A lot of "voice hearing" isn't an auditory experience at all

The message from recent surveys is that it's not just people with a diagnosis of schizophrenia who hear voices in their heads, many people considered mentally well do to. This revelation may have a welcome de-stigmatising effect in terms of how people think about some of the symptoms associated with a diagnosis of schizophrenia, but a new study published in Psychosis asks us to hang on a minute – to say that one "hears voices" can mean different things to different people. You might assume that "hears voices" means that a person has an hallucinated auditory experience just like someone is talking to them. But what about hearing an inner voice that is experienced like an out-of-control thought rather than an external voice? Or a heard voice that's not like either a thought or an external voice?

Our knowledge of the experience of voice hearing among patients has been limited by the fact that a lot of psychiatric research in this area (though not all) has been categorical in nature. For instance, a typical psychiatric scale used in research or the clinic includes a vague item like "[Patient] Reports voices than no one else hears" and a tick here can conceal a huge range of different experiences.

For the new research, Nev Jones and Tanya Luhrmann conducted in-depth interviews with 80 people diagnosed with schizophrenia in the US, India and Ghana about their first-hand experiences of hearing voices. There was great variety between participants in their descriptions of voice hearing and also within each individual participant's own descriptions. Perhaps most importantly, while 79 per cent of the participants reported at least some limited experience of the hallucinated sound of external voices – as if someone was audibly speaking to them – a much smaller proportion (17.5 per cent) said this was their dominant experience of "voice hearing".

The most common dominant experience for the participants was to say they had a mixture of auditory and thought-like voices – 29 per cent reported having this. Another 15 per cent said their dominant experience was to hear thought-like voices that seemed "foreign and alien" but clearly "non-auditory". Other categories were "in-between", being neither auditory or thought-like; "limited auditory" (an auditory experience but just simple words or sounds); "transformed", which is when real voices or sounds were misheard as saying something different; and "multi-sensory", involving visual experiences as much as or more than auditory – for example, one participant described how "the voice will show me all my enemies".

Intriguingly, some participants described how a voice could begin as thought-like, but if they ignored it, then it became more auditory: "If I try ignoring them inside my brain, like they come out. They start telling me things."

The researchers said the interviews showed there is huge variety in the ways that people diagnosed with schizophrenia hear voices, and that it is very difficult for both patients and clinicians to find ways to accurately describe these experiences. Another thing – many of the participants said that what they found most difficult about "hearing voices" was the disruption to their thoughts, rather than the sensory aspect of the experience. Indeed, by emphasising the normality of the auditory aspect of hearing voices, the researchers said there was a risk of mental health professionals presenting a "misleading view of what at least some patients are in fact struggling with".

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Jones, N., & Luhrmann, T. (2016). Beyond the sensory: Findings from an in-depth analysis of the phenomenology of “auditory hallucinations” in schizophrenia Psychosis, 8 (3), 191-202 DOI: 10.1080/17522439.2015.1100670

--further reading--
The voices heard by people with schizophrenia are friendlier in India and Africa, than in the US
What's it like to hear voices that aren't there?
The same voices, heard differently?
You hear a voice in your head when you're reading, right?

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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Killer wives are "wicked", killer husbands are "stressed" – uncovering the sexism in judges' closing remarks

Judges are not perfect, but we expect them to approach their cases clinically and with detachment, interpreting them on their merits, uninfluenced by stereotypes around skin colour, age, or … gender.

Unfortunately, a new study in Psychiatry, Psychology and Law has analysed the sentencing remarks made by judges in domestic murder cases (defined as murder between heterosexual spouses) and found that they framed killings by men in far more lenient and forgiving terms than killings by women.

Guy Hall and his colleagues at Perth’s Murdock University looked at cases from the 2000s in the Australian states of Victoria and New South Wales. The team worked through nine judges’ sentencing remarks for male offenders, analysing the text qualitatively to find patterns and themes, stopping after nine cases as the themes firmed up. Against these nine cases, the team analysed remarks from five trials that involved female perpetrators. The sex of the judges is not specified but the accounts include plenty of references to "His honour" but none to "Her honour".

Sentencing remarks are given together with the court sentence itself, and are the judge’s reasons for choosing the sentence they did, using plain language to explain their reasons to the community, the victims, and the offender themselves.

When a man was in the dock, judges frequently talked about the offender's character, making references to endorsements from other authorities such as employers or community figures. They also emphasised the man’s suffering, such as anguish at being left by his wife. In fact, the mental state of male offenders seemed of great, sometimes peculiar interest to the ruling judges.

Hall’s team outline how remarks in eight of the nine male cases had an extensive description – "suffering from severe psychological distress", "acted as a man stressed and depressed, rather than as one in control" – and that one judge spent 11 of his 34 paragraphs of remarks discussing the offender’s mental state. Judges would do this even when they explicitly noted that this had little mitigatory relevance to the crime. Hall’s team also found cases of victim blaming, with one judge stating bluntly "your wife was the source of the conflict" – you may have resolved the conflict with lethal means, the judge seemed to be implying, but let the court be aware, she started it.

When a woman was in the dock, praise was rare and faint, for example one judge stated that a woman murderer "was clearly doing well in her studies". In contrast, negative references to character were frequent, citing issues such as "inability to pay her household debts", or that her crime indicated a "lack of concern for [her] children’s wellbeing" – an issue not raised when a man was the murderer.

Judges also brought into consideration the sexual conduct of the women offenders in the time period following the murders they committed, the relevance of which I struggle to see. The judges who presided over these cases sometimes sprinkled in some warmer character references – "good provider" or "honest, hard-working" … but these were for their (male) victims.

