[MUSIC PLAYING]
SUSAN LLEWELYN: I'm delighted
to be here today, and thank you
so much for coming.
It's a great
audience, and I hope
I'll introduce you to a subject
that I've been interested
in for most of my adult life
and have tried to distill
into this little book.
I've got a co-author
who was actually
a student of mine, Katie van
Doorn, who works in the US.
And so we tried to make sure
that the book wasn't just
a UK-based book.
She's brought in some ideas.
And she's also Dutch, so we've
got the European and the US
perspective.
So she works in the
US at the moment.
So I'm going to try and
just briefly introduce you
to this area.
It covers a range
of specialities,
but I'm going to tend to speak
from my own experience, which
is inevitable.
I worked as a
clinical psychologist,
originally training just
to work in clinical work.
But in later years,
I found myself
being more interested
in research
and then eventually in
teaching and training.
So the last 20 years has been
running the doctoral training
course in Oxford to train
new clinical psychologists.
And as such, I had to have an
overview of the whole subject
and hopefully was therefore
in a good position
to write this very
short introduction.
As you know, 35,000
words-- and I
worked in the area
for about 40 years.
So about 1,000 words per year
of my life went into this book,
and therefore it's
quite crammed.
So what I'm going to try
to do is really talk to you
about what it's
about and what we're
trying to do as
clinical psychologists.
And I suppose the best
place to start is--
if you like, what I often say
to my own family and to myself--
which is it's actually
tough being human.
Being a human
being is difficult.
We have so many differences
and difficulties
to deal with in our lives--
complex feelings, emotions,
desires, challenges throughout
life, managing other people,
managing ourselves, managing
the world around us.
So I've always been
interested in how
do people do this,
how do people tick,
and what happens
when it goes wrong.
And there have always
been difficulties in life.
We are not unique in finding
life sometimes problematic.
If you've never experienced
emotional difficulties
or relationship
difficulties in your life,
then you're incredibly
lucky, and I think
you're probably quite rare.
Sooner or later in
your life, there
are things which go wrong.
I'm not going to
talk in great depth
about any individual case.
But later on in my talk,
I will talk about a couple
of examples of people
I've worked with.
But it's tough
managing all the things
you have to do-- your ambitions,
your needs, your family,
your parents, pressures,
and the world around you.
And that's, I say,
always been the case,
not just now in this century
but in many other centuries.
We know that there
has always been--
not everybody finds it easy just
to get on happily in the world
that they're born into.
And there have always
been ways that society
has had to offer people
some way of feeling better
about themselves
and other people
when people find
things difficult.
And I've just
listed historically
a range of ways in which
society has offered people
who are struggling a bit.
And there are many ways of
dealing with this stress.
If you like, let's
start off with the law.
People who behave
differently or oddly,
we deal with them legally.
We put them in a class.
Maybe somebody who's behaving
badly, we put them in prison
or we put them away somewhere.
So the law deals with people.
And to this day, when people
start behaving strange
in the street, or something
happens which is challenging,
we may call the police or
a lawyer to deal with that.
That's one way of
dealing with people
who are behaving differently.
Another way, of
course, is medicine,
and medicine has
always been a place.
Nowadays we tend to turn to--
if you are unhappy,
go to your GP
and maybe they can find some
way of helping you with that.
Other ways include religion and
in some way that, if you like,
you can go see your priest.
And typically and historically,
these three methods--
the law, medicine,
and religion--
have been the way
that people have
dealt with feeling low, having
difficulties, children behaving
who are challenging, behaving
in ways which we want to change.
If you like, those
are the big ways
in the past that people have
dealt with difficulties.
I've also put magic
there, because, again,
another approach is, for
example, using astrology
or some other sort
of technique to deal
with people who are
behaving strangely
or feel bad about themselves.
And to this day, you can look
up your astrological signs
and read the future.
People still use that.
It's a way of making
themselves feel
better when they're not happy.
I mentioned politics there
again because changing society
is another way of trying
to change people's emotions
and ability to get on with life.
In fact, those have been the
big ways in which in the past
we've dealt with distress.
But increasingly, and certainly
since the 19th century,
people have tried to
understand the mind.
People have tried
to understand what's
going on inside our heads,
and the science of psychology
has developed.
And that's the background
to clinical psychology.
I will just briefly
mention what that is.
Psychology is now the most
in-demand undergraduate course
in the UK to do your
degree in, and it's
one of the most
competitive degrees to do.
And it's the study of human
experience and behavior.
And very quickly, I run
through some of the things that
happens within psychology.
In order to become a
clinical psychologist,
you study this first.
And the kind of
things we study is
how is it we learn things,
how our memory works,
and importantly, how
we forget things.
That's a very important
part of the system.
What stress does
to us and how we
are different from
other species,
how hormones operate
on us, and how,
for example, drugs alcohol
work on the body and the mind.
Why do we sleep?
Why don't we sleep?
And how the perceptual system
works, how the brain sees,
feels, and how emotions
work, how perception works.
How we recognize people and
how we attend to other people
or to anything else and
how we make judgments.
So the whole way in
which the brain works
is the subject of psychology.
And as a science, it's
really quite recent.
It's maybe 200 years or
so, but the most progress
has been made within
the last 50 years.
Other things
psychology does is why
we have emotions, why we
feel, and particularly
child development--
how children learn,
how they learn social
behavior and language,
and how people
attach to one another
and how important
relationships are.
How children separate
when they eventually
do what that process is
and how important it is
and what the effects
of aging are,
how we get along, how we
behave differently socially
with other people, and how
groups differ from one another
and why and how we get
along with authority--
those are just a sample of
what you study in psychology.
So if any of you might have
done a psychology degree,
this will be familiar to you.
And this is the
equivalent, as in medicine,
of studying genetics,
physiology, anatomy.
So if you want to be a
clinical psychologist,
you do all this
first so you have
a notion of how the human mind
works and how people behave.
So that's our bread and butter.
So that's, if you like, the
degree that I originally
studied.
