging from ‘Death in Service’ to ‘Voluntary Resignation – Promotion’ (to download the original dataset, click here).

Concerning trends 

Overall, the number of staff leaving jobs every year has been fairly stable with around 200,000 leavers per year. However, given the workforce crisis, there is a need to increase staff retention, and there is no sign that this is happening. There is also evidence that staff are increasingly leaving for specific negative reasons:

  • More staff are leaving due to poor work-life balance. In fact, more than twice as many cited this as their main reason for leaving in 2018-19 than 2011-12. This fits with broader data indicating increasing rates of burnout (see my previous blog post on burnout in mental healthcare staff for more on this).
  • More staff are leaving due to a lack of opportunities. Over 4800 cited this as their main reason in 2018-19 – more than twice as many who cited this as their reason in 2011-12.
  • More staff are resigning for health reasons. Similar to patterns seen with work-life balance and lack of opportunities, over twice as many staff cited this as their main reason for leaving in 2018-19 compared with 2011-12 – 4479 compared with 2126.

 

reasons for leaving

 

Positive trends

Sometimes staff leave their jobs for positive reasons, and the dataset reveals trends in some of these areas.

  • More staff are resigning due to gaining promotions. Over 15000 cited this as their main reason for leaving in 2018-19 – double the number who did in 2011-12.
  • More staff are leaving to take up education and training opportunities. Remarkably, the pattern is similar to that seen with promotions. Nearly 5000 left for this reason in 2018-19 – twice as many who said this was their reason in 2011-12.

 

positive reasons for leaving

 

The need for caution

These results highlight some concerning trends which suggest that dissatisfaction with work is one factor contributing to the current healthcare workforce crisis. However, they also reveal some positives – more staff than ever are leaving for education, training or a more senior post. When considering this data, there are two key issues to bear in mind. First, just because a staff member has left their job, it doesn’t mean they’ve left the NHS or even their organisation – they may simply have switched to another role. Second, if a person has had a few job changes over this 8-year period, they will be represented multiple times within the dataset. Both these issues could inflate the overall impression of the problem provided by this analysis.

Four tips for building psychological resilience

Life is often stressful. These stresses can come in all shapes and sizes, from the burden of financial debt to the hassle of a fender-bender; from the heartache of a sick parent to the irritation of a late train. The bottom line is that whatever form it comes in, we can’t avoid stress. So what can we do about it? One obvious suggestion is to reduce the amount we’re exposed to: pay that bill a.s.a.p. and be careful to avoid other cars when parking in multi-storey car parks. This is good advice, but the reality is that not all stress can be avoided. For these types of stresses, it can help to increase our capacity to cope: our ‘psychological resilience’. But how can we do this? Here, I offer four tips based on research I have conducted into the factors that confer resilience.

1. Know your strengths: build your confidence. My research has shown that having high self-esteem helps people be resilient to stressful events. In a previous blog post, I outline one evidence-based technique for building self-esteem. Briefly, this works by encouraging you to consider your personal ‘strengths’ and then getting you to think of specific pieces of evidence which show that you have this strength. For example, if your strength is that you’re a good listener, a piece of evidence might be that a friend from work confided to you about their recent break-up last week. 

First though, you have to be willing to allow yourself to do this. When I deliver resilience training, many people I speak with are embarrassed to acknowledge the things they’re good at, for fear of appearing egotistical or narcissistic. This belief is both misleading and detrimental, as some individuals who are highly narcissistic in fact report low levels of underlying self-esteem. The reality is that knowing your strengths can help you to build a quiet confidence that will improve the way you work, and will not make you appear egotistical.

resilience

2. Learn to let yourself off the hook. Being a perfectionist is one of the worst things you can do for your mental health. It’s linked with higher levels of depression, anxiety and self-harm and it’s terrible for psychological resilience. What this tells us is that reducing our perfectionism could boost our psychological wellbeing and levels of resilience. There are misconceptions around perfectionism though, with people sometimes fearing that being less perfectionistic could make them less effective or high achieving. This isn’t the case. Perfectionism is about rigidity: it’s when people push themselves hard, no matter what. Being less perfectionistic involves self-awareness. It’s about knowing when to strive and push forward, and when to let yourself off the hook. If you’re a fitness enthusiast, this might involve knowing when it’s time to take a couple of days off training. If you’re a dedicated student, it might be knowing when it’s time take the afternoon off revision to see friends. For detailed suggestions on tackling perfectionism, see my previous blog post.