Perhaps the most striking language difference was how the judges reached for old notions of evil when describing women who kill men. In three of the five cases, the sentencing judge used the word wickedness – "your wickedness knew no bounds" – and one judge went fully biblical by describing the financial gain associated with the murder as "30 pieces of silver", drawing associations between a woman murdering a man, and a man murdering a god.

Hall’s team discuss the implications of the judges’ bias in terms of severity of sentencing, but it’s difficult to draw any conclusions as the sample is too small. It’s true that in the 14 cases under study, the two most severe punishments were for women, and the average female sentence was higher than the most severe sentence given to a man. More systematic work suggests that typically men get harsher sentences, although we should note that this past research didn’t focus on domestic murder, and that some of the suggested drivers for harsher male sentencing don’t hold in this case – for example, the "girlfriend theory" that women get lighter sentences when convicted together with a man, as they are considered more of a hanger-on than the driver of the crime.

What I find interesting about the sexism on display in the current study is how it is partly explained by the judge’s decisions about whether or not “general deterrence” is served by the sentence. General deterrence is the motive of punishing an individual to send a message to those who might consider doing the same thing. In several cases with male perpetrators, but none of the women, the judge explicitly mentioned general deterrence – denying its appropriateness – as they attributed the criminal action to the mental state of the man.

The judges’ message seems to be that it’s a sad fact of life that "good men" kill because of anguish due to conflict-initiating women, and there is no way to do anything about this, because it’s just the way the world works. Meanwhile, women who kill are wickedly calculating and a message should be sent to prevent other women getting the same idea. As this study does not attempt to match cases for context or severity, it is possible that this is an artefact of the particular crimes covered, and that another study might find wicked scheming men and hot-blooded women. But note, as Hall’s team do, how much the findings track broader stereotypes about male violence and tally with taboos about women acting against men.

Are these findings particular to Australian culture or is this something we would also see in the UK and elsewhere?  This study should open a conversation, and further research into how judges treat domestic killers in the dock.

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Hall, G., Whittle, M., & Field, C. (2016). Themes in Judges' Sentencing Remarks for Male and Female Domestic Murderers Psychiatry, Psychology and Law, 23 (3), 395-412 DOI: 10.1080/13218719.2015.1080142

--further reading--
Judges are more lenient toward a psychopath when given a neuro explanation for his condition
The psychology of female serial killers
How our judgments about criminals are swayed by disgust, biological explanations and animalistic descriptions
Fingerprint matching is biased by the assessor's prejudices

Post written by Alex Fradera (@alexfradera) for the BPS Research Digest.

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How depression affects couples – in their own words

Depression has been called a "we-disease" because when the dark clouds arrive, it's not just the depressed person who is affected, but all those close to them. A new study in the Journal of Social and Personal Relationship explored these spillover effects in the context of romantic couples, where one or both individuals have a diagnosis of clinical depression. The US study broke new ground by asking both partners in each couple to provide their perspective on how depression had affected their relationship. Liesel Sharabi and her colleagues said their results show how "the experiences of both partners should be considered when treating depression."

In all, 135 couples, most being heterosexual and white, provided open-ended answers online. The average age of the participants was 40 years, and just over 70 per cent of the couples were married or in a similar life-long commitment. The researchers identified several key themes, the most commonly mentioned was the emotional toll of depression on the relationship. Other themes included: problems with romance and sexual intimacy, over dependence on the relationship, and feelings of uncertainty about the relationship.

The study provides striking examples of the impact of depression on the non-depressed partners. For example, many of them spoke of the support they were required to give to their partner: "Raising a child in our household poses its own challenges since many times I feel like a single parent. And many times I have to parent my spouse such as making certain he wakes up, stays motivated ... eats, exercises and baths" said a 34-year-old woman. Another participant with a wife who has psychotic depression, described the contagion effects of depression: "If my partner is sad or depressed, it makes me feel sad and helpless". And the wife of a man with major depression described her loneliness: "I feel like my husband's depression affects our sex life. He always seems to be not in the mood, like he is sad."

The answers given by depressed participants (with a non-depressed partner) also illustrate how the dynamics between the couple can sometimes make life extra difficult or complicated for the depressed person, including the frustrations they can feel at the lack of understanding. "He doesn't understand what depression feels like, that feeling of being at the bottom of a deep, dark hole with no way out," said one woman. "When I am feeling depressed, I feel guilty for not acting like my 'normal self'," said another. "I feel sometimes he thinks I can just 'get myself out of it' so to speak," said a 33-year-old woman with postpartum depression.

There was a silver lining in that some couples – more often those where both partners were depressed – described feelings of enhanced intimacy that were fostered by depression. "It brings us closer at times by supporting one another," said a woman with depression who's husband is also depressed.

Another approach the researchers took was to see how often partners in a couple mentioned the same issues. In fact, 80 to 100 per cent of the time, partners described different effects of depression on their relationship – a potentially useful insight for clinicians working with couples.

Overall, the researchers said their findings show just how "difficult it is to disentangle the effects of depression on the individual versus the relationship." For example, their participants' stories show how: "When a depressed person’s sex drive is suppressed, the sexual needs of his or her partner go unmet; when a depressed person goes into isolation, his or her partner is shut out; when a depressed person refuses to leave the house, his or her partner must face the world alone. Thus, our findings provide poignant illustrations of how depression ripples beyond individuals to reverberate within couples."

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Sharabi, L., Delaney, A., & Knobloch, L. (2015). In their own words: How clinical depression affects romantic relationships Journal of Social and Personal Relationships, 33 (4), 421-448 DOI: 10.1177/0265407515578820

--further reading--
What does it feel like to be depressed?

