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With the British Psychological Society Annual Conference underway, we checked in with Susan Llewelyn, Professor of Clinical Psychology at the University of Oxford, and David Murphy, Joint Course Director for Oxford Doctoral Course in Clinical Psychology. We spoke to the co-editors of What is Clinical Psychology? about psychosis, provision of care, and careers in clinical psychology.

When did you first become interested in clinical psychology?

Sue: When I was an undergraduate studying psychology, I realised clinical psychology was by far the most interesting aspect of psychology. I was particularly interested in psychosis and what “madness” was.

David: Although I covered aspects of mental health in my undergraduate degree, I don’t think I really decided to pursue clinical psychology as a career option until I began working as an assistant psychologist and saw the range of different roles for clinical psychologists in the NHS. I worked for a while in a residential centre for people with epilepsy and became fascinated with the relationship between the brain and behaviour.

What do you think has been the most important development in clinical psychology in the past 100 years?

Sue: Probably the articulation of the cognitive, or information processing model of human behaviour and emotion, to balance the biological or the psychodynamic.

David: Clinical psychology is still such a young discipline that almost all the developments were within the last 100 years and most within the last 50 years. I think the pioneering work in behaviour therapy by Vic Meyer and others, helped open up the notion that psychological therapy could be effective in severe and intractable psychiatric problems like OCD and really changed the role of the clinical psychologist.

What is the most pressing or controversial issue in clinical psychology right now?

Sue: How we can deliver high quality clinical psychology services to meet all the so far unmet need.

David: I agree with Sue, we know from epidemiological surveys that there are large numbers of people with mental health problems who don’t or cant access services. We need to be better at using the resources to provide the most effective and responsive services we can; this often means trying to intervene early.

How might your current research have an impact on the wider world?

Sue: I am not sure I can be that grandiose! But our work tries to show how psychologically grounded ideas can make a big difference in people’s lives, and how taking the psychological realm seriously can improve the nature of the health care that can be offered to people in distress.

David: I agree with Sue; hopefully reading about the applications of psychology in practice across a diverse range of settings might inspire the next generation of clinical psychologists to pursue what is quite a long and challenging path into the profession.

Which famous psychologist has been most influential to you?

Sue: My friend and colleague Professor Glenys Parry in Sheffield has helped me to understand two important areas of psychological functioning: first how broad social and political influences shape the psychological (particularly how social and political gender issues become internalised and intimately lived by individuals), and second, how both the insights of psychodynamic, interpersonal therapies and CBT therapies can be effective combined to maximise how much we can help people.

David: That’s a really tough one! I’ve been lucky enough to work with a number of really inspirational psychologists through my career to date and, of course, many psychologists I haven’t met have influenced me through their work. One person who stands out on a personal level to me is Padmal De Silva who was my clinical tutor during training in London. Padmal was an internationally renowned expert in an array of areas; obsessive compulsive disorder, sexual and marital therapy, post-traumatic stress and Buddhist psychology. One of the most intelligent people I have ever met, he was also one of the most kind and humble. He always seemed to have time for people, even us trainees, and was genuinely interested in what they had to say. I feel very privileged that now in Oxford I have responsibility for training the clinical psychologists of the future and I am fortunate to have Padmal and others as role-models to aspire to.

What advice would you give to someone wanting to specialize in your field?

Sue: Try to be open minded about ideas: you can gain insights about the human condition from so many places including the newspapers, politics, art and literature, and conversations with friends, as well as psychology textbooks.

David: Read my OUPblog post “Five top tips to getting into Clinical Psychology” tomorrow!

What do you see as being the future of research in your field in the next decade?

Sue: We may be able to track more carefully what are the important components of our interventions, so that we can tailor what we offer more precisely to our clients

David: Wow, there are no easy questions, are there! I think research in psychological therapies, at least, will need to be not only carried out with larger sample sizes with longer follow ups but also with very detailed analysis of individual factors and therapy process factors to really enable us to answer the question “what works for whom”.

If you weren’t teaching clinical psychology, what would you be doing?

Sue: Reading really beautifully written literature, and also walking with friends and family in the mountains

David: Learning about clinical psychology! I’ve always found teaching to be just a natural extension of learning and practicing, if I can pass on what I’ve learned to trainees then hopefully I will hopefully have contributed in some way to them going out and generating more knowledge and innovative practice. I do have a life outside Psychology though, and in that life I enjoy playing football (even though I’m still not very good at it) and travelling to new places with my family.

Susan Llewelyn is Professor of Clinical Psychology at Oxford University, and Senior Research Fellow, Harris Manchester College, Oxford.  David Murphy is the Joint Course Director of the University of Oxford Clinical Psychology Doctoral Training Programme. They are co-editors of the new edition of What is Clinical Psychology?

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Image credit: Teenage Girl Visits Female Doctor’s Office Suffering With Depression. © monkeybusinessimages via iStockphoto.