3. Focus on the future. When the present is no fun, it’s important to have things to look forward to, and research shows that having hope for the future can help us be more resilient. These don’t have to be big things, but they need to be clear in your mind. For example, you might enjoy going for a coffee and reading the paper, going for a walk in a park, or reading books. This practice is often incorporated into cognitive-behaviour therapy (CBT), and is called ‘pleasant event scheduling’. A recent study which tested the impact of pleasant event scheduling when done in isolation, without any of the other aspects of CBT, found it was effective in reducing risk of depressed mood. It’s not rocket science though – you can easily do this yourself by making a list of things you’d like to do and then scheduling these in your diary.

resilience

4. Don’t beat yourself up when things go wrong. There are three main ways that we explain negative events in our lives. First is how much we blame ourselves, compared with other people or the situation. Second is how permanent our explanations are: whether the problem that caused this one event is likely to keep on causing negative events in our future. Third is how all-encompassing are explanations are: whether this cause is going to make trouble in other areas of our life, as well. For example, if we were to fail an exam, we could think, “This is all down to my own general stupidity. I knew I’d never get through it”. This explanation is negative as we’re taking the blame entirely on ourselves. We’re also doing it in a permanent, all-encompassing way: if we’re stupid, it’s probably going to affect everything we do, forever.

The way we tend to explain events is habitual and it’s called ‘attributional style’. Resilient people explain events in a way that is more positive. In an exam failure situation, a resilient person would acknowledge any stress they’re under, or any other factors that could have affected their performance. Furthermore, they’ll do this in a way that doesn’t leak into other areas of their life and gives them hope for the future. In this example, a resilient person might think, “It was a stressful time with my mum being ill. I haven’t had to manage this kind of situation before, and the result was that I didn’t allow enough time to revise. I’ve learned for the future though: I know what I’ll do differently next time”. Not only will this person feel less bad about the exam failure, they’re also more likely to pass next time. It’s possible to change the way that you explain events with cognitive-behaviour therapy. For a do-it-yourself approach to improving your attributional style, I’d encourage you to ask yourself three questions when you know you’re beating yourself up about something:

  1. What range of factors contributed to this event? When things go wrong, they can rarely be pinned on just one thing. List all the things you know contributed to the event, to help yourself create a balanced perspective.
  2. What else has gone right recently? Think about other things that went to plan, no matter how small. This might be, for example, a friend’s birthday that you remembered, a work task that you completed well or a tricky conversation that you handled sensitively. It’s important to remember that this negative event doesn’t define you.
  3. What can you do to reduce the chance that a similar event will occur in future? Think about anything you’ve learned from this. Think about any actions you can take, whether this is personal (e.g., allowing more revision time in future) or external (e.g., asking for input from a tutor).

With all of these tips, it’s important to know that having good relationships with friends or family can help. Talking to others about stress you’re experiencing can help you to realise when it’s time to take action and can help you to change your perspective. Have you ever moaned to a friend about a rough day at work, and appreciated it when they pointed out that it wasn’t all your fault? Well, that’s an example of them helping you to develop a more positive attributional style for that event. The take home message is: talk about it! It’s easier than trying to do it alone.

This article was originally posted on the Psychreg website on 14 June 2019.

Breaking bad news in healthcare: why we shoot the messenger

Breaking bad news is a cornerstone of healthcare delivery. From the doctor delivering blood test results in cancer services to the sonographer communicating the discovery of a pregnancy loss, healthcare professionals regularly find themselves in this challenging situation.

But why is it so challenging? In theory, the healthcare professional is simply the messenger: the person relaying information about an event they did not cause and had no influence over. The reality is nothing like this, though. Research tells us that healthcare professionals find these situations highly stressful, particularly when the news is unexpected or seems unusual or unjust. Some end up coping in unhelpful ways; distancing themselves from the patient by using technical language, delaying the communication of the news or avoiding it altogether and passing the task on to someone else. These coping tactics often backfire by creating a more negative experience for the patient and further increasing the stress the healthcare professional feels.

breaking bad news

A recent study has shed light on these conversations, identifying some of the underlying reasons for why these events are quite so difficult for healthcare professionals. This study conducted a series of 11 experiments, which together showed that:

  • After receiving bad news, people feel a need to try and ‘make sense’ of it
  • To help them ‘make sense’ of bad news, people dislike the person who told them, even if they clearly are not to blame for what has happened
  • People dislike the messenger even more if the news is unexpected, or if it is particularly unjust or unusual
  • The reason that people dislike those who tell them bad news is because they think these messengers have bad motives: they mean badly
  • This effect is reduced if recipients of bad news have reason to think the messenger has benevolent motives or means well