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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One woman's deradicalisation: from right-wing extremist to preacher of tolerance

An in-depth interview with a formerly violent right-wing extremist has provided psychologists with rare insights into the processes of disengagement and deradicalisation. John Horgan at Georgia State University and his colleagues interviewed "Sarah" face-to-face for several hours, and also followed up with telephone calls. Their account is published in Behavioral Sciences of Terrorism and Political Aggression. The woman had previously been a member of various Neo-Nazi right-wing groups and was ultimately imprisoned for her part in the armed robbery of a shop. Today, Sarah works to combat violence and racism by speaking to at-risk youths, and says she feels a "responsibility to go out and try to undo damage."

The background to this from a research perspective is that violent extremism remains, thankfully, rare. Therefore psychologists rely on insights into the deradicalisation process mostly from interviews with professionals, family and friends who have contact with extremists. Interviews with extremists themselves are hard to obtain, making this in-depth case study a rare opportunity. A major limitation is that some or all of the processes involved in this case may not generalise to other extremists.

The researchers applied their "arc framework" to Sarah's story – this is the idea that the path from extremist to de-radicalisation goes from involvement, to engagement, to disengagement, and that the nature of disengagement and deradicalistion – often a long-term process, rather than a sudden moment – will likely be shaped by the reasons behind initial involvement and engagement.

Sarah's involvement in right-wing extremism came about through teenage feelings of alienation. These feelings were fostered by a religious schooling that clashed with her parents' alcoholism and racism, and her emerging sexual interest in other girls. Sarah fell in with skinheads at high school. This group later split into Neo-Nazi and anti-fascist groups, and Sarah chose the former where she found a sense of purpose and belonging.

Sarah's true engagement began when she volunteered to expel another member. "That to me was my crossover and where I said okay this is ... now at this time I'm making this commitment, you know, to follow these rules, to be a member of the group." She got more Neo-Nazi tattoos and was exposed to right-wing literature – she says this didn't influence her beliefs, so much as give her a way to impress the other extremists around her. In fact, she says ideology only played a small part in her involvement – rather, she found the alternative and socially challenging lifestyle an attractive option, especially in light of her uncomfortable family circumstances.

The roots of Sarah's disengagement run deep. She describes feeling doubts very early on, not least because she engaged in activities that she knew ran contrary to the beliefs of the groups she was involved with, such as her sexual promiscuity, including being involved with a Hispanic man. Her doubts were later compounded by the 1995 Oklahoma City bombing (by a right-wing extremist), including the image of an infant victim. But still, as her doubts intensified, she drowned them in more drink, drugs and deeper extremist involvement. As this tension between her desires to leave and her commitment took their toll, Sarah says she simply lacked the resources to leave and her involvement continued to provide her with "self-worth, validation and protection".

The turning point came when Sarah was arrested for her part in an armed robbery, which she'd undertaken with her then-boyfriend who was a key figure in her extremist group. Her subsequent imprisonment meant involuntary disengagement from the group. This changed Sarah. She took responsibility for her actions, and whereas we often hear about people being radicalised in prison, the researchers say it was clear that the physical distance created by imprisonment provided the space and opportunity for Sarah to confront her doubts.

Once in jail she befriended black women and was surprised by their acceptance of her (despite her notoriety and racist tattoos). Sarah took a degree, broadened her outlook. She "started realizing the world truly is so much bigger than [her] and [her] beliefs and ideas and, you know, [her] feelings" which, she says, gave her a "terrific sense of freedom". She subsequently began teaching in prison, including tutoring other inmates in how to read and write. She discovered her capacity for compassion and empathy, "you know actually caring about people that I professed to hate for so many years – those kind of experiences changed me tremendously."

On her release, Sarah was terrified that she had "hardwired her brain" in her earlier life, but she made a conscious decision to challenge any racist thoughts that emerged in her mind, a process she likens to "breaking a bad habit". Sarah's feelings of responsibility to undo past damage and her newfound social role as preacher of tolerance have also been protective – helping to deepen her disengagement and making it psychologically meaningful. Today her fears of being hardwired to be racist have subsided.

The researchers acknowledged that their account of Sarah's case is "partial, idiosyncratic and limited", but they noted that "most of what is said and written about violent extremist offenders [is] rarely complemented by insights from the offenders themselves." They concluded: "We do firmly hope that this case study serves as an illustration for future research purposes."

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Horgan, J., Altier, M., Shortland, N., & Taylor, M. (2016). Walking away: the disengagement and de-radicalization of a violent right-wing extremist Behavioral Sciences of Terrorism and Political Aggression, 1-15 DOI: 10.1080/19434472.2016.1156722

--further reading--
The psychology of violent extremism - digested

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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It's important to respect the different ways that young women feel after mastectomy

One woman said she was proud of her
scars – the "war wounds of life".

In the UK, nearly 10,000 young women are diagnosed with breast cancer every year and the treatment for many is mastectomy – the surgical removal of one or more of their breasts. It's easy to assume that the effect on their body image will be negative, and UK guidelines currently state that all mastectomy patients should be told about options for reconstructive surgery. However, a key message to emerge from a new survey of young women who have undergone mastectomy is that there is huge variability in how they are affected, and that any support therefore needs to be individualised.

Sarah Grogan and Jayne Mechan (the latter has a diagnosis of breast cancer) conducted an online survey of 49 women recruited via an online support network, all of whom had undergone unilateral or bilateral mastectomy before the age of 45. Analysing their answers, the researchers identified four main themes.

The first concerned the way the women spoke of how they'd initially downplayed worries of aesthetics because their priority was survival. They also distanced themselves from the affected parts of their breasts and objectified them: "The thing for me was just to remove the offending article", "I just had a gut feeling that I wanted the whole thing taken ...".