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By Donald W. Black

For many years I have pondered the mental state and motivations of mass shooters. The tragic events in Newtown, CT this past week have brought this to the fore. Mass shootings have become everyday occurrences in the United States, and for that reason tend not to attract much attention unless the circumstances are especially heinous, such as this instance in which the victims were young children. We are all left wondering what can be done. While the attention span of the general public and the media is usually a matter of nanoseconds, this mass shooting seems different, and I hope will lead to positive policy changes. This tragedy presents an opportunity for our leaders to step up to the plate and lead and, one hopes, implement rational gun control legislation most of us agree is necessary.

But back to the shooters. As a psychiatrist with an intense interest in bad behavior, I expect that discussions will center on mental health issues which many believe motivate the shooters. I am intensely interested in these “issues” because, to me, the main issue that keeps coming up is that of psychiatric diagnosis. Everyone seems interested in the possibility of a psychiatric diagnosis, because it suggests that we might “understand” the shooter, and this may lead to better identification of future shooters, and both improved treatment and prevention.

But will the presence of a psychiatric diagnosis improve our understanding? Probably not, because — at least in the cases we know about — the apparent psychiatric diagnosis runs the gamut. Some shooters appear to have schizophrenia, others a depressive disorder, and still others a personality disorder, as has been alleged in the case of Adam Lanza. While we seem able to understand that a “crazy” person out of touch with reality might carry out an otherwise senseless act, the thought that someone who is not psychotic carrying out such an act is very unsettling. How could a person who is not psychotic behave this way? For example, depressed persons are by and large not psychotic, yet some will — in the context of being hopeless and suicidal — want to take others with them: spouses, children, etc. More typically, while planning to harm themselves, most depressed persons have no desire to hurt anyone else.

What about the non-psychotic people with a personality disorder? The Diagnostic and Statistical Manual of Mental Disorders — a compendium of psychiatry’s officially recognized disorders (about to come out in its 5th edition) — lists ten personality disorders; the most relevant to our discussion is antisocial personality disorder. This disorder is quite common (up to 4.5% of the population) and causes all manner of problems because the antisocial person always seems to be in trouble with the law, their spouses and families, or their employers.

The term antisocial is almost always misunderstood and is often construed to mean ”shy” or “inhibited,” yet in a psychiatric sense the term suggests rebellion against society. My profession has done a poor job in educating the general public about the disorder and for that reason it remains under the radar screen. (An older term that seems more entrenched is sociopathy.) In the DSM, the diagnosis rests on the person having three or more of seven symptoms (such as deceitfulness, impulsivity, irritability and aggressiveness, etc). Perhaps the most important is “lack of remorse,” which occurs in about half of those diagnosed antisocial. This is what allows the antisocial person to hurt, to mistreat, or even to kill others. These are the “psychopaths” we read about and fear. (Psychopathy is at the extreme end of the antisocial spectrum of behavior.) Few antisocials are killers, but many of today’s mass shooters would fit the description of antisocial personality disorder. I don’t know if Adam Lanza would, but as we peel back the layers of his personal history, we might find that he does.

We don’t know what causes antisocial personality disorder, but like many disorders it probably results from a combination of genetic and environmental factors. I have argued for many years that the federal government needs to direct more funds to investigating its causes and developing effective treatments. Despite its high prevalence and the fact that it contributes to so much of society’s ills, the government has shown little interest in funding research on the disorder. The National Institutes of Health RePORTER website lists only two projects in which the term “antisocial” appears in the title and only five in which the terms “psychopathy” or “psychopathy” are used. Considering that NIH funds literally thousands of projects, this can only be considered hopelessly inadequate. Overcoming this resistance to research on antisocial personality disorder and related conditions must be a priority.

We need wide-ranging projects to explore the origins of antisocial behavior and search for methods to change its course. Geneticists should investigate the mechanisms underlying antisocial behavior, locating genes that might predispose individuals to antisocial behavior and determining how these genes function. Neuroscientists should pinpoint brain regions or networks linked to antisocial behavior and identify biochemical and physiological pathways that influence its expression. A range of treatments — both drugs and therapy — need to be developed, tested, and refined.

Will these steps help us understand the conundrum of the mass shooter? Will they allow us to treat antisocial persons and prevent youth with antisocial tendencies from developing a full-blown disorder? We can certainly hope.

Donald W. Black, MD is a professor of psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City. He is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy), Revised and Updated (Oxford University Press, 2013).

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By Rochelle Caplan, MD

Surely the time has finally come to put our heads together and focus on three seldom connected variables regarding mass murders in the United States: the lack of comprehensive psychiatric care for individuals with mental illness, poor public recognition of the red flags that an individual might harm others, and easy access to firearms.