But I was most interested
in, when it all goes wrong,
when people are
unhappy, and what
happens during the periods
of life when most of us
have some challenges, what
can we learn in the same way
as when you do in anatomy
and physiology and genetics?
If you're a doctor, if
you understand that,
then what is it when
it doesn't work?
So clinical psychology,
which is, I say, my interest,
is the application of
psychology in clinical settings
where people have emotional
or psychological difficulties.
And these include hospitals,
in particular mental health
but also child
health or clinics--
wherever people present
the psychological distress.
So clinical psychologists
work in a variety
of different places.
My early years in
the 1970s, '80s
was working in
psychiatric hospitals,
but people also work
in general hospitals.
So it works across the
lifespan from infants--
so how people may have
difficulties in early
relationship attachments,
things like adoption and some
of the difficulties that
children can experience
and the relationships
between parents and babies--
through to the very old
and the process of letting
go of life at the end of life.
Now, we as clinical
psychology work very closely
with medicine.
I mentioned the training
to become a doctor.
One of the things you can do--
if you know all this,
forgive me if I'm
telling you stuff you
know, but just in case.
One of the specialties
within medicine--
when you've done
your basic training,
you can choose to do psychiatry.
Now, psychiatry is different
in clinical psychology,
in that to be a psychiatrist,
which in fact our daughter is,
you have to do medicine first.
So she's done the whole
business of anatomy,
physiology, and all that
stuff, which I didn't do.
So she's very familiar
with, and psychiatrists
know about how the body works.
And their treatment of
mental health problems
tends to be oriented
towards the physical.
So for example, the treatment
psychiatrists tend to give--
so if you're suffering
from depression or stress
and you go see a
psychiatrist, they
will tend to-- first
of all, they'll
do a very thorough
physical examination.
And they may well give you some
medical treatments, for example
antidepressants or some other
sort of physical treatment
for your condition.
Now, I'm not
qualified to do that.
I'm not a doctor.
I wouldn't do that.
But I work very
closely with doctors
so that we will see people where
perhaps medical treatment isn't
appropriate or it's not thought
to be helpful in this case.
We have a close relationship.
We cross-refer to
one another, but we
have a different treatment.
Our treatment is
psychological, not physical,
though I'm very aware,
of course, we have bodies
and therefore hormones
and things are important.
And drugs do have an impact.
Indeed, there's nothing wrong
with psychiatric treatments,
like antidepressant.
They can be used very much
with psychological treatments
so we work together,
particularly with psychiatry.
And we offer different
perspectives.
So by and large, the
model underling psychiatry
is a physical one,
which is there's
something wrong with
your hormone balance
or with the endocrines
or the brain chemicals.
So you can fix it
with medication.
Whereas we'll understand
when people have distress,
depression, or
personality/relationship
difficulties or children behave
challenging ways or families
breakdown that isn't an
illness that's happened to you,
though that's a
convenient label.
It's not an illness.
It's a complex human response
to trauma or challenge
or difficulties.
So what's wrong with you
is, while we can treat it
medically-- and often those
treatments help, interestingly;
they do help--
their cause may
be something else.
So by and large, what
we do is help people
to develop solutions
to their problems
rather than come and find
a medical way of fixing it.
But again, we do
work with doctors.
And if you do have depression,
often the very first
useful thing to do is to try
antidepressants, because we
know they're effective.
And if they're effective,
fine, because you can get back
to work and that's great.
But if it doesn't
fix it or you don't
want to use
antidepressants, often
the psychological
approach is the next step.
To complicate matters,
many psychiatrists also
use psychological treatments.
So they will use the
methods I might use,
but I won't be
prescribing because that
isn't my background.
So we do work with them, but our
specialty as the psychological,
based on all that research,
all that knowledge,
do with how people think,
how people perceive,
how people develop,
all that stuff
I mentioned earlier,
which is our basic stuff.
So we work with people to
try and develop a solution
to the problem and
base it very much in
a collaborative relationship.
So patients are referred
to clinical psychologists
usually because they go to see
their GP or somebody suggests
they maybe need a bit of help.
Perhaps that they've got
difficulties in the family.
The child is repeatedly
challenging or difficult,
or the child is very anxious--
or perhaps the adult, you or me.
It's very much like all of us
could be in this situation,
feel depressed,
feel anxious, have
difficulties or relationships.
Or maybe granny is getting
more and more challenging
to us, living at home with us.
We don't quite know how
best to help the family
to adapt to the fact that we've
now got granny living with us,
and that's difficult.
We've also got
a teenager who wants
to go out drinking
and all sorts of problems.
These are human problems
which aren't illnesses.
Can we find a way of solving it?
And we very much
work with people
who bring their problems
to us and tell us
about them in confidence.
Because it's confidential
and collaborative,
ethics is very important to us.
So we have a very
strong ethical code.
We are regulated by
the Health Professions
Council, which is like the
General Medical Council.
And we also have a professional
organization, the British
Psychological Society,
which has codes of ethics
that we have to abide by.
And these specify very
clearly that we are there
to help the patient,
not ourselves.
And that's important
because typically
what happens is that a
patient will come see me--
and I should mention I've
mostly worked with adults--
with a problem,
a difficulty, and
would trust me, hopefully, with
telling me some very intimate,
personal things.
And my responsibility
is to help them
the best I can to solve
their problems, not to--
not because I think
I've got the answer.
I can't say to them, oh,
well, if you voted Labor,
your problems would be solved.
That wouldn't be
my responsibility.
I've got to help them
work out the solution.
And in fact, this little
cartoon summarizes it.
"We're encouraging
people to become
involved in their own rescue."
I don't think that's very
ethical there, though.
That man is busy
reading his comic book
while the person is drowning.
We wouldn't quite do that,
but we certainly don't come up
with answers for people.
Because there isn't
any point in that.
We don't have an answer.
We help people to
think differently
and to help them to see how
they got into the situation
they're in when
they're feeling muddled
or they're feeling upset.
So we are a helper.
We work with them to
change the situation.
So the kinds of people
who go and see clinical
psychologists-- these
are typical clients--
peoples with phobias or
fears, which are very common,
or anxiety.
These are, in a way, some of
the easiest problems to solve.
