In Conversation… Prof. Roz Shafran

Professor Roz Shafran covers a range of subjects on mental health, including looking at the work her and her team undertake at Great Ormond Street Hospital. This includes innovations such a mental health ‘booth‘ for children and families. Roz also looks at the rise of dysfunctional perfectionism, what makes a young person vulnerable and the implications and interventions.

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Transcript

Intro: This podcast is brought to you by The Association for Child and Adolescent Mental Health, ACAMH for short. You can find more podcasts and other resources on our website www.ACAMH.org and follow us on social media by searching ACAMH.

Interviewer: Hello, welcome to the ‘In Conversation’ podcast series for The Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today, I’m interviewing Professor Roz Shafran, chair in translational psychology at the UCL Great Ormond Street Institute of Child Health. Roz, welcome. Thanks for joining me. Can you start with an introduction about who you are and what you do?

Prof Roz Shafran: I’m a Honorary Consultant Clinical Psychologist, with an honorary contract at Great Ormond Street Hospital and I work in the psychological medicine team, and I’m also a Professor of Translational Psychology at the UCL Great Ormond Street Institute of Child Health. So, they go together and my main area of work is the translation of research findings into clinical practice.

Interviewer: What prompted your interest in this field?

Prof Roz Shafran: I think my entire career is guided by what do I think are the really important questions and whilst I am interested in theory and academic side of things, I think I wouldn’t wanted to have spent my life thinking, oh, that was good. I wrote a paper but no one’s ever read it. In fact, remember my old professor, the very first thing he said to me when my very first paper was published was he goes, congratulations. He said you and your mother will read it and actually he meant it in a joking kind of way. But for me, my broad and diverse areas I’ve been interested in, really boil down to what I think is really important. That changes a bit over time but I do think what is really important is helping children with long-term chronic illness, who have mental health needs, get the right treatment at the right time because they are a pretty neglected group.

Interviewer: You have many clinical research interests. Can you tell me about some of these?

Prof Roz Shafran: A lot of it really was luck, I think and who my undergraduate tutor was when I was studying. So, I studied experimental psychology at Oxford and I ended with Professor Paul Salkovskis as my tutor because the person in the year above told me he didn’t make you hand in your essays on time. So, when I was studying there, Paul has a special interest in OCD. This is the place to go and I ended up working in Canada with Professor Jack Rachman, who was a real inspiration and a bit of a mad genius and just creative. So, I became interested in OCD, but also in other areas to do with anxiety. At the same time, I was volunteering at Great Ormond Street and worked in the inpatient psychiatric unit where I saw some medically unexplained symptoms. So, it wasn’t known as that, then. It was called pervasive refusal syndrome, and I also worked with Bryan Lask and Rachel Bryant-Waugh, on their eating disorders team and that continued all through university. So I had these two strands. My obsessive compulsive disorder strand, my eating disorder strand and they really culminated when I worked with Chris Fairburn in Oxford and his team. We were looking at barriers to progression for treatment with eating disorders and perfectionism came up. So, that was an area that interested me. