Mental Health Interventions in Schools

On 5th June, the Royal Society for Medicine hosted a workshop to explore the some of the issues - particularly the practicalities surrounding mental health interventions in schools. The event brought together medical and educational professionals and provided a forum to discuss ongoing projects supporting young people’s mental health, difficulties and potential courses of action for improvement. In the following, I summarise some of the talks.

Lord Richard Layard, Director of the Wellbeing Programme at the Centre for Economic Performance, London School of Economics, discussed the idea of schools having wellbeing as an explicit goal. The next step is to have as many schools as possible measuring progress towards this goal.

Richard proposed that one way to do this is through a wellbeing code debated on by children, teachers, parents, (every 2 years) regarding how people relate to each other in classrooms, assemblies, the playground, and so on. Such a code would cover not simply anti-bulling policies, but would take a broad and deep perspective on emotions and social relations across all young people’s experiences.

He discussed how the Healthy Minds project, a four year programme for secondary schools, is working towards some of these goals – its primary outcome for participating schools being a ten percentile point improvement in life satisfaction compared to the control.

Are clinical delusions adaptive?

Eugenia Lancellotta is a PhD student in Philosophy of Psychology at the University of Birmingham. Under the supervision of Lisa Bortolotti, she works on the adaptiveness of delusions, especially outside schizophrenia spectrum disorder. In this post, she discusses her paper “Are clinical delusions adaptive?” co-authored with Lisa Bortolotti, that recently appeared in WIREs.

In popular culture, and even in part of the scientific culture, delusions are still considered as the mark of madness. It would then seem to be counterintuitive to ask whether such bizarre, irrational and often harmful beliefs can be biologically or psychologically adaptive. 

A trait or mechanism is considered to be biologically adaptive when it favours the reproductive success and survival of the organism it belongs to (Wakefield 1992). By analogy with biological adaptiveness, a trait is deemed to be psychologically adaptive when it delivers psychological benefits which support the wellbeing and good psychological functioning of a subject. How then can delusions and adaptiveness - be it biological or psychological – fit together, if they seem to be one the opposite of the other? 

In our overview article (here), we try to reconcile the terms of this apparent contradiction, showing how delusions can be both adaptive and harmful at the same time. Our thesis is that, although data show that delusions are most likely psychologically and biologically maladaptive in the long run, they might be psychologically adaptive in the short term, by delivering psychological benefits which help people cope at times of difficulty. 

Delusions are defined as fixed, irrational beliefs which are particularly resistant to counterevidence (DSM V). They span from the exotic to the common - from believing that one is the left foot of God to thinking that one is the target of an international conspiracy - and they are symptoms of a number of illnesses, such as schizophrenia, depression, OCD and dementia. 

Despite their being usually defined in negative terms, by the harm and the difficulties they cause, in recent years research has suggested that delusions can also present some positive features (Bortolotti 2015; Fineberg and Corlett 2016; Mishara and Corlett 2009). 

In our article we highlight these features, weigh them up against the well-known detrimental effects of delusions, and consider if the benefits exceed the disadvantages or vice-versa, I.e. if delusions are adaptive or maladaptive. Our conclusion is that, although delusions seem to be psychologically harmful and biologically maladaptive in the long run, in the short term their adoption can be seen as psychologically adaptive, as it delivers some psychological benefits in the face of difficulties that the subject is experiencing.

Such benefits vary depending on the type and content of the delusions, spanning from the relief from anxiety given by delusions in schizophrenia, to the restoration of intrapsychic coherence of delusions in depression and most likely in OCD, as well as to the negotiation of emotionally overwhelming circumstances found in many cases of motivated delusions. However, what all these apparently distant cases share is that delusions seem to be an (imperfect) solution to an already existing biological or psychological problem rather than the beginning of it. 

To use a popular metaphor in the literature on the topic (McKay and Dennett 2009), delusions would be similar to shear pin mechanisms. Shear pins are emergency mechanisms installed in some machines, whose function is to break in times of emergency. By breaking, the shear pin allows the machine to keep functioning, although in a less than optimal manner. Similarly, by delivering some psychological benefits, delusions would allow a subject to keep functioning (in a less than optimal manner) in times of emotional or biological struggle, preventing the complete breakdown of the emotional, epistemic or biological machinery.

Although further studies are needed to investigate the precise role of delusions, a more complex picture, which takes into account both the costs and benefits of this phenomenon, has started to emerge.

On the Power of Imagination: Two Events

As announced, project PERFECT organised and co-hosted two public engagement events as part of the Arts and Science Festival at the University of Birmingham. Both celebrated the role of imagination and the importance of relationships in growing and healing.

Here I report on how they went!

Red Hands Film Screening

A scene from Red Hands

Director and screenwriter Francesco Filippi presented his short film in 2D and stop animation, Mani Rosse (Red Hands), to an engaged and diverse audience at the Midlands Arts Centre on 18th June. The film has been honoured with awards at film festivals worldwide and sparked lots of interest. The screening was followed by a panel discussion featuring experts in youth mental health and experts with lived experience of domestic violence, one of the themes of the film.

Panel discussion: Lucy

Some of the audience's comments and questions were about how the film was made, what it was inspired by, and what some specific scenes or symbols recurring in the film meant. The development of the two leading characters (Luna and Ernesto) was also object of some discussion: we were lucky to be joined by the director and animator Francesco Filippi and Lucia Gadolini, psychologist and actor, who helped develop the characters and gave her voice to Ernesto. We learnt that Luna and Ernesto's story was inspired by two real-life stories of domestic abuse, and that the key concepts of freedom and friendship were represented not just in the plot and the dialogue but also in the choice of landscape and in Ernesto's dream sequences.

Francesco Filippi

Other comments and questions, mostly directed at the panel of experts, concerned the effects of domestic violence on mental health, and the psychological realism of the film. From our experts from experience, Lucy Wright and Gemma Hickman, we learnt that whilst the decision to leave an abusive relationship needs to be owned by the victim of abuse and nobody can 'save' them unless they are ready to leave, friendship is a very important source of support, especially for young people. 

Michael Larkin and Bonny Astor also remarked on the many layers the film has, some of which can be appreciated only after a number of viewings, and the ambiguities left in it, that is, aspects of the story of Luna and Ernesto which need to be inferred or reconstructed and are not openly revealed. Finally, they both pointed to the role of colour in the film and the power of expressing oneself, dreaming, and imagining.

Panel discussion: Michael

Participants' feedback showed a thorough engagement with the topics of the discussion. The film generated strong reactions, as was to be expected, and the audience found the opportunity to engage with the director and the experts very useful and stimulating. Many were struck by the sheer beauty of the film and some expressed disagreement with some of the director's choices. 

Here are some of the participants' comments:

• "The film was aesthetically great and the topic and the theme was thoughtful and inspiring."
• "I enjoyed very much the discussion about the ambiguities in the movie and the female/male roles."
• "I have definitely deepened my understanding of domestic abuse and more or less explicit forms of violence."

Overall, as project PERFECT's first film screening, it was a success! 

Double Bookkeeping and Doxasticism about Delusion

In this post, José Eduardo Porcher, Research Fellow at the Rutgers Center for the Philosophy of Religion working primarily in the philosophy of psychiatry and philosophical psychology, outlines his target paper “Double Bookkeeping and Doxasticism about Delusion” in the newest issue of Philosophy, Psychiatry & Psychology.

Doxasticism about delusion is the theoretical stance according to which delusion is a kind of belief. Although doxasticism is taken for granted in the psychiatric literature, it has been a major point of contention in the philosophical literature, where it has faced many objections and alternative accounts (see e.g. Bortolotti, 2018). In my paper, I show how double bookkeeping, a distinctive characteristic of delusional patients, motivates two kinds of argument against doxasticism. I then examine these arguments and find them inconclusive.

So what is double bookkeeping? Consider the following excerpt of an interview with a patient who showed symptoms of Capgras delusion and reduplicative paramnesia, maintaining that both his house and his family had been replaced by duplicates.

E: Isn’t that [two families] unusual?
S: It was unbelievable!
E: How do you account for it?
S: I don’t know. I try to understand it myself, and it was virtually impossible.
E: What if I told you I don’t believe it?
S: That’s perfectly understandable. In fact, when I tell the story, I feel that I’m concocting a story . . . It’s not quite right. Something is wrong.
E: If someone told you the story, what would you think?
S: I would find it extremely hard to believe. I should be defending myself.

(Alexander, Stuss & Benson, 1979, p. 335)

Conscious Will, Unconscious Mind

It was a pleasure be invited to the “Conscious Will and the Unconscious Mind” workshop, held at the Department of Philosophy, University of Duisburg-Essen, on the 28th of June this year. Organised by Astrid Schomäcker and Neil Roughley, the workshop intended to explore whether influences like implicit biases present a threat to free, responsible agency and a series of related questions. The following is a summary of the talks by the three speakers.

Sven Walter Osnabrück, Professor of Philosophy at the Institute of Cognitive Science, University of Osnabrück, began by outlining two opposing ideas about the role of science in the free will debate. Firstly: free will incompatible with a naturalistic view of world (a view that often crops up in popular science magazines and journals). Secondly: the question of what free will amounts to is a philosophical one, and so empirical science is not the appropriate disciplinary home for an investigation into free will. For Sven, neither of these ideas are quite right.

Sven argued that there are two distinct projects to be done in each discipline. Project 1: we need to establish what conditions would need to hold in order for free will to obtain. This is a conceptual question, and the appropriate work is philosophical. Only then comes project 2: using the methods of empirical science, we need to establish whether those specified conditions in fact obtain.

Sven then considered various free will theories to come out of project 1-type work, and whether any project 2-type work shows whether that sort of free will does not obtain. For instance, if project 2-type work shows that determinism is true (or, perhaps, is our best model of the world) then this would only rule out libertarian kinds of free will - those that rely on a strong interpretation of the possibility of doing otherwise, compatibilist free will accounts are safe.

Project 2 work demonstrating that unconscious influences on action which render our actions normatively detached from our system of reflected preferences and values might show that free will is limited. Sven went over some examples of this sort of work that might show that free will is impaired, but qualified the claims with the acknowledgement of the replicability crisis in social psychology (like this, for example). He discussed whether a capacity for reasons responsiveness (such as in the theory of Fischer and Ravizza 1998) could save free will in these cases, but worried what the use of a capacity is if we regularly fail to exercise it in a wide variety of circumstances.

Beate Krickel, Principal Investigator and Scientific Coordinator of the Situated Cognition Group at Ruhr-University of Bochum, gave the next talk. Beate started by drawing on research showing that implicit biases are sometimes available to awareness. For instance, in a study by Hahn et al. (2014), participants were able to predict the content of their biases. Beate also drew on Gawronski and Bodenhausen’s (2014) APE model, in which the rejection of propositions contrary to those already accepted appears to be a conscious process. And yet, as Beate pointed out, people are still often surprised to learn they have implicit biases. What should we make of this?

Beate suggested we could draw on work on repression in the Freudian tradition to understand the puzzle. Repression starts with an inner conflict between beliefs and desires. Beate drew on an example in which a person desires her best friend’s partner, but also believes that if she pursued the desire, she’d hurt her friend. This conflict triggers an unconscious process that leads to an unconscious product: the desire becomes unconscious and the inner conflict is resolved.

Beate used an account of repression in which the state becomes access-unconscious. Access consciousness is usually tested for by asking the subject for a report. As Beate showed us, the process preceeding the report of a conscious stimulus is complex. It could comprise: some early visual processing, attention to this, categorization, storage in short term memory, semantic processing, and finally motor activation necessary for speech. There are many stages at which this process might be halted, all of which lead to failure to report a stimulus.

Beate then presented her model, in which we might often be driven by self-image concerns and internalized social norms to repress certain feelings so they end up not being categorised and ultimately available to access consciousness. However, these mental states still drive behaviour (for instance, they may be picked up by an Implicit Association Test). Beate concluded by demonstrating how her model solves a number of difficult problems in the self-deception literature, and outlined the need for a future research project to deliver a taxonomy of difference kinds of unconsciousness. 

In my talk, I wanted to explore the nature and measurement of the attitudes (often described as our sincerely held beliefs and values) that implicit attitudes are supposed to stand in contrast with. Implicit attitudes are usually postulated to explain systematically biased behaviours observed in both lab tests (e.g. time-pressured categorisation tasks like the Implicit Association Test – see an excellent discussion on recent issues here) or real world decision making (e.g. lawyers evaluating a piece of legal writing as in Reeves 2014: unbeknownst to the lawyers, their responses were collected by experimenters, who found that errors were more readily identified (in one and the same piece of writing) when the author was presumed to be black vs. white).