If you've got a fear of lifts
or wasps or spiders or cliffs
or something, airplanes,
those are quite relatively
straightforward difficulties.
And often that's
to do with people,
over a long term avoiding,
discovering those things are
actually quite harmless.
So that's a very
common difficulty,
very common amongst children.
People often grow out of
them, but again, people
can get stuck.
People with depression, that's
a more complicated problem,
and there are lots
of reasons why you
might experience depression.
Life is challenging for you.
We can't solve that.
Life is difficult. Life
is tough, remember I said.
But we can maybe help
you to understand
the ways you've tried to
solve your depression are,
paradoxically, not helping you.
So things like
relationship problems,
people who've got, again, stuck
in things which are difficult,
needs another perspective.
People with eating
disorders and psychosis.
Psychosis is, if
you like, how we
tend to use the term now,
rather than schizophrenia
or manic depression.
Those are words we tend
not to use so much now,
because we're much more
thinking about what's
going on in the mind.
Psychosis is
disordered thinking.
We're starting to
understand it better now,
based on lots of very good
psychological research.
But very serious
mental health problems,
which are very
challenging and very
disruptive to people's lives.
People who have long term
difficulties in the past
used to be
hospitalized, but now we
have better ways of
managing it, together
with psychiatrists who
have better drugs to help.
Also, people with
physical illnesses,
like cancer, stroke,
or spinal injury--
if you have a
life-threatening illness,
it affects the way you
think and feel, inevitably.
And children with
a range of family
and individual disorders
or different types,
difficulty in relationships,
school refusals,
disruptive behavior
in the family,
or child anxiety,
which is very common.
And people with brain injuries
and developmental disorders,
all of which have a
psychological component.
You can't just have, say,
diabetes or a stroke or heart
disease without
it also affecting
how you think and feel.
So we use a number of models.
Some of you have heard of CBT.
That's very common now.
The cognitive model says the
thing let's pay attention to
and is a disorder on
happiness is how you think.
So we look at how it is you're
understanding, your perceptions
of what's going on.
The underlying idea here
is that sometimes people
can understand something
in a particular way which
leads them to have
particular emotions,
and what's difficult is
the way they're thinking.
When you are depressed,
for example--
we know when people
suffer from depression,
they tend to think in
more concrete ways.
They jump to conclusions.
They'll see things in
more black and white,
which can lead you to make
assumptions about the world.
And I'll come back
to that in a minute,
but that can aggravate
your low mood.
So when we're working
with depression
using a cognitive
model, we try to help
people to see how their thinking
is actually unhelpful to them.
Behavioral people would use
treatments, for example,
say, with children,
whereby we help people
to train how they behave.
And again, that leads to
different consequences.
CBT is a combination of
behaviorism and cognitive
therapy, which is
increasingly popular.
A lot of evidence suggests
it's very effective.
Psychodynamic, this is
more Freudian thinking,
trying to understand
relationships
and particular attachments
and difficulties
people have with attachments--
or what I call systemic.
This is trying to understand
how the system around you,
perhaps at work
or in your family,
is aggravating or difficulties.
So we'll use all these models.
The way we work is, I feel
like, a series of stages.
First of all, the
person is assessed.
So the person seeing
me, I will ask them
about what's happened
in their lives, what's
happened to them, what's the
history of the problem, what's
going on in your life,
who's in your family.
Are you working?
What else is happening to you?
So we might use questionnaires
or just talking to somebody.
Or we might pay
attention to how they
are in a relationship with us.
So are they very challenging,
or are they very passive?
So we'll pay attention to
those things in the room,
in the assessment room.
We'll then come up
with a formulation,
which is a bit like the
diagnosis in medicine.
And in particular, we're
interested in the predisposing
factors.
Why does this person
have this problem here?
And is there something
in their background?
Perhaps they come from a
background where people--
branches in the family.
What precipitated it?
What happened last week or
a month ago that led to it
happening now?
And what is a
presenting problem?
What's going on?
Why is it staying there?
Why is it perpetuated?
Why haven't people--
people don't want
to be sick or ill or unhappy.
Why is it going on?
What's going on?
Why is it perpetuating?
And if you like, what is going
on which is protecting them
in their lives?
Everybody has some good things.
So have they got
good relationships?
Have they got a good job?
Have they got something
somewhere which
is also helping them to manage?
So we need to know all of that.
We then come up
with a formulation,
which is like a diagnosis.
And I'll show you some
formulations in a minute.
We then do an agreement.
We'll draw up a plan to
intervene to change things.
For example, if we're
using a cognitive model,
we might set about a series
of cognitive experiments,
helping them to
think differently
about whatever the problem is.
Or behaviorally, again, we may
set up some little experiments
to do with the person.
Just an example,
someone who's frightened
of going up and down the
lifts, they're frightened
that something catastrophic
will happen, very scared
of going near a lift--
you'd have to walk up and
down the stairs every day.
It'd be a pain.
So what we'll do
is help the person
who's very frightened
of this first of all
watch me going up, trusting me.
I'll go up and down a lift.
They'll watch me doing it.
Then eventually we'll
stand inside the lift
without closing the doors,
and I'll get used to that.
Next time we'll go inside.
Perhaps we'll go up together
one floor, which is very scary.
But I'll be with them helping
him to relax, helping them
to experience less tension.
And then the next time we might
get them to go up three floors
and then finally to go on
their own, up and down.
So that would be a very
simple behavioral treatment.
If it's a relationship problem,
it's not quite simple as that,
as you can imagine.
But we would come up with
some other ways of perhaps
suggesting an alternative.
We'd then evaluate, did
it work, didn't it work.
If it didn't work, go
back to square one.
Try something else.
At the same time,
we're doing research
because we want to make sure
we have the right treatments
for the future.
How we tend to work-- well,
it takes about eight years
to train, see somebody.
So as I said, degree
in psychology first.
Then we don't like to take
somebody straight off,
because they're very young
and a little inexperienced
when you're 21.
So we often ask them to go and
get some work in the workplace,
maybe in hospitals or
somewhere where they're
working with people,
to make sure that they
get a bit more experience.
We then do a
three-year doctorate.
So that's why it's
around eight years
altogether, which is
what my last job was,
doing that to train people.
Our model underlying is
science practitioner.
In other words,
we're practicing.
We're not in labs, but we are
using the notion of science.
Because we test something--
does it work, doesn't it work.
If it doesn't work,
we try something else.
We're always measuring how's
it work, what's the outcome.
So we get people to
fill in questionnaires.
It drives them mad,
but we need to do
that to make sure we
are on the right lines.
And we use research-based
evidence, trials,
which indicate what
works and what doesn't--
a role for that.
We spend a long time reflecting.
We need to make sure
we're behaving ethically
and we're aware of the context
of what people want to do.
And one context with
one ethnic grouping
might be different
for another one.
In the UK, this is pretty
much based in the NHS.
Our training is
funded in the NHS.
In the rest of the world,
it's very different.
People very much self-fund their
training and work privately.
There's a little bit of private
work in the UK increasingly,
but I've never worked
privately myself.
I've spent all my life in
the NHS or in academia.
If you want to see a
clinical psychologist,
they do advertise.
They're increasingly
working privately.
Normally it's people
referred by a GP
or another medical specialty.
So for example, a renal
specialist might say,
this person is having
difficulty adapting the need
to be on dialysis,
can you help them.
Or, this person's had a brain
injury, let's work with them,
with their families to help
them back to normal life.
And it's typically based
on a series of sessions
over several months.
So the course of
treatment might be
six months or whatever,
or less, depending
on what the problem is.
So I'll come back to the
candidates in a minute.
I'm just going to show
you a formulation.
This is a bit tricky,
but we often do diagrams.
So I want you to have a
look at this person here,
at the very bottom
of this diagram,
if you can see this person.
And this is a case taken out
from a book by Ryle and Kerr.
It's mentioned in the book.
At the very bottom,
this person--
she's a woman, her
name was Beatrice--
comes to see the
psychiatrist or psychologist
feeling really depressed.
She describes herself as
being like a frozen chicken
in the supermarket.
She says she's like
wrapped up in cling film
as a frozen chicken.
That's a self-image
of herself-- frozen,
no longer in relationships,
unable to do anything, really
miserable, in her early 30s.
That's how she comes along.
What do I do?
Well, antidepressants
might help a bit,
but actually there's
something else going on.
So we try to
understand the story.
Go right back to the
beginning of her story,
inside the red box.
It turns out she has
parents who really
were quite critical of her.
They rejected her and were
quite demanding of her.
And in response to her parents,
she felt very guilty about it,
but she also tried
to work really hard.
So she's in the red box there.
She's striving and needy.
Her needs aren't
being met by parents.
She's quite independent.
She's also quite
rebellious at school.
So there she is at
school as a young girl.
She actually gets expelled.
So if you look on the side
there, "rebel" gets rejected.
Can you see that?
She gets expelled
from school, which
just makes her feel worse.
So she longs for
closeness, because she's
an attractive young woman.
Makes a series of relationships.
She often has relationships.
She fears abandonment.
She's in the center now.
She fears abandonment.
She avoids getting
close to her boyfriends.
She feels very lonely.
She withdraws from people.
Her needs are often unmet.
She feels depressed, and she
feels like a frozen chicken.
She doesn't dare reveal herself.
So she went sometimes
on the other side,
on the left-- is
it left or right?
This side here.
She risks becoming
close to people.
She tends to idealize the
person she falls in love with.
She makes them
out to be perfect,
has a moment of
complete being in love.
They're a perfect relationship.
She then feels totally--
she feels has been worthwhile,
but she fears being abandoned.
She then runs away
again, because she
can't cope with the
idea of being abandoned.
And she's back to
the frozen chicken.
Sometimes, on the
other side, she
strives very hard
to please people.
She pretends to be
something she isn't.
She hates herself.
Her needs are unmet.
She doesn't reveal itself,
and then she feels depressed.
So if you like, this is a
joint collaborative formulation
we've made of the kind
of problems that she has.
That's a formulation.
Another example of
a formulation here,
this was a man called Terry
who used to drink too much.
He had very-- again, inside
the red box, red circle.
He had very rejecting,
abandoning parents who
were very contemptuous of him.
As a child, he's in the
place of B. He's very alone,
felt his needs for closeness,
wanting was very contemptible.
And what we find in
life is you often
tend to reproduce
psychologically
some of the things your parents
did to you in your attachments.
So he to himself
was very rejecting.
He was very angry with himself.
What he tended to do, again--
he worked in industry.
What he would find is that--
because he was quite
contemptuous and angry
with people.
He'd look around at his
peers, and he'd often
find that other people
weren't as good as him.
So he would say to other
people, other people
were-- he's the best.
Other people, would
be better than them,
and he would reject
other people.
Not surprisingly, when he did
that, other people reject him.
And he would then end
up being very lonely.
And in fact, what he ended
up doing was drinking.
So he would end up
being very depressed.
He was down here.
"I'm the worst person in
the world," and he'd drink.
So he'd have a pattern
of being contemptuous
of others and
contemptuous of himself.
And he would
reproduce that pattern
when we analyzed his
relationships with others.
He would constantly feel he was
either the best or the worst.
He had one way of
thinking about people.
He had to be the
best at something
or the worst at something.
He was always winning
awards at work.
And then he would win awards.
He'd boast, and other people
would then reject him.
And he'd end up drinking.
And it was a pattern.
He went round and
round and round,
and he found it very difficult
to accept himself as he was.
So that's the kind
of formulation
we might draw up in
collaboration with the patient.
And then following a
formulation like that,
we would then introduce
ways of change.
So for example, if you
look at this lady here,
we then talked about her sense
of being rejected by others--
what it was about her
which wasn't worthy,
why she was avoiding closeness--
and try to help her to accept
herself more and
gradually, therefore,
to stop idealizing
the men she met,
when she would go into her
completely over-the-top
relationship where she'd want
to move in the day she met them
and they would then
run away from her.
