Pigeonholes and Johari windows: Rehumanising ethnicity categorisation in health care.

CATEGORISATION CAN BRING CLARITY: Categorisation is just what we do in health care. It allows for definitions to be shared, so conditions can be targeted and treatments standardised. It allows for concepts and constructs to become testable objects of research. And, with the increasing push for diversity and inclusion, it allows for disparities to be identified to evidence progress and enable accountability. CATEGORISATION CAN ALSO CONFOUND: But could these distinctions be doing as much harm as good? In this article, I review work from the field of inclusive education, focusing particularly on "awarding gaps" and "differential attainment" (i.e. differences in the proportions of degrees with higher grades awarded to some groups of learners compared with others). In doing so, I draw attention to the paradox inherent in empirically studying these topics: increasing recognition of unfairness is dependent on categorising individuals into groups of students, which risks reinforcing negative, reductive associations and alienating those who cannot relate to their designation. CATEGORISATION REQUIRES CARE: Using the case of ethnicity categorisation (and mixed ethnicity categories in particular), I use this paper to explore this unwelcome impact of categorisation in more detail. I acknowledge how difficult it would be to overhaul our system of categorisation and finish with thoughts on how we might mitigate its impact in our practice.

General Practitioner Educators on Clinical Debrief: A Qualitative Investigation into the Experience of Teaching Third-Year Medical Students to Care.

Phenomenon: There is a paucity of research reporting the experiences of general practitioner clinical educators. Providing education for students could lead to better clinical skills and greater job satisfaction for the educator. However, it could also result in increased stress and mental fatigue, adding to what is an already pressured situation in the current primary care climate. Clinical Debrief is a model of case-based learning with integrated supervision developed to prepare medical students for clinical practice. This study aimed to explore the experiences of general practitioners who facilitate Clinical Debrief. Approach: Eight general practitioner educators with experience of facilitating Clinical Debrief participated in semi-structured qualitative interviews. Results were analyzed using Reflexive Thematic Analysis, and four main themes were developed. Findings: Themes included: Personal enrichment: psychological "respite" and wellbeing; Professional enrichment: Clinical Debrief as a "two-way" door; Becoming a facilitator: a journey; and, Relationships in teaching: blurred boundaries and multiple roles. Insights: Being a Clinical Debrief facilitator had a transformative impact on the personal and professional lives of the GPs who participated in this study. The implications of these findings for individual GPs, their patients, and the wider healthcare system, are discussed.

An investigation of whether emotion regulation mediates the relationship between attachment insecurity and suicidal ideation and behaviour.

OBJECTIVE: The aim of this research was to examine relationships between attachment insecurity and suicidal ideation and behaviour. Secondary aims were to explore the mediating role of emotion dysregulation and the moderating role of betrayal trauma in explaining hypothesised relationships. METHOD: Sixty-five participants with experience of suicidal ideation completed questionnaire measures assessing attachment security, suicide ideation, emotion regulation, betrayal trauma, depressive symptoms and hopelessness. RESULTS: A direct relationship was found between avoidant attachment and suicide ideation after controlling for age and gender. Multiple suicide attempters had higher anxious attachment. Anxious and avoidant attachment, suicide ideation and betrayal trauma were associated with emotion dysregulation. The relationship between attachment insecurity and suicide ideation was not mediated by emotion dysregulation. In the mediation model, only anxious attachment remained a significant predictor of emotion regulation and there was no significant effect of emotion regulation nor betrayal trauma, on suicide ideation. CONCLUSION: Suicidal individuals may benefit from therapeutic intervention that explores attachment-related difficulties and therapies such as dialectical behavioural therapy, which support skills in emotional regulation. Future longitudinal research should identify other important mediators of the association between attachment and suicidality to develop more targeted psychological interventions for suicidality.

The role of psychological and social factors in the relationship between attachment and suicide: A systematic review.

Insecure attachment is widely accepted to be a risk factor for suicidal thoughts and behaviour. To increase our understanding of this distal association, the current systematic review aimed to evaluate empirical evidence that has investigated the role of psychosocial mechanisms within this relationship. Sixteen original research articles were identified, with the majority carrying out mediational analyses to test their hypotheses. Substantial heterogeneity was found across studies with regards to their theoretical approach to assessing attachment, suicide-related outcomes, sample population, statistical analyses, and the psychological factors under investigation. Nevertheless, this emergent evidence base indicates that a range of predisposing, precipitating, and crisis-state factors may mediate the association between attachment security and suicidality. Studies that investigated moderating factors did not report significant findings, and the mediating role for psychiatric diagnoses remains unclear. Furthermore, this emerging research base is limited by an over-reliance on cross-sectional designs and self-reported data. Longitudinal and experimental designs are required to verify causal pathways and to investigate whether trait vulnerabilities interact with acute stressors to increase suicide risk. Finally, disorganized attachment has been overlooked so far and should be given greater consideration going forward.