This study used a range of news delivery scenarios, including one where a person was told that they had not won a $2 bonus and another where their scheduled flight was running late. However, I think this study has important implications for healthcare settings for three main reasons:

  1. It brings a new perspective to why these events are so challenging for healthcare professionals. It’s not logical, but the truth is that patients will like professionals less when they deliver bad news, and consciously or subconsciously, professionals know this. Building good professional-patient relationships is a key part of healthcare delivery, and having to deliver bad news works against this.
  2. It highlights the situations where delivering bad and difficult news is going to be most challenging. Specifically, these are likely to be where the news is unexpected or where it is particularly unusual or unjust. I think that two key settings where staff should be better supported with this task are obstetric ultrasound and maternity services more broadly, as the news is often unexpected and paediatrics, where bad news could be more likely to be perceived as unusual and unjust. In these situations, the recipients of bad news may have to work harder to make sense of the information they have received, and as such, may be more likely to ‘shoot the messenger’.
  3. It offers a suggestion for how healthcare professionals can reduce the ‘shoot the messenger’ effect: namely, by communicating their benevolent intentions. For example, this could involve saying ‘I’m so sorry, I hoped to bring you better news than this. This must be so difficult for you to hear’. However, doing this requires professionals to be forthcoming and open. Unhelpfully, the impact of stress often has the opposite effect: it inhibits people, making them more careful and wary of saying ‘the wrong thing’; therefore increasing the chance that they’ll say very little. What this research shows is that by going against the natural instinct to say little in stressful situations, healthcare professionals can reduce the ‘shoot the messenger’ effect and help create a better experience for both themselves and their patients. It is also consistent with findings of a review I conducted which showed that training healthcare professionals in breaking bad news works: it enhances their confidence of how to manage these difficult situations and improves their skills.

How to become a psychological therapist without completing an undergraduate psychology degree

It’s not unusual to choose to become a psychological therapist later in life, perhaps as a second career. For example, in 2017, 395 of the applications to the UK Doctorate in Clinical Psychology came from candidates aged over 35. However, most training courses in psychological therapy require an undergraduate psychology degree. What are your options if you don’t have this? Here I offer three routes you might want to consider, depending on your current situation.

  1. You have an undergraduate degree in something else? Do a psychology conversion course

If you have an undergraduate degree in any other area, you can ‘convert’ your degree by completing a psychology conversion diploma (PGDip) or MSc course.

The key thing is to check that your chosen course is accredited by the British Psychological Society (BPS) and will provide you with Graduate Basis for Chartered Membership (GBC). The BPS currently lists 171 such courses nationally. The entry requirements for these vary, so it’s worth checking these on their websites and contacting them directly with any queries you might have. Two to consider are:

  1. Birkbeck, London’s ‘evening university’. Birkbeck offers two accredited psychology conversion courses, the Postgraduate Diploma and the Psychology MSc, both of which are designed for candidates with an undergraduate degree in another area. Both courses can be completed in a year full-time or two years part-time and involve attending lectures 4 or 2 evenings a week. I spoke to the admissions tutor, Dr Eddy J Davelaar, who is a Reader in Cognitive Science about Birkbeck’s entry requirements. He said “While the course is designed for non-psychology graduates, it is a postgraduate course. A certain level of pre-existing knowledge in research methods is needed. Where applicants have no such background, they may be made a conditional offer dependent upon their passing an online entrance exam in research methods. They will need to pass at 60% (if applying to study full-time) or at 50% (if applying to study part-time)”. However, if this is you: don’t panic. Birkbeck will assist you in identifying relevant courses (online or at the university) or practice materials to help you prepare for the entrance exam.john-schnobrich-520019-unsplash
  2. If you’re looking for a distance learning course, check out the MSc/PgDip Psychology (Conversion) courses offered by Manchester Metropolitan University. These can be completed in 12 months full-time or around 2 years part-time (21 months for the PgDip; 24 months for the MSc). These courses are taught entirely online, requiring no attendance at the Manchester campus. In terms of entry requirements, pre-existing psychology credits are needed for the PgDip route but not for the MSc. Further guidance on the qualities the course looks for in prospective candidates are outlined on their website and include commitment and motivations, IT skills and the ability to study independently.