Help her to be a little bit more
careful about the relationships
she got into and gradually
develop relationships
where she could be with
people without them
being perfect, but more
egalitarian relationship.
And again, with Terry,
to help him to not
be so contemptuous of others,
because the pattern he got into
was always to put other
people down, which meant
they put him down.
So that's what you might
do in your treatment.
So as I say, that's quite
a different approach
than giving someone
antidepressants, though we
might well work with
antidepressants,
say, somebody with depression.
What the challenges are is
how scientific is all of this.
You may say, well, what's
that got to do with science?
We try to be science
practitioners.
Really, it's based
on studies which
have used models like this.
Do they work?
Don't they work?
And so a lot of evidence
that CBT is effective,
as I've mentioned.
And there's a lot of work done.
What are the studies?
Does this treatment work?
Doesn't it work?
With which patients
does it work?
And one of the problems we have
in psychiatry and in psychology
is that, actually, humans
are terribly varied.
Everybody in this room
has a different story.
Doing psychological research
is complicated because you all
have different experiences,
whereas probably
most of your kidneys or
livers work the same,
one would imagine.
But your history,
your psychology
is going to be so different.
And we've tended to give
one treatment to everybody.
And what the research
demands is that we
have more and more
nuanced treatments
for different people.
You wouldn't want
the same treatment
as the person next to
you, because your life
story is different.
And that's why often
we don't get it right,
because it's very
difficult to get it right.
Laws and medicine--
if you like, I
like to say that they're
difficult subjects--
are probably simpler because
people are not so different.
I mean, there are many ways in
which you can be physically ill
and break the law and
have legal complications.
But the number of ways in which
people relate to each other
is so infinitely
complicated, it's difficult.
And we do our best
to be scientific,
but we don't always
get it right.
Therefore we do spend a lot
of time thinking about it,
and sometimes we
get over-reflective
when we spend our time thinking.
And maybe that's
not always helpful.
There are not so many of us
because it's very expensive
to train somebody to become
a clinical psychologist--
several hundreds of thousands.
And so the NHS can't afford
that many, and we tend to be--
there are relative few of us.
So I don't know how many
of you've ever-- actually,
just out of interest,
how many of you
have heard of clinical
psychologists as a profession?
Ah, you've heard of us.
Great.
But probably not
many-- how many of you
actually know a clinical
psychologist personally?
About four or five of you.
And that's great that you do.
There are not many.
There are many, many
more psychiatrists.
Psychiatrists are much
more numerous than us.
And, of course, many,
many more doctors.
There are many more--
most mental health care,
certainly in the UK,
is provided through the NHS.
It's provided by
nurses and doctors,
and we're very small in number.
And so how can we have--
these models are
very interesting,
but it's hard to
actually see somebody.
The chances of seeing
a clinical psychologist
are really quite small because
there are so few of us.
And one of the other
things is that we
know very well that the
things often precipitate,
the background to mental
health problems in particular,
are things like
poverty and exclusion.
So we know that
mental health problems
are much more
dominant within groups
that have poor resources.
And if you want to improve the
mental health of the nation
as a whole, you might want to
pay more attention to things
like education and
employment, unemployment,
and so on, and inequalities.
And we're looking at
the individual victims,
if you like.
We get the people
who've been damaged
by some of those things.
And maybe a better
thing would be
to change society as
a whole, because those
are the things that lead to some
of the mental health problems
that there are.
We're fixing the individuals.
I appreciate you
have to do both,
but often there's
a tension between
should we treat the people
or should we try and change
the system which leads to
people having these problems.
We can talk more about that.
And one of the other things is
could you make much more better
use of information technology?
The treatments,
particularly CBT treatments
that are increasingly
used, they are
open to being used
with technology.
For example, some of the
individual treatments, rather
than coming to see me
to do a desensitization,
which is a treatment for your
fear of lifts or something,
could you do that online?
And there are treatments
which can be provided online.
I had a go at this myself,
actually, a few years ago,
because there's a very
good program for people
who have sleep problems
called Sleepio, which
is a CBT online treatment.
It was, in fact, set up by a
colleague of mine from Glasgow
University, now in Oxford.
I don't have a
major sleep problem,
but I thought, well, I quite
fancy sleeping a bit better.
So I did this sleep
program, which
meant every week I had to go
online about an hour and answer
questions and do
things differently.
And it was very well-designed.
And actually, I have to
say it really did work.
It increased my ability to
sleep well through the night,
and it was very nice.
[INAUDIBLE] I stepped
back into my bad habits
after a while, which was reading
in the middle of the night
and stuff and staying in bed
late, which you shouldn't do
if you've got sleep problems.
But we should use
information technology better
to try and spread, if you
like, psychological treatments
to more people.
And there are ways
of doing that.
It's very much what I think
the next generation is
going to include.
So I think that's the
next-- and [INAUDIBLE],,
because here I am at
Google, thinking with you,
thinking about what can we do
to spread good mental health
practice.
We know that depression is
a major cause of dysfunction
in the world out there.
Most of us in our
lifetime will have--
either ourselves or one
of our friends and family
will have some mental
health problem,
and it will cause
distress to families.
And we can treat it medically,
although not everybody responds
to medication.
And in many ways,
what we know is
that psychological treatment
and medical treatment
together is one of the best.
But it's hugely time
consuming and it's demanding,
and it's expensive.
So is there some way in which we
could deliver better treatment
better?
One of the things that
makes it difficult
is that one of
the things we know
is important in making the
psychological treatment work
is the relationship that you
develop with the person you
are helping.
So that's very important, that
we have a close relationship.
How can you reproduce a
relationship with a computer?
Because we know that that bond--
the person who goes up
and down the lift with me,
the reason she's prepared
to do it is we've
spent several hours beforehand
where I've listened to her,
I've given her my attention.
She trusts me.
She knows that I respect her.
I'm not belittling her, and
therefore so she trusts me
in order to try doing it.
How could you do that
if you're on a computer?
So that's one of
our challenges, how
to deliver more widely the
mental health treatments
that we have to people.
I think I've probably
talked enough.
I was asked to talk about
30 minutes, which I've done.