A Qualitative Exploration of the Use of Attachment Theory in Adult Psychological Therapy.

UNLABELLED: There is a growing interest into how attachment theory can inform psychotherapeutic practice with adults. This study aimed to explore how a group of therapists with an interest in attachment theory use it in their work with adult clients. A cross-sectional qualitative design was adopted. Sampling, data collection and analysis procedures were guided by grounded theory principles. Semi-structured telephone interviews were conducted with 12 therapists from a variety of training backgrounds. Data were coded and developed into thematic categories. Six primary themes were identified to describe how attachment theory influenced the clinical practice of the sample through the following: (i) complementing other therapeutic models; (ii) providing a framework to understand the development of clients' mental health problems; (iii) working with different attachment styles; (iv) thinking about the therapeutic relationship as an attachment relationship; (iv) influencing the different stages of the therapeutic process; and (vi) influencing clinical service design and delivery. It is concluded that attachment theory can play a significant role in influencing the practice of therapists and can be usefully adopted to complement therapeutic processes irrespective of the therapist's dominant clinical orientation. Further research is needed to explore the views of clinicians from different theoretical orientations and to investigate the security of the client-therapist attachment within the context of therapeutic change processes. KEY PRACTITIONER MESSAGE: Attachment theory may have implications for practice across a range of different types of therapy and may help therapists to bridge apparent differences between modality-specific formulation and techniques. Attachment theory can be used to understand the development of mental health problems. Therapists should assess and formulate clients' attachment styles, and these formulations should guide therapeutic approaches. Attachment theory provides a comprehensive framework for facilitating the therapist's attentiveness to relational issues and use of the therapeutic relationship as a fulcrum for change. The principles of attachment theory can be used to inform all stages of the therapeutic process, as well as the design and delivery of mental health services.

Changes in attachment representations during psychological therapy.

OBJECTIVES: This review systematically examines research that investigates changes in adult attachment representations during psychological therapy. METHOD: Studies from two adult attachment approaches are reviewed (interview and self-report) with the aim of concluding whether psychotherapy can improve attachment representations. To guide the interpretation of findings, the methodological quality of studies is assessed. RESULTS: The results suggest that attachment security increases following therapy, whereas attachment anxiety decreases following therapy. Findings are unclear with regard to attachment avoidance. Improvements are observed across different methodologies, patient groups, therapeutic approaches, and therapy settings. Findings also appear to be consistent across different levels of study quality. CONCLUSIONS: Overall, research supports the suggestion that attachment styles may alter during the course of psychotherapy, but further controlled trials are required to confirm this conclusion.

Colonization, cadavers, and color: Considering decolonization of anatomy curricula.

Anatomy is a discipline that, despite its universal nature, offers limited diversity in terms of representation in cadavers, imagery, technology, and models used within teaching. The universal move toward inclusive curricula has put anatomy education under the microscope, particularly with respect to efforts to decolonize curricula. This paper considers the challenges and opportunities to diversify the anatomy curriculum. Decolonizing anatomy education curricula will entail addressing the ingrained cultures within the disciplines, such that produces a number of challenges including: underrepresentation of certain bodies, difficulty talking about difference, and the hidden curriculum in anatomy education. In order to aid educators in achieving inclusive anatomy curricula, a toolkit and considerations are presented, alongside both do's, don'ts and case examples. We highlight the black-or-white dichotomy, and the absence of brown in between. The paper is a conversation starter for what it means to begin the process of decolonizing the curriculum within anatomy education.

A systematic review of the relationship between momentary emotional states and nonsuicidal self-injurious thoughts and behaviours.

BACKGROUND: Nonsuicidal self-injury (NSSI) is associated with high levels of distress, co-morbid mental health issues, and elevated risk of suicide. Previous literature indicates that emotion regulation is the most endorsed function of NSSI. Experience Sampling Methodology (ESM) provides a powerful tool for investigating the moment-to-moment associations between emotional states and NSSI thoughts and behaviours. The aim of the current study was to systematically review and evaluate ESM research concerning the relationship between momentary emotional states and NSSI. METHODS: A systematic search of electronic databases from date of inception to 16th April 2021 was conducted. This was supplemented through backwards citation tracking. A risk of bias assessment was completed prior to data synthesis. RESULTS: Nineteen eligible studies were identified for inclusion in the review. Heightened negative affect was found to typically precede instances of NSSIT thoughts and behaviour. Results were less consistent for positive affect. LIMITATIONS: Sample sizes across studies were often small, meaningful effect sizes were not always reported, and non-validated measures of NSSI thoughts and behaviour were used during ESM assessments. CONCLUSIONS: The results support affect regulation models of NSSI, and demonstrate the value of ESM studies, specifically those sampling more than once per day, in plotting the temporal, "in-the-moment" characteristics of these processes.

"Cover up your arms, you're triggering people": A Mixed-Methods Investigation of Shame in those who Self-Injure.

BACKGROUND: Shame can be a powerfully aversive emotion that is associated with a wide variety of mental health difficulties including non-suicidal self-injury (NSSI). This study used a novel mixed-methods design (Qualitative Experiential Sequence Tracking; QUEST) to investigate the experiences of shame in a sample of individuals who self-injure. METHODS: Six participants received prompts to complete brief online diaries three times per day over a period of 2 weeks. These diaries captured information about the experience of negative emotions, especially shame. Participants then underwent an individualised qualitative interview about their experiences over the previous 2 weeks. RESULTS: Thematic analysis suggested that participants experienced shame as a social and relational emotion. Further themes included shame being associated with feelings of failure, being trapped, dangerous or contaminated, and hidden or exposed. The phenomenology of shame, and coping with shame, were also themes. NSSI could occur as a response to shame, but often shame was triggered or exacerbated by the responses of others to NSSI. CONCLUSIONS: Consistent with previous research, shame was described as an aversive emotion occurring within interpersonal and broader societal contexts and involving a negative self-focus. A lack of compassion or understanding in response to NSSI, or anticipation of negative responses from others often triggered more intense shame than the NSSI itself. Future studies could use QUEST methodology with more diverse samples or different populations to further investigate experiences of shame.

Attachment Security and Suicide Ideation and Behaviour: The Mediating Role of Reflective Functioning.

BACKGROUND: To understand why attachment difficulties predispose individuals to suicidal thinking (suicide ideation) and behaviour, a leading cause of death, we need to explore the role of pertinent psychological mechanisms. Attachment processes are closely linked to the development of mentalisation capabilities, or reflective functioning; the ability to understand and interpret self and other behaviour as an expression of mental states. Interventions designed to improve mentalisation have been associated with a reduction in suicidal behaviour, yet reflective functioning has not been directly investigated in relation to suicidal ideation and behaviour. AIM: We aim to further verify the link between adult attachment security and suicidal ideation and examine whether deficits in reflective functioning mediate this relationship. METHODS: Sixty-seven participants who experienced suicidal ideation within the past 12 months completed self-report measures of adult attachment, current suicidal ideation, reflective functioning, depressive symptomology and hopelessness. Partial correlations, mediation analyses and group comparisons were conducted to explore relationships between these factors. RESULTS: Findings did not support a mediational role for reflective functioning in the relationship between attachment security and suicidal ideation. A direct relationship was established between attachment avoidance and suicidal ideation, after controlling for age, gender and depressive symptoms. However, participants with a history of attempted suicide were higher in anxious attachment compared to participants with no such history. CONCLUSIONS: This study shows that the attachment dimensions of attachment anxiety and avoidance may play differential roles in increasing risk for suicidal attempts versus ideation. This has important implications for tailoring interventions. Those aimed at reducing suicide attempts should focus on reducing attachment anxiety by helping people develop skills in emotional regulation. Interventions aimed at reducing suicidal ideation should focus on reducing attachment avoidance by helping people develop closer relationships with significant others. However, longitudinal and experimental designs are required to verify causality.

Clinical Debrief: learning and well-being together.