Post-mastectomy, body confidence became an issue, but some coped better than others. "I have lost all self-confidence in my naked body," said one woman. "Body image has never worried me. I am who I am and I don't go out to impress people," said another.

The third theme was "changed identity". Some women described compensating for their changed appearance: "wearing skirts, more make-up", said one. "I want my body to look and feel strong so am doing quite a lot of weight lifting to try and remove the feeling that my body was weak and failed me," said another. Others described the difficulties of adjustment: "I feel like I don't recognise myself anymore. I used to wear low cut tops and now I cover up."

The final theme on the effects of cancer treatment, including scars, weight gain and early menopause also revealed a variety of experiences among the women. Some took a positive view: "My scars are my war wounds of life. ... I'm proud of them". Others described how they were more bothered by the overall changes to their appearance: "Do not feel great about body image at all. Have gained weight due to early menopause, think that bothers me more than my breasts".

The researchers said their results suggested women undergoing mastectomy may benefit from interventions that include body acceptance techniques and advice on media literacy, to help them critique cultural pressure to be slender. Above all they said they were struck by the "variability of experience of women experiencing a relatively similar event." They said this insight has implications for health professionals – "it is important [they] do not expect homogenous patterns of negative responses in women who have had mastectomies so that they are able to provide tailored support if and when needed."
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  Grogan, S., & Mechan, J. (2016). Body image after mastectomy: A thematic analysis of younger womens written accounts Journal of Health Psychology DOI: 10.1177/1359105316630137

--further reading--
Which health beliefs held by women predict how often they check their breasts?
Existential angst can deter women from checking their breasts

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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What is it like to "come out" as asexual?

Participants were recruited via online asexuality communities

Sex, or talk of it, is everywhere, whether filling our TV screens or the conversations at the bar after work. Imagine then that you're one of the estimated one per cent of the population who actually don't have any sexual desire – an increasingly recognised status usually referred to as being "asexual". What is it like for such people to "come out" and tell the world that this is the way they are?

For a new study published in the Archives of Sexual Behavior, Nicolette Robbins at Yale University and her colleagues asked 169 self-identified asexual people to write an open-ended account of the development of their asexual identity and the disclosure of that identity to others. The participants were predominantly, but not exclusively, young women and they were recruited through three online asexual communities: AVEN, Apositive.org and Asexuality Livejournal.

Their answers give insights into their motives for coming out, their frequent relief at finding and sharing their identity, and they provide examples of how their disclosures were received, both positively and negatively.

The participants wrote about strong feelings of validation and liberation upon discovering online asexual communities. Many said they subsequently decided to come out as asexual so that their friends and family could understand them better, and to counter the pressure to meet cultural expectations to engage in sexual relationships. Other participants had only disclosed to their romantic partners, as a way to negotiate the terms of their relationship.

While the overall message from the study is of coming out as a positive, empowering experience, many participants described experiencing negative reactions from others. For example, one woman said: "My friends didn't believe me. One friend's exact response was 'you're not a tree'". Others spoke of the way people frequently told them it was "just a phase" and that they'd feel differently once they met the "right person".

Some participants had sought support from lesbian or gay friends, not always with much success: "I came out to my lesbian friend. She laughed at me and told me that I was being ridiculous ... My local gay switchboard told me that asexuality doesn't exist and that everyone wants to f*** someone."

Other participants said they'd been pathologised: "I've been called unnatural, and had people attempt to fix me by taking me to psychologists and therapists without my consent."

But there were also accounts of positive reactions: "When I told my parents, my mom was ecstatic. She knew that I had little to no sexual feelings growing up, so she thought it was great that I found the term asexual to legitimise myself." Another participant said: "When I told my friends none of them were really shocked. They had figured it out long before I did."

Not all the participants had chosen to come out, mainly because some just didn't see their asexual status as a big deal: "My orientation is not an important enough part of my identity for me to need to share it with others."

Based on their participants' accounts, the researchers have proposed a model of the asexual coming out experience with six stages from "identity confusion" all the way to "identity integration" with many of the ideas resembling similar theories proposed for the emergence of gay and lesbian identities. But Robbins and her team acknowledge this is all very preliminary – after all, their sample was confined to people who have participated in online forums – and they do not meant to impose or suggest there is a normal way for asexual identity to emerge. "Additional research on asexuality is needed before conclusions can be drawn about how identities emerge within this community," they said.

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Robbins, N., Low, K., & Query, A. (2016). A Qualitative Exploration of the “Coming Out” Process for Asexual Individuals Archives of Sexual Behavior, 45 (3), 751-760 DOI: 10.1007/s10508-015-0561-x

--further reading--
AVEN - The Asexual Visibility and Education Network
People's "coming out" experiences are related to their psychological wellbeing years later

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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Elite golfers describe their experiences of being in the zone

They talked about two main states: "making it happen" and "letting it happen"

The psychological concept of "flow" has been around for a while and yet it still retains an air of mystery. Most experts agree that it involves an enjoyable sense of being fully absorbed in a task or skill, and that in sporting contexts it often coincides with peak performance. Now further insights into the nature of flow in sport come from a new study of elite golfers published in the Psychology of Sport and Exercise. Christian Swann and his colleagues interviewed 10 male players who'd recently won or performed extremely well in top European competitions. The players described having experienced two similar but distinct kinds of psychological state during their successes: "letting it happen", which closely resembles formal definitions of flow, and "making it happen", which seems similar to flow in some ways, but not others.

Most previous research on the relevance of flow to peak sports performance has come from interviews in which top athletes reflect on their entire careers. This study has the advantage that the golfers were interviewed within just a few days of a specific exceptional performance. The researchers studied these performances, including specific shots, and used this as a basis to probe the golfers' psychological states during periods when they'd displayed brilliant skill.