So I'd be more happy to take
the conversation further
in any direction that
people would be interested.
Somebody at the back and
somebody in the front.
AUDIENCE: Is an educational
psychologist the same as
a clinical psychologist?
SUSAN LLEWELYN: Thank
you for asking that,
and I perhaps
should've clarified.
When you've done
your first degree,
as I mentioned all
those subjects,
either you can just--
that's a degree.
It could have been history
or physics or something.
You go and work for
Google or something
that uses psychology again.
Or you can come at
applied psychologists.
And there are about seven
branches of psychology
which are applied.
One is clinical.
That was the bit I wanted to do.
One is-- you
mentioned educational.
There are things
like occupational,
which help in designing
work places and things.
Educational is
particularly working
with children in schools--
how children learn and looking
in particular at family
difficulties.
So that if you're interested in
how to be effect-- how dyslexia
and how children
behave in schools,
that's an area to go into.
Whereas where I trained was in
the NHS, in clinical settings,
hospital settings.
Education psychologists
often do teaching first.
So they're very familiar
with the education system
before they start working with
teachers about how to work.
Because I worked in the NHS
as an assistant occupational
therapist for a bit, so I got
used to how the hospitals work,
how doctors, how teams work.
So you know the workplace.
Educational psychologists would
use many of the same models,
like CBT.
So our theories are the same.
It's the workplace
that is different.
Thanks for that question.
AUDIENCE: I wanted to ask about
widespread models, I guess,
widespread processes.
Because, of course,
depression and anxiety,
they come from things such as--
or they stem from skills
like resilience and things
like that.
Do you know if they're
doing such resilience
course at schools nowadays?
SUSAN LLEWELYN: That's
interesting, yes.
Because indeed, I think it's
very important, the context.
Although when you experience
depression, anxiety, you think
it's you, because obviously
that's how you experience it.
It is indeed your life which
is in disorder or discomfort,
but you're not alone.
And many other people
have the same issues.
And things like stress and
the demands of commuting
and the demands of managing
workplace and the family
and all that stuff--
all this adds.
And yes, so the
context is important.
So could we do something
about that context
to reduce some of that stuff?
And of course, the
real world in which
we are all competing
and all these demands--
it's difficult to
change all of that,
unless we all go and give up
and live in the countryside.
But assuming we don't do that,
can the workplace do something?
Can schools do something?
One of the fashionable
ideas is mindfulness.
Mindfulness is a way--
people who've heard of that--
of trying to help you get away
from particularly critical
thoughts.
And the underlying model of why
mindfulness works-- and they
are teaching this in schools
now and maybe in workplaces--
is like relaxation.
It's helping you to
get off the treadmill.
So if you look at, if you
like, this poor person here,
she is in a treadmill.
Because people don't
want to be unhappy.
We sometimes say, oh,
she's her own worst enemy.
She doesn't want to get better.
It's not that you don't
want to get better.
You don't know how to change,
and change is very scary.
Because if you always walk
in the same way and someone
asks you to walk differently,
how do you do that?
It's really hard, and we
shouldn't underestimate that.
So what mindfulness and
these trainings try to do
is to help you to get off
the treadmill that you're on
or think about it differently.
So yes, there is an
attempt to do that,
and then that is going to be a
better way of solving problems.
But it's such a huge thing.
And what we know is that
mindfulness does work
to a degree.
But then, again, it's
not good enough yet.
We still don't have a panacea.
AUDIENCE: Do you think, on a
broad spectrum, [INAUDIBLE]
impact things like
mindfulness in psychology?
SUSAN LLEWELYN:
Again, the evidence
shows that it has
some small effect.
The evidence on teaching
mindfulness in schools
is for some children
it is helpful,
but not for all of them.
Partly it's just difficult
to engage all the kids in it.
So yes, the evidence is that--
well, again, trying to
be scientists about it--
it works for some
people some of the time.
And we're on the case.
But there isn't a
solution to everything
yet, because it's complex.
So I know that's not
a good story to tell.
I'd love to say yes,
but we don't know yet.
Somebody here had something.
AUDIENCE: Thank you.
I was wondering how do clinical
psychology practitioners deal
with all the heavy information
and all the difficult stories
after work, how they decompress?
SUSAN LLEWELYN: Yes,
how we deal with it.
I think that's very interesting,
and increasingly we're
getting a bit better
at that than we were.
I'd mentioned one of our
skills was being reflective.
How reflective should we be?
Everybody in
practice is supposed
to have a supervisor,
which doesn't mean someone
to tell you what to do.
It's somebody you can go
and talk to about things.
And in a sense, it's
like being a doctor.
You get used to it.
And I have to say
that over my life,
I think I've become a bit inured
to stories that people tell me.
And sometimes I think
I'm getting hard-hearted.
Because there isn't
too much horrible
stuff that I've not heard.
You do get used to it.
The thing that I
find quite difficult
is that when I was first
working on one of the big issues
I talked about, trauma--
one of the things we
know, for example,
is that childhood abuse
and neglect and abandonment
as a child is bad for you.
We know that having an unhappy
childhood is not good for you.
That's one statement I can make.
And when you hear stories about
how children have been harmed
by society or by families,
that's very difficult.
I used to find that
really hard to hear that.
And particularly when
I had my own children
and I was hearing stories
about children being abused,
that was difficult.
The idea is you have somebody
who's been through it before.
And I think you focus
on what to do about it
rather than going on about it.
Again, we tend not to talk
too much about the past.
We're talking about how
things are playing out now,
because you can't
change the past.
What is happening now, today,
in your relationships which
maybe we could change?
For example, one of things we've
found about people who've been
abused as children is not
that they abuse others,
because often they don't.
There's a myth
sometimes that they do.
What they do is they
abuse themselves.
They often attack
themselves rather than
attack anybody else.
So that's what you
want to work with,
is people self-harming
and psychological
harming, rather than
going to the past.
So I think you hear
it, but then you say,
what do we do about it now?
So you hope for a way out of it.
There's various hands.
AUDIENCE: So what do you think
the biggest difference is
between approaches to
clinical psychology in the US
and the UK are?