BACKGROUND: Clinical environments can be so stressful to medical students as to be detrimental to their learning and well-being. Our intervention, Clinical Debrief, integrates learning through clinical experience with the development of positive coping strategies. Students shared cases and experiences during weekly small group classroom discussions, facilitated by general practitioners (from outside their current hospital placement), throughout two consecutive 12-week blocks of their first clinical year. Alongside enquiry-based and clinical reasoning learning, we gave students a safe space to reflect on their affect. Our aim was to critically examine students' views in Clinical Debrief. METHOD: Anonymised quantitative and qualitative evaluation data were collected over 3 years using online questionnaires on completion of each 12-week block. The data relating to psychological supervision were analysed independently and in parallel, using thematic analysis for qualitative data. We aim to help students develop positive coping mechanisms, promoting empathy,self-awarenessand wellbeing RESULTS: A total of 1857 evaluations were extracted (response rate 67%). The median (interquartile range) overall rating for Clinical Debrief sessions was 9 (8-10), where 10 indicates 'excellent' and 1 indicates 'significant improvement needed'. The rating for the supervisory aspects of the sessions and free-text comments were positive. Students appreciated safe environments, the session structure, facilitator role modelling, transitional support and processing of emotional experiences. DISCUSSION: Mandatory integrated longitudinal supervision, using trained clinician facilitators, was positively received by students in transition to clinical placements. Normalising the emotional impact of medical work destigmatises distress. Linking clinical reasoning with affective state awareness to contextualise case management, following Mezirow's transformative learning theory, brings added benefit to learning and well-being. Student demand for the expansion of Clinical Debrief is evidence of success.

Biases in the subjective timing of perceptual events: Libet et al. (1983) revisited.

We report two experiments in which participants had to judge the time of occurrence of a stimulus relative to a clock. The experiments were based on the control condition used by Libet, Gleason, Wright, and Pearl [Libet, B., Gleason, C. A., Wright, E. W., & Pearl, D. K. (1983). Time of conscious intention to act in relation to onset of cerebral activities (readiness-potential): The unconscious initiation of a freely voluntary act. Brain 106, 623-642] to correct for any bias in the estimation of the time at which an endogenous event, the conscious intention to perform a movement, occurred. Participants' responses were affected systematically by the sensory modality of the stimulus and by the speed of the clock. Such findings demonstrate the variability in judging the time at which an exogenous event occurs and, by extension, suggest that such variability may also apply to the judging the time of occurrence of endogenous events. The reliability of participants' estimations of when they formed the conscious intention to perform a movement in Libet et al.'s (1983) study is therefore questionable.

CAMHS dependency scoring: clarity and clinical relevance of the CAMHS-AID.

AIM: A dependency measure (the CAMHS-AID) was developed in Birmingham and Manchester to support more accurate decisions about whether a young person can be accommodated on a child and adolescent mental health services (CAMHS) inpatient unit. This study aimed to test the content and face validity of the scale. METHOD: Eighty-six nursing staff were provided with booklets of the randomly ordered CAMHS-AID items and asked to rate the clarity of the items and how well they reflected clinical practice on a 5-point scale. RESULTS: The majority of the items were given a score of four or five, indicating that the majority of the CAMHS nurses felt that the CAMHS-AID items were very clear and understandable and accurately reflected clinical practice. There was greater variance when rating the clinical relevance of the items; the higher the grade of nurse the more likely they were to rate the items a 5 for clinical relevance. CONCLUSION: The CAMHS-AID has good content and face validity. We are continuing to investigate other aspects of validity and reliability of this context specific dependency scoring tool.

Measuring patient dependency in child and adolescent mental health.

Within the context of child and adolescent mental health inpatient services, a literature review was undertaken to understand the concept of inpatient dependency and how it can be measured. Articles and books relating to patient dependency and its measurement in various contexts were retrieved, and other published measures were identified. It was found that dependency has been defined in many different ways, and various techniques have aimed to quantify or categorize patients' dependencies. This article focuses particularly on measures used in adult psychiatry and paediatric services. At present, there is no available established measure of patient dependency in child and adolescent inpatients. This article identifies the need to develop a measure of inpatient dependency that is specifically designed for these services, and outlines a tool that the authors have recently designed.

Attachment-informed therapy for adults: Towards a unifying perspective on practice.