Although the golfers described both the "letting it happen" and "making it happen" states as being "in the zone", there were also important differences. "Letting it happen" was more likely to occur earlier in a competition, and tended to result from a sequence of good play. This built the players' confidence until they became absorbed in effortless play. "I didn't have any negative thoughts," said one player. "Everything I saw was positive". They lost sense of where they were and their goals became open-ended: "let's see just how well I can do".

The other state, "making it happen", tended to occur later in the competitions as players scented victory. This state involved intense concentration and seemed to produce exceptional play, rather than be caused by it. It was also associated with specific goals and a keen sense of the situation, including the current score and what the player needed to do to seal their win: "This was it, this was my time now. This is where I can win". The descriptions of conscious effort and heightened awareness of the situation distinguish this state from typical flow states.

Swann and his team said they hoped their findings could help "provide a refined understanding of the psychological states and processes underlying exceptional performance in sport". However, they acknowledged the limitations of their qualitative approach: "while we have presented our interpretations of the data, others could have coded them differently and may well have arrived at alternative conclusions," they said.

_________________________________

Swann, C., Keegan, R., Crust, L., & Piggott, D. (2016). Psychological states underlying excellent performance in professional golfers: “Letting it happen” vs. “making it happen” Psychology of Sport and Exercise, 23, 101-113 DOI: 10.1016/j.psychsport.2015.10.008

--further reading--
Does your heart rate hold the secret to getting in “the zone”?
Sports psychologists understand surprisingly little about "the yips"
Speed matters when it comes to imagining the perfect putt
Social flow - how doing it together beats doing it alone

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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What's it like to live with uncontrollable tics (Tourette Syndrome)?

Affecting around 1 per cent of the world's population, Tourette Syndrome (TS) is described by the NHS as a neurological condition "characterised by a combination of involuntary noises and movements called tics". What is it like for children, teens and adults to live with this diagnosis? A new study in the British Journal of Psychology rounds-up all that we know so far, based on published research.

Heather Smith and her colleagues found 10 relevant studies involving interviews with 132 people of both sexes who had been diagnosed with Tourettes (a further 124 people – health professionals and relatives of those with Tourette's – were also involved). The interviewees were located in the UK, Spain, the USA, Canada and Australia. Their testimony paints a sad picture, but there are also glimmers of hope. As you read on, it's worth bearing in mind the message from the charity Tourettes Action: "People with TS can live a perfectly happy and normal life and children do cope with the issues."

Six main themes emerged from the new "meta-synthesis" of studies, and all were found across the life-span. The first related to the interviewees' frustrations about how their condition is perceived by society at large and also by people close to them. For example, one teenager expressed her frustration at the widely held, but mistaken, belief that the condition always involves swearing-based tics (in fact, this symptom only affects around 10 per cent of people with the condition). Others described how people interpreted their tics as a sign of naughtiness and/or found them annoying, and assumed they were under their control.

On that last point, one adult interviewee said a typical reaction from people was: "... if you weren't in control of this, all kinds of words would be popping into your mouth. Don't tell me it's just an accident you're saying that!"

Another theme was how people with TS felt they were treated by their schools and workplaces, and the experiences they had there. One teenager said: "In class I felt embarrassed, I couldn't pay attention because I heard a laugh and I thought my colleagues were laughing at me." Although there were some reports of supportive teachers, many felt that teachers misperceived their symptoms as inattention or rebellion.

On the theme of treatment, many of the interviewees expressed negative views of health professionals – there was a perception that they often lacked knowledge and sympathy. Pharmaceutical treatment approaches were sometimes described as helping remove tics but at the cost of other side-effects, such as fatigue and weight gain.

The participants also described how TS affected their relationships, including with their parents. They told how tension can arise because parents want to hide or justify their child's tics, while the young person wants the right to be open about their condition, leading many to feel stigmatised within their own family. "My dad didn't just tell me to stop," said one male teenager, "he used to shout at me and make me stop it, and that's what made me worse."

Concerns about the future was another theme, including fear of having a child with the condition and worries about the effects of medication. The interviewees also talked about their coping strategies including creating opportunities to express tics when alone, and hiding tics by pretending to perform another action (e.g. rubbing the eyes to conceal blinking tics). Some of the young participants said they often resorted to humour: "Every time I meet someone new it's almost as if I try and be funny and make them laugh," said another teen participant. "But that's just me covering my tics, and then everybody just thinks that I'm weird from that moment on."

On a more positive note, although many young people described their TS as "distressing" and "disabling", some reported an acceptance of their condition: "Well, I suppose if I didn't have it I wouldn't be myself" said one 17-year-old boy. There were also descriptions of supportive peers, and one recent study the researchers looked at indicated that levels of bullying were lower than in earlier research, suggesting the social stigma of the condition may be in decline. Also, some interviewees were hopeful about the future, believing that their tics were likely to reduce as they got older.

The researchers said the quality of the studies they reviewed was overall rather poor, that more qualitative research is needed, but that their synthesis had captured "the complexity of the individual's lived experience". Concluding with a message that will likely resonate not only with people diagnosed with TS, but with anyone living with a challenging condition, the researchers also argued their results suggest that rather than interventions focusing on changing individuals with TS (for instance through hiding or suppressing tics, which may only serve to increase social stigma), "a more adaptive approach could be to focus on changing the environment – for example, through acceptance by peers."