SUSAN LLEWELYN:
That's interesting
because my colleagues
who work in the UK--
and I did spend a
couple of months
in the University of Florida
and looking at the health system
there.
I'm not that experienced,
but what I understand.
One of the big differences
here-- because we're NHS-based,
clinical psychology,
by and large,
we tend to have shorter
treatments because
of the cost of treatment.
And so we're very
much evidence-based.
What is it that works
in the shortest time?
So there's more pressure
to do things more quickly.
Tends to be therefore CBT
is the model of choice,
whereas in the US it's more
psychodynamic therapies, which
is more Freudian-based
or relationship-based,
which take a bit longer.
The evidence is they're equally
helpful, but they take longer.
So that's a
difference we notice.
That's the most
obvious difference.
There was somebody--
lots of hands.
Good.
I like this.
AUDIENCE: Would you
expect, in years to come,
that there will
be lots of things
in your red box associated with
social media and social media
pressures, particularly
on adolescents?
SUSAN LLEWELYN: Yeah,
that's very interesting,
because I think you
are-- one is humans
are enormously influenced
by the people around them.
And your close relationships,
your parents, your friends
are very important to you.
Especially for adolescents,
there's a huge--
that process of
separation from parents.
As humans, we need
attachments to others.
The separation process
from your parents
means you start to attach,
particularly in the teen years,
to your peer group.
And if your peer group
is a perfect peer
group on social media, who
all look fantastic and go
to parties all the time and have
a great time, but you're not,
that teaches you you're not
a very worthwhile person.
So I think, yes, I do
see that's a problem.
And particularly
for adolescents,
we know that mental
health of young people
today is getting worse.
And I suspect, but I
don't know well enough
what the evidence is--
I have a social
psychologist [INAUDIBLE]
do you know what the evidence
is on the social media side?
AUDIENCE: By and large--
well, it's your
"for some people."
For some people, social
media is clearly bad.
And it's a mixture
of two things.
One is, we always make
social comparisons.
But normally, if
you like, that's
within a group of 25, 30 people.
Suddenly, you've got 700,000
to make more comparisons with.
And guess what?
You come out badly.
And the other thing
is that people
behave worse to each other
when they're not face to face.
It's anonymity.
People do much nastier things
to each other over social media
than they would face to face.
So those two factors make it
a very dangerous place to be,
even though it's got
lots of positives.
But it can go badly wrong.
SUSAN LLEWELYN: And I think,
going back to programs,
it's teaching people
how to use social media.
Because I don't use Facebook.
Whenever I see anything, I
think, oh, god, these people
have much more fun
than I'm having.
But of course, it's
all myth and story.
I know that.
But it's hard.
When you're young, how do
you know that for sure?
So yes, I think that's
one of the boxes
you would put in there, which
is that the world around you
is much more likely to be
a less comfortable place
to be when you're
just that little
you with all your problems.
So I think that's
certainly true.
And I think that helping people,
ways of dealing with that
and understanding--
well, of course,
you spend hours making
the perfect selfie.
Most of us don't look like
that most of the time.
So yes, I'm sure that's true.
AUDIENCE: You've
mentioned the relationship
between the therapists
and therapy.
How do you deal with
people that get addicted
to you or to the relationship,
relying more on the therapy
than solving their
problems on their own?
SUSAN LLEWELYN: Yes, it's
a very interesting issue.
Because one of
things you're doing--
when a patient or client,
whichever word you're using--
we use both-- comes
to see and tells you,
they feel like,
their difficulties,
my professional job is
to listen to the person,
give them my full attention,
and understand them.
So I'm giving them a lot of
cues that I'm there for them.
We have to be very careful
that's not misunderstood
in the relationship.
Because normally when
you sit on your own
with somebody in the room
and they're paying you
really good attention
for an hour or something,
that's a very nice
experience, to be listened
to, being valued,
especially if the person
has very few other places where
they are experienced as valued,
which is why it's
very important we
have a lot of signals
and signs around,
which is this is a
professional relationship.
This is not a personal issue.
And there's always that
difficulty at some point
where the person
may start to wish
they had a personal
relationship with you.
I've certainly had people
want to ask me out to dinner,
and people have wanted a
more personal relationship.
And that's understandable,
because you're
being terribly nice to them
and you're listening to them
and being there for them.
But again, it's very important
that you're also very clear.
That's why we often use
our professional titles
and we only see people
in consulting rooms.
This is not a social space.
This is a work space.
And all the time,
you're helping them
to understand that this is a way
of talking about your problems.
This isn't solving our problems.
Problems are out there.
We're going to help you
get back out there again.
This is limited.
And we also often talk
about time limits.
So we'll say, I'm going to
see you for six sessions.
And in some models, we
actually say-- well,
we count down the
sessions, so they know
it's going to come to an end.
But it's a very
good-- and going back
to the question
of the USA, where
you work in a more psychodynamic
model, Freudian model,
that model, where you have a
longer term relationship, that
can be more problematic.
And it's part of our
training to handle that.
And it's understandable why
people can get dependent,
because that happens.
And the other thing
is many trainings also
require you to have
experience with therapy.
So you, as a therapist, can go--
part of your training
is to be a patient.
And you then discover how easy
it is to idealize the person
or to start rehearsing what you
tell them, tell them a partly
true story and not
a whole true story
because you're worried about--
so that's a good
way of handling it.
AUDIENCE: The
clinical body, NICE,
have to make really
difficult decisions about how
they allocate resources.
We can't afford this
particular medicine
for this group of people.
Given there are so few of you,
I was just interested to know
how is it triaged in terms of
who's going to get treatment.
SUSAN LLEWELYN: Yes, this
is the national body--
it stands for
clinical excellence,
National Institute of
Clinical Excellence--
which will provide--
that's the right
acronym, isn't it?
Yeah.
And they provide guidance
on what treatments.
They do recommend
psychological treatments
for a number of different
conditions, based on evidence--
and again, quite rightly
based on evidence.
If I have treatment,
I want to know
that it is the right treatment
for my particular condition.