PURPOSE: We aimed to provide an integrated overview of the key goals and strategies of an attachment-informed psychotherapy by summarizing the literature describing the clinical implications of attachment theory for psychological therapy for adults. METHOD: We carried out a narrative thematic review of 58 texts from a diverse range of therapeutic schools, until we agreed that we had reached a saturation of themes. RESULTS: We identified six key themes: Changing internal working models; the therapeutic relationship and creating a secure base; formulating and processing relationship experiences; countertransference; separation, termination and boundary issues; and working with different attachment styles or patterns. We discuss empirical evidence in relation to each theme and highlight areas for research. CONCLUSIONS: Attachment theory provides a useful framework to inform psychological therapy with adults, but there is a pressing need for further research to empirically demonstrate the 'added value' of an attachment perspective. PRACTITIONER POINTS: Attachment theory should be used to inform individual psychological therapy in adulthood. From the outset of their careers, therapists should receive training and supervision to enhance their awareness of their own and their clients' attachment experiences and how these play out during therapy. There is a need for greater empirical research to investigate whether the degree to which therapists formulate and meet clients' attachment needs influences outcomes.

Dependency scoring for child and adolescent inpatient mental health services.

Child and adolescent mental health services (CAMHS) inpatient units provide multi-disciplinary treatment for young people with a wide range of complex needs, many of whom have co-morbid presentations. There is no reliable, validated measure of CAMHS patient dependency. This article reports the first stages of a project to develop a properly researched dependency measure for use before (i.e. by those referring the young person) and during the young person's stay. Expert opinion was sought to develop a list of statements regarding a young person's care which could be rated according to level of need. Initial piloting demonstrated face and concurrent validity; next steps include exploring issues of item ambiguity and weighting.

The role of attachment style, attachment to therapist, and working alliance in response to psychological therapy.

OBJECTIVES: Working alliance (WA) has been shown to be an important process influencing the success of therapy. The association of clients' underlying attachment representations with WA and the subsequent success of therapy has increasingly been recognized. This study explores the association between adult attachment representations, specific attachment to the therapist and WA in patients receiving psychological therapy. METHOD: Fifty-eight participants due to receive therapy were recruited from primary care psychological services. Participants completed self-report measures of attachment, WA, and psychopathology. RESULTS: Patients with greater secure attachment to the therapist showed significantly greater WA. In a subset of participants completing therapy, change in outcome was also correlated with baseline attachment towards the therapist. CONCLUSIONS: The study suggests that attachment towards the therapist is an important predictor of WA. The results suggest that in terms of WA, attachment to the therapist may be more important than pre-existing attachment representations. PRACTITIONER POINTS: A more secure attachment to the therapist was associated with greater WA and improvement in therapy. Clinicians should be mindful of signs of an insecure attachment to themselves, reflecting a difficulty around trusting the therapist and viewing them as a secure base. Missed sessions and an ongoing reluctance to disclose personal information to the therapist may be signs of an insecure attachment. This may be the case even in cognitive-behavioural approaches to therapy where relational processes are not necessarily a focus of therapy. Incorporating attachment processes in the formulation, including attachment to the therapist, may provide one way of exploring these issues in therapy.

Using attachment theory to inform the design and delivery of mental health services: a systematic review of the literature.

PURPOSE: The aim of this review was to propose and describe the design and delivery of an attachment-informed general mental health service. METHOD: We systematically searched the PsycINFO, MEDLINE, Web of Knowledge, COPAC, CINAHL, and Science Direct databases from 1960 to 2013. We also searched reference lists of relevant papers and directly contacted authors in the field. Literature describing attachment theory and its applicability in designing and delivering general mental health services was synthesized using thematic analysis. Papers published in English, books or chapters in edited books that described applying attachment theory in designing and delivering mental health services for adults and adolescents were included in the review. Of the 1,105 articles identified, 14 met inclusion criteria for the review. Eight key themes, and four subthemes, were extracted and organized to reflect the experience of a service user moving through the mental health system. RESULTS: Key themes extracted were as follows: service policy and evaluation; referrals; assessment and formulation; intervention; support for staff; support for carers; moving on; and potential service benefits. Papers reviewed suggested that service users with severe mental health problems have attachment needs that should be met in general mental health services. CONCLUSIONS: Attachment theory provides a useful framework to inform the design and delivery of general mental health services. The resource implications for services are discussed, as are limitations of the review and recommendations for future research. PRACTITIONER POINTS: Attachment theory should be used to inform the design and delivery of general mental health services. Mental health services should evaluate the extent to which they meet service users' attachment needs. Attachment-informed mental health services should assess outcomes, including cost-effectiveness over time. Papers included in this review focus on long-stay residential care or secure services and there is a limited experimental evidence base to show that providing an attachment-informed service improves patient outcomes.