_________________________________

Smith, H., Fox, J., & Trayner, P. (2015). The lived experiences of individuals with Tourette syndrome or tic disorders: A meta-synthesis of qualitative studies British Journal of Psychology, 106 (4), 609-634 DOI: 10.1111/bjop.12118

--further reading--
What is Tourette Syndrome? (information and advice from the UK charity Tourettes Action).
Tourette's Syndrome associated with superior timing control
Children with Tourette's show superior grammatical ability
Patients with Tourette's have more self-control, not less
What Is It Like To Experience Mental Health Problems?

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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What stops people raising the alarm when a friend heads down the dark path to violent extremism?

A timely study published in Behavioural Sciences of Terrorism and Political Aggression has looked into the crucial role played by the friends of would-be terrorists, in preventing their descent into radicalism.

Michael Williams and his colleagues began by interviewing over 150 law enforcement professionals, Muslim community leaders, and members of the public of various faiths in Los Angeles and Washington DC about who they thought was best placed to notice and raise concerns about a person who was considering violent extremism.

The official programmes to counter violent extremism in these neighbourhoods are well-established with communication links between local police, social services, faith-based organisations, psychological services, and so on. However, a recurring point made by the interviewees was that the people best placed to notice a person sliding to extremism are his or her friends.

A typical observation was this, from a Pakistani-American father, who said of the (in)ability of clergy and family members to spot the early signs of extremism:

"... the priest will not know [if youth are getting involved in illegal activities], because when he [the youth] goes to church, or the mosque, or the temple, he's the finest guy. He's on best behaviours," and "the family is the last one to know."

Worryingly, the interviewees also noted that there is a disconnect between these "gatekeepers" (the friends of at-risk people) and the safety networks in the community. Indeed, many of the members of the public interviewed said they would be reluctant to reach out, not just to the police, but to any of the community safety networks about their concerns. The most popular reasons given were related to fear about getting a friend or family member in trouble; concerns about getting into trouble themselves; fear that the friend would get mad at them; and concerns about being identified. Interviewees rarely said that they didn't think it would help (to report their concerns), or that they thought they could handle the situation themselves, or that they didn't have time.

To follow-up on this issue of fear about the consequences of raising the alarm, the researchers interviewed more community members and law enforcement professionals in the DC area, specifically in Montgomery County, Maryland, looking for factors that might exacerbate people's fears of seeking help about a friend on the path to violent extremism. They found evidence that the more a person feared harming their relationship with the (hypothetical) at-risk friend in question, the more they voiced reluctance about the idea of raising the alarm. Interviewees spoke of concerns that the at-risk friend might feel embarrassed or looked-down upon. Another key factor was how much interviewees identified with the at-risk person – the more they identified with them, the less willing they'd be to intervene – "just because you want to protect your own," said one police officer who was also a parent.

Williams and his team cautioned that this was exploratory, qualitative research – they sought out evidence to back up their predictions about the factors likely to be relevant. "Such findings warrant further testing," they said, "ideally via experimental methods." But the results do point to important practical steps, for example the need to "empower", support and provide reassurance to gatekeepers (i.e. the friends of at-risk would-be extremists) and the need to "develop the curricula and protocols for how" people should respond when they're concerned that a friend is being radicalised.

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Williams, M., Horgan, J., & Evans, W. (2015). The critical role of friends in networks for countering violent extremism: toward a theory of vicarious help-seeking Behavioral Sciences of Terrorism and Political Aggression, 1-21 DOI: 10.1080/19434472.2015.1101147

--further reading--
The psychology of violent extremism - digested

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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What's it like to meet the man who murdered your brother?

Traditionally, the criminal justice system has been so focused on ensuring that offenders are suitably punished that the interests and needs of victims are often overlooked. Nowhere is this more of an issue than in murder cases, where the relatives and friends of the victims are dragged through traumatic retellings of the crime.

One approach that seeks to give relatives and friends (known as "co-victims") a voice, and to help address their suffering, is known as "restorative justice" and it involves victims (or, in the case of a murder, co-victims) meeting face to face with the offender.

While restorative justice is becoming an increasingly common practice, psychologically informed research into its effects is relatively rare. Indeed, a recent issue of the British Journal of Criminology presents the first ever case-study investigation into the effects of restorative justice on the relatives of a murder victim (specifically, two sisters of a young man who was murdered). The paper makes for difficult reading but provides some valuable insights.

John (names have been changed), a bar manager in London, was murdered at the age of 30 by two men he'd invited back to his flat one night after work. He'd encountered the men by chance in an area of London where gay men meet for sex. Their plan was to take advantage of his inebriated state and rob him, but the plan went awry, there was a violent confrontation, and one of the men – Michael – strangled him to death. Michael is serving a life sentence for murder, the other aggressor had his sentence reduced to manslaughter on appeal after claiming to have a diagnosis of Asperger's.

Fifteen years later, two of John's sisters accepted an invitation to take part in a restorative justice plan for them to meet Michael. They had both suffered terribly since losing their brother: one sister Janet was diagnosed with clinical depression and missed 18 months of work; the other, Barbara, developed an alcohol problem and attempted to take her own life. Mark Walters, the author of the case study, explains that these long-term difficulties are common among the co-victims of murders. Often, as was the case especially with Barbara who compulsively re-watched a documentary about her brother's murder, they become "stuck in a cycle of re-living incoherent pain and suffering".

Janet and Barbara were both keen to meet the man who killed their brother. They wanted to ask him why he'd killed John, and especially whether he'd been motivated by homophobia. This desire to discover an offender's motives is apparently very common among victims, perhaps because it can help bring coherence to their narrative of the crime. Michael told the sisters that he was not homophobic, and that he and his accomplice had simply seen John as an easy target. He said he'd had no intention to kill John, but that things had gone wrong in a way he'd regretted ever since. Janet said this gave her a new understanding of her loss, one that (in Walters' words) "put a stop to 15 years of recurring questions."