They do recommend-- for example,
one of the things we know
in psychosis--
I mentioned psychosis, when
people have major mental health
problems, hallucinations,
and delusions--
that the evidence shows that
if you provide treatment
for the individual as early
as possible, the first episode
of psychosis, which
normally happens
in the late teens, early 20s--
slightly different
between men and women--
is there can be a
devastating life
course if it fully develops.
If you can get it really early
and get early treatment in,
you can prevent the
condition from developing.
You can help the person
psychologically and medically
if a teen gets in early.
So that's the really
good news story,
is that we don't have
long term patients.
If you can get them quick,
you can divert the psychosis.
You can prevent it.
And it's really late teens-ish,
often connected with-- well,
some of it is connected with
cannabis use, not always.
And there are now sources
of evidence that show--
clear evidence-- that
one of the components
is family treatment, where
you work with the family
to understand how to deal
with the young person.
Because they're often
still living at home.
And that is what the
evidence shows we should do,
but there aren't enough people.
So a lot of people don't
get the right treatment.
So sadly, there are people
out there not getting
what NICE says they should
get because there just
aren't enough people.
AUDIENCE: But is
it self-defeating
in terms of they
invested upfront,
you wouldn't have the costs
associated with that family
breakdown or relationship
breakdown, supplying the drugs?
SUSAN LLEWELYN: Absolutely.
All those things are
true, but it's expensive.
It's the question of how
we want to spend our money.
I mean, one of the problems--
I mean, I have to say, the
last few successive governments
have tried.
And you'll hear on the
news this notion of--
this concept that's
called parity of esteem,
that we esteem our mental health
as much as our physical health.
But it is not the case.
If you are suddenly diagnosed
with some kidney disease
or cancer or something, you
will get seen pretty quickly
and be seen by the best experts
in your area, hopefully.
If you have a mental
health problem,
like psychosis, you
don't know whether you're
going to get
treatment, because we
don't invest as much in
mental as physical health.
That's always been
the way, because we
stigmatize mental health.
We think there's something
wrong with you, you're to blame.
Somehow you've
brought it on yourself
if you have a mental
health problem.
And it goes quite
deep-rooted, that.
We use the word--
I use it in casual speech.
Oh, it's psychological,
I'll say.
If I've got a stomachache,
oh, it's psychological.
In other words, it's not real.
Of course, it doesn't
mean that at all,
because what is psychological
is absolutely real.
And we are a physical
and mental being.
We're all together.
You can't have a
mental health problem
without a physical health
problem or vice versa.
But over history, we've tended
to put one in a box and one
in the other.
And one's good and one's bad.
So mental health hasn't
had the investments
and the serious treatments.
I think that's changing.
I'd say that is changing.
There is more importance
now placed on that.
And certainly going back to
the question about the US--
I don't know if he's still here,
the gentleman that asked-- oh,
yes--
is that we've been much
more nervous to talk
about mental health in the UK.
I think that's changing
now, especially with CBT,
having people more access to it.
To say you're having
therapy is now reasonable,
and people talk about that.
It used to be anathema.
For example, in our training,
when we trained people,
I remember my
father saying to me
when I was thinking
about training, well,
that's very interesting.
But if you want to
go into this, not
working with very nice people,
and it's very important
that you yourself don't have
any mental health problems.
Now we see it very
differently from that.
We see we as trainers, and as
students and as practitioners,
may well have mental
health problems ourselves.
Everybody has mental
health problems.
We're not different.
In the same way as I might
break my leg or have diabetes,
it doesn't make me a bad doctor.
Likewise, I might be suffering
from mental health problems
as well.
It's OK to do that.
It's not I'm a bad person.
So we're trying very much to
change the attitudes, which
are difficult. But you're
absolutely right about that.
We should spend more, but
that's a political discussion,
which we can have elsewhere.
AUDIENCE: Thank you.
You mentioned that CBT and
online therapy is quite new.
Is there any evidence
at the moment
whether it's more effective
than that face-to-face therapy?
SUSAN LLEWELYN: Well, what's
interesting is it seems to be,
with certain groups,
as effective, which
is quite challenging
to all of us who've
been doing it for years.
But what was interesting is--
yes, so it is as effective,
and that's a good thing to do.
But it has to be set
out right, and you
have to get that relationship
factors in there right.
I mentioned I did the
Sleepio program, which
was interesting to do.
But what I found
myself doing was
I would assume that I
was talking to this guy.
I would think, well, what's
he thinking about me now?
Of course, it wasn't
he who was thinking.
It was a program.
But what people do is they like
there to be a person there.
So I think when we
design these things well,
they can be helpful.
One of the very, very
important things to do
is change how people
think about it.
And one of the good things
about rolling out programs
is it helps people, I
think, to normalize it more.
Just quickly, one point I should
make about the cognitive model
I talked about,
where you can think,
one of the most
damaging things people
can think about is how
abnormal their thinking is.
And if you can normalize
it, help people to know--
one of the things we know about
post-traumatic stress disorder,
when you've had a traumatic
episode, when something
happens-- if a bomb drops on
us, it's ghastly and traumatic.
We will all have--
hopefully we survive it--
flashbacks.
We will have bad experiences.
If you can understand
that that's normal,
that normal people always have
bad experiences after trauma
and gradually they
fade over the days,
the months, your traumatic
experiences will fade.
Then you will get better.
If you think you are
odd and unusual--
and this is what
the evidence shows--
that you are uniquely
weak and mentally ill
because you've had this trauma,
this traumatic reaction,
then you won't get
better so quickly.
One of the great things
about rolling out large scale
is perhaps people will
understand that their reactions
are actually normal.
It's OK to feel trauma.
It's OK to feel bad.
And rolling out
larger scale programs
will help people to see
their mental health problems
are not unique.
You're not the only one to feel
depressed, sad, angry, have
relationship problems.
It's normal.
It's human.
And that's, I think,
large scale programs,
which hopefully organizations
such as ourselves
will be helpful to
us in developing.
AUDIENCE: Thank you very much.
That was great.
[APPLAUSE]
SUSAN LLEWELYN: Thank you.