Once you have your conversion degree, you can choose to pursue any psychology career which appeals to you, such as Clinical Psychology, Counselling Psychology or Forensic Psychology. Each of these requires further study, but there are opportunities for paid employment and development within these training routes. For example, once you have your degree, you can apply for Assistant Psychologist roles within the NHS which are usually appointed at Band 4 or Band 5 and provide further experience for subsequent psychology career specialties. Sign up to jobs.nhs.uk for alerts. You can also apply for research assistant posts at universities, which offer paid experience for psychology graduates interested in pursuing research-related careers. Sign up to jobs.ac.uk for updates. For further info on therapy-related psychology careers, see my previous blog.

  1. You have a background in mental health from a non-psychology discipline? Train in Cognitive Behaviour Therapy

An alternative to traditional psychology specialisms is to train as a Cognitive Behaviour Therapist. Cognitive Behaviour Therapy is an evidence-based, goal-oriented, time limited therapy. It is the most commonly delivered therapy in the NHS and the main focus of the Increasing Access to Psychology Therapies (IAPT) initiative, which delivers psychological therapies in primary care settings.

Perhaps the most interesting thing about this route is that it isn’t accredited by the BPS, but by the British Association for Behavioural and Cognitive Psychotherapies (BABCP). As such, you don’t need a psychology degree to start training. Instead, you need to have a background in one of the listed ‘Core Professions’, which include Mental Health Nursing, Occupational Therapy and Social Work, amongst others. If you have one of these core professions, you already hold the basic entry requirement for further training to become an accredited CBT therapist.

If you are choosing to self-fund your CBT training, check out the BABCP list of accredited ‘Level 2’ courses. Completing one of these will make you eligible for registration as a CBT Therapist and able to apply for Band 7 CBT posts in the NHS. Courses are 1 or 2 years long and involve supervised CBT practice on placement and attending teaching at university. You can apply directly to universities such as Birmingham and Bucks New University. Entry requirements vary between courses, but most stipulate that 2 years’ experience of working in mental health is a pre-requisite. Self-funded applicants are expected to have a pre-arranged placement where they can undertake supervised CBT practice to gain the relevant experience they need. At Birmingham, this is stipulated as 3 days a week for a year. At New Bucks, this is stipulated as 200 hours in total.

There is also the option to pursue paid training routes in CBT. For less experienced mental health professionals, this may initially involve training and working as a Psychological Wellbeing Practitioner (PWP) in Primary Care. These posts are usually appointed at Band 4 and promoted to Band 5 once training has been completed. PWPs deliver low-intensity CBT interventions, such as guided self-help and psychoeducation groups. To then train as a CBT therapist (termed ‘High Intensity Therapists’ or ‘HITs’), you apply directly to services for specific roles, rather than to universities. HITs train on a Band 6 and can apply for Band 7 roles once qualified. For training opportunities in both roles, search nhs.jobs.uk for ‘trainee’ positions.

you've got this

  1. Looking for a third way? Consider a career in counselling or psychotherapy

While the BPS is the accrediting body for psychological therapists and the BABCP is the accrediting body for Cognitive Behaviour Therapists, the BACP accredits counselling and psychotherapy courses. They all share similar letters, so beware of confusing them!

Counsellors can train in a range of therapy modalities, from Freud’s psychoanalysis to Roger’s person-centred (or ‘humanistic’) counselling. Once qualified, they can work independently, for the NHS or for third sector organisations. Training courses usually focus on one of these therapy modalities in particular, but the BACP suggests that counsellors may use a mix of techniques if they think a client would find this helpful.

Counselling training pathways exist separately from psychology or CBT training routes, and as such, no background in either of these is needed. Instead, the training involves 3 stages:

Stage 1: An introductory course lasting 8-12 weeks, usually run as evening courses at local Further Education colleges.

Stage 2: The Certificate in Counselling Skills, a year-long part-time course also usually run at local colleges.

Stage 3: The core practitioner training at diploma, undergraduate, postgraduate or doctorate level.

For Stage 1 and 2 courses, the BACP recommends contacting local colleges and education centres. However, for the core practitioner training, check their website for accredited courses. A wide variety of options are available, from weekend courses run by independent training centres to university-run MSc degrees. For an example of an independent training centre, see the South Manchester for Psychotherapy, which offers a 4-year, part-time Diploma in psychotherapy. For an example of university-run core practitioner training, see the University of Salford which runs both a postgraduate diploma and an MSc. These courses run part-time, with the diploma last 2 years and the MSc lasting 3 years.

This article was first posted on the Psychreg blog on 23rd May 2019.