Another motivation that the sisters had was to explain to the killer the profound consequences of his actions. They told him about their brother ("if he wasn't my brother he could quite easily have been our friend ... he was a nice guy ... the guy that went with the Soup Kitchen helping the homeless ... he was that guy"). In turn Michael apologised to Janet and Barbara, and they felt his apology was genuine and that they'd successfully conveyed to him how his actions were having consequences all these years later.

The sisters also heard Michael's perspective: he'd been abused from an early age, was homeless from age 11 and had drink problems. They were sceptical at first, but then they began to soften.

"I thought, you know, 'he's a thug', 'he's a monster' ... and it was quite shocking to see him, he was just ... normal you know? ... I could understand where he was coming from, what he was saying, and why it happened," said Janet. 

In a way, Walters explains, the two parties (the sisters and the killer) were revealing each other's humanity. The meeting ended with them shaking hands and Michael promising not to return to the problems of his earlier life. The sisters said the process had been extremely beneficial. Barbara had previously rung Janet almost daily for years to discuss their brother's murder. After the restorative justice meeting, this stopped.

However, there was an unexpected emotion that Walters highlights as potentially problematic and important for future research ("We must remain cautious about 'rolling out' a measure that can give rise to new psychological challenges," he says). That is, Janet came to realise that she actually liked the murderer Michael, which ultimately led to difficult feelings of guilt.

"I came out feeling very, very guilty ... cause I felt I shouldn't have been thinking anything like that [liking Michael] at all ... I shoulda, absolutely hate him and not feel any, not have any positive thoughts about him or have any compassion about him but I did."

For his part, Michael said the meeting was one of the toughest things he'd ever done, and that nothing could be as intense as coming face to face with your victim's family:

"...one sister asked 'do you consider yourself to be evil to the core?' ... to be asked that by anyone is difficult but to be asked by [the] victims [of] their brother you've murdered, it was extremely hard to answer. [Interview: What did you say?] I answered honestly, I said that what I had done was serious and was evil but I don't consider myself evil to the core. The sister said that they thought we don't think you are. [Interviewer: how did that make you feel?] it made me feel very emotional to hear your victims, whose brother you've murdered, at the end of the day you've murdered their brother [and] they don't consider you're evil to the core. I was welling up ... the sisters had tears rolling down their eyes."

Walters said this effect of restorative justice on offenders could help break the self-fulfilling prophesy whereby criminals come to behave in ways consistent with how they believe the world sees them, as evil monsters.

This case study appears to show restorative justice as a beneficial process for the close relatives of a murder victim and for the offender. Of course the findings need to be interpreted with caution: this is just one story and as Walters explains, "it is not possible to draw generalisable conclusions." Also, restorative justice is not for everyone: indeed, John's two other sisters declined to take part because they felt too angry. However the research certainly highlights interesting points for future research.

"Most significantly," Walters concludes, "The emotionality behind such [restorative] dialogue further enabled [all involved] to develop a renewed understanding of each other. Collectively, the interpersonal connections that emerged allowed all stakeholders to move beyond their experience of homicide better equipped to deal with its painful aftermath."

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Walters, M. (2015). ‘I Thought “He’s a Monster”… [But] He Was Just… Normal’ British Journal of Criminology, 55 (6), 1207-1225 DOI: 10.1093/bjc/azv026

--further reading--
When a client confesses to murder
What makes revenge sweet?
How jurors can be misled by emotional testimony and gruesome photos

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

Our free fortnightly email will keep you up-to-date with all the psychology research we digest: Sign up!

What is it like to experience mental health problems?

Tomorrow, Saturday 10 October, is World Mental Health Day and to join in we've rounded up some of the research we've covered over the years that's explored what it's like to live with mental health problems, from obsessive compulsive disorder to hearing voices. Psychologists call these kind of studies "qualitative research", where the aim is not to put a score against particular symptoms, but to discover the first-hand perspective and experience of the people who take part, based on their own words. Such studies are often distressing to read, but their insights make a vital contribution to our understanding of the human condition.

Depression feels like a kind of emptiness

A recurring theme from interviews with seven people diagnosed with depression was their sense of depletion and emptiness, both bodily and in thinking about the past and future. "It's like something's gone inside me and swept my happiness away," said one participant. "I feel like sometimes my life is on hold," said another. Isolation was another key theme, as captured by this man's description: "You get into a state I think mentally where, you're just like out on an island ... You can see from that island another shore and all these people are there, but there's no way that you can get across [ ] or there is no way that you want to get across." Writing in 2014, the researchers Jonathan Smith and John Rhodes said it was clear that all the interviewees had in common that they felt alone, empty and that they had no future.

Selective mutism does not feel like a choice
People with selective mutism can't speak in certain situations even though there is nothing physically wrong with their vocal chords and they don't have brain damage. Four people diagnosed with the condition were interviewed via Skype's instant messenger interface. Their descriptions challenged the traditional idea that selective mutism is a choice. "It isn't me," said one participant. "I know who I am and I’m not shy or quiet, maybe that makes it harder. When I’m with my parents I can be myself but around everyone else it’s like it [selective mutism] takes over. I can get the words in my head but something won’t let me say them and the harder I try the more of a failure I feel like when I can’t." The interviewees also revealed how the condition became self-fulfilling as people came to expect them to stay silent. And they talked about the extreme loneliness they experienced. "It's like that scene from Scrooge where he looks through the window and he can see people having fun being together," said one interviewee. "I'll always be stuck outside looking in."