How should we address the first problem? The fiscal problems this country has faced during the past decade, combined with skewed budget priorities, have lead to a significant reduction in public health care, in particular for mental illness. Insurance companies have limited the time providers have for mental health assessments, the duration and frequency of treatment, and the types of intervention they cover. These cutbacks have forced psychiatrists to do abbreviated and superficial psychiatric evaluations and to prescribe medications as stopgap treatment in lieu of more effective evidence-based therapies. Furthermore, the number of individuals without mental health coverage who also face unemployment, homelessness, or insufficient money to feed and clothe their families — all significant mental health stressors — is steadily rising.

How then can mental health professionals conduct the comprehensive, time consuming evaluations needed to determine if an individual might be dangerous towards others? Self-report questionnaires, another quick method professionals use to conduct psychiatric evaluations, are clearly not the answer. Few people with homicidal or suicidal thoughts acknowledge these “socially unacceptable” intentions or plans on paper. Expert clinical acumen is needed to carefully and sensitively help patients talk about these “taboo” topics and their triggers. A five-to-ten minute psychiatric appointment clearly doesn’t do the job!

The lack of comprehensive mental health care is most sorely evident for such conditions as schizophrenia, as well as psychosis associated with substance abuse, depression, bipolar disorder, neurological disorders, or medical illnesses. In these conditions individuals can be plagued by and act in response to hallucinations that include voices commanding them to kill or visions that incite their aggressive response. Delusions (rigid, pervasive, and unreasonable thoughts) that people threaten them can also cause an aggressive response. Mass murderers might act out their hallucinations and delusions, as in the attempted assassination of congresswoman Gabrielle Gifford and murder of five bystanders, and in the Columbine, Batman, and Virginia Tech massacres.

Lack of time often precludes pediatric professionals from seeing children without their parents and detecting early warning signs of homicidal or suicidal plans. Similarly, physicians might have time to talk to adolescents but not to their parents. As a result, they might miss hearing about red flags of possible aggression by the youth and/or his peers.

The Affordable Care Act (Obamacare) will provide health insurance for more people, but what about quality mental health care? Few mentally ill patients are able to fight for their sorely needed unmet mental health care needs. Due to the stigma of mental illness and the related financial and heavy emotional burden, their families seldom have the power and resources needed to lobby elected officials or use the Internet and other media to publicize their plight.

How can we recognize the red flags of a potential mass murderer? In addition to well-trained mental health professionals with expertise, clinical acumen, and sufficient time with their patients, there is a need to educate the public about severe mental illness. Parents, family members, teachers, community groups, and religious leaders all need instruction to recognize possible early signs of mental illness. This knowledge will help them understand the plight and suffering of individuals with severe mental illness. And, most importantly, this awareness can lead to early referral, treatment, and prevention of violence due to mental illness.

Prompt recognition and early treatment of these symptoms are essential because firearms are so easily obtained in the United States. To get a driver’s license, individuals complete a Driver’s Ed course, pass a knowledge test, take driving lessons, drive a car with an adult for a fixed period, and then take a driving test. The underlying assumption is that irresponsible driving can physically harm others, the driver, and property. For this reason, individuals with epilepsy who experienced a seizure within the past year are barred from driving. Shouldn’t the same principles apply to guns? Yet, individuals can obtain guns without prior psychiatric evaluations, and there are no laws and regulations to safeguard these weapons in homes to prevent children and individuals with severe mental illness from gaining access to them. Reports on accidents caused by children and suicide by adolescents with their parents’ guns are common. According to a Center for Disease Control study, 1.6 million homes have loaded and unlocked firearms (Okoro et al., 2005).

As a child psychiatrist and parent, I regard the Newtown horrific mass murder of elementary age children as a final wake up call so that we will never again ask, “How many more children have to die?” Nothing can justify this preventable tragedy to the parents and families of their murdered beloved ones. The time has come to halt the unrelentless chipping away of our mental health care services and quality of care for mental illness, to educate the community about severe mental illness, and to implement strict controls on access to firearms.

Rochelle Caplan, M.D. is UCLA Professor Emeritus of Psychiatry and past Director the UCLA Pediatric Neuropsychiatry Program. She is co-author of “How many more questions?” : Techniques for Clinical interviews of Young Medically Ill Children (Oxford University Press) and author of Manual for Parents of Children with Epilepsy (Epilepsy Foundation). She studies thinking and behavior in pediatric neurobehavioral disorders (schizophrenia, epilepsy, attention-deficit hyperactivity disorder, high functioning autism) and related brain structure and function; unmet mental health need in pediatric epilepsy; and pediatric non-epileptic seizures.

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FIVEnFIVE With Sherry Ashworth

Sherry Ashworth answers 5 questions about her new young adult novel, MENTAL, published as an ACHUKA(e)book, and 5 more general questions about her writing.

She also tells us what she's been reading, watching and listening to recently.