To be a refugee with psychosis is to feel there is no future
The first-hand experience of refugees with symptoms of psychosis was documented for the first time in a heart-wrenching study published this year. Based on interviews with seven African refugees or asylum seekers, the researchers identified six main themes: bleak agitated immobility; trauma-related voices and visions (mostly the sounds or sights of lost relatives or attackers from the past); fear and mistrust; a sense of a broken self; the pain of losing everything; and the attraction of death. The last theme was captured by the words of 26-year-old Sando: "The worst part," he said, "is I keep harming myself, ... and you know knocking my head to the wall, kinda too much stuff in there, you know, I just want to open my head and finish with this."

Some people have a love-hate relationship with their OCD
Based on their hour-long interviews with nine people diagnosed with obsessive-compulsive disorder, the researchers Helen Murphy and Ramesh Perera-Delcourt identified three main themes: "wanting to be normal and fit in"; "failing at life"; and "loving and hating OCD." The first two themes were often related to the painful situations provoked by the interviewees' compulsions. One man who house-shared described how he had to scrub the entire bathroom with powerful cleaning product for an hour every day before he could use it. But at the same time, the interviewees explained how they actually feared losing the crutch that the condition provides. "I wish I could do that [stop checking], I wish I could stop," one man said, adding: "Well, not totally."

Being labelled as "schizophrenic" feels hugely stigmatising but also unlocks much-needed treatment
In a 2014 study, seven patients diagnosed with schizophrenia described their dilemma: they needed the diagnosis to access treatment, but had also feared and avoided the label because of the stigma associated with it. The interviewees said they tried to hide their diagnosis from people, and they noted how mental health professionals used alternative words like "psychosis" as if aware of the stigma of schizophrenia. "People are always afraid of saying that word to me," said said one woman, "... because it is a dirty word." The interviewees also described the chasm between their clinician's view of the illness as biological (a "chemical imbalance") and the perspectives of other people in their lives. "My mother ... all she said was 'I told you, it's because you're psychic ...," said another interviewee. The researchers said more needs to be done to overcome delays in treatment caused by ill people's fearful avoidance of a diagnosis.

For many people who self-harm, seeing their own blood makes them feel calm
Among 64 people who self-harm, recruited from a mass screening of 1,100 new psychology students, just over half said that the sight of their own blood was important to them. The most common explanation the students gave was that seeing their blood made them feel calm. Other explanations were that it "makes me feel real" and shows that "I did it right/deep enough". Those students who highlighted the importance of seeing their blood tended to cut themselves more often than those who didn't (a median of 30 times compared with 4 times) and they were more likely to say they self-harmed as a way of regulating their own emotions. Another study from 2013 asked self-harming teenagers to carry a digital device for two weeks, in which to record their motives for self-harming as they occurred. Just over half the sample reported self-harming to achieve a particular sensation, the most common being "satisfaction", followed by "stimulation" and "pain".

Anorexia starts out feeling like a solution but then takes over
"Anorexia became a friend," said Natalie, one of 14 people recovering from anorexia who were interviewed as part of a study published in 2011. "When I was alone ... I knew that at least I had A." Eventually though, for Natalie and the others, anorexia became overpowering, almost like a separate entity which they had to fight against for control of their own mind. As Jon, another interviewee, put it: "It's like there are two people in my head: the part that knows what needs to be done and the part of me that is trying to lead me astray. Ana [his nickname for anorexia] is the part that is leading me astray and dominates me."

For some people, mirrors are addictive and imprisoning 
A diagnosis of Body Dysmorphic Disorder is made when someone has a disabling and distressing preoccupation with what they see as their perceived physical flaw or flaws. In upsetting interviews that were published this year, 11 people diagnosed with the condition described their complicated, troubling relationship with mirrors. One woman said she'd once stared into a mirror for 11 hours straight, searching for a perspective where she felt good enough about herself to be able to go out. Another interviewee, Jane, described mirrors as "f*cking bastards" and mirror gazing as a "form of self-harm". The interviewees also described what they perceived as the ugliness of the person staring back at them. "I look like a monster," said Hannah. Jenny said she is "truly hideous" and "repulsive". Lucy said: "Everyone else, everyone is beautiful. I just feel that I am that one ugly person."

People's experiences of hearing voices vary hugely 
Last year, researchers analysed seven previous studies that had explored people's first-hand experiences of hearing voices. Taken together, the most striking finding was that to hear voices that aren't there is not a homogenous condition. While most people described attributing an identity to the voices, they differed in whether they saw the voices as separate from their own thoughts or not, and in whether they felt in control of the voices. Those who subscribed to a biomedical account, believing that their voices were caused by a chemical imbalance in the brain, tended to feel less in control of their voices. Similarly, heard voices could interfere with social relationships, for example by making critical comments about friends or family. But voices could also play a beneficial role by reducing loneliness. "I have not got many friends … so the only thing I can stay very close to are the voices and I do stay very close to them," said one interviewee.

Positive change is a gradual process that is realised suddenly
As well as asking people about their experiences of mental illness, psychologists also research what the process of recovery feels like. In 2007, researchers interviewed 18 women and 9 men diagnosed with conditions like depression and anxiety about their experiences of positive change during Cognitive Behavioural Therapy. “It was gradual but the realisation was sudden," one interviewee said. Many of the participants could remember the exact moment: “I could actually hear it,” one said. Other themes in the clients' descriptions of how change happened were: motivation and readiness (“I was desperate to get back to my old self”); tools and strategies (“It's the changes in behaviour that I learned”); learning (“I would take a lot of stuff home to read about assertiveness”); interaction with the therapist (“...they don’t judge your character or think they know you”); changes to self-perception (“I am a strong person mentally”); and the relief of talking (“Let me get everything out, let me relieve myself of everything”).
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--further reading--
What is mental illness?
World Mental Health Day 2015
   
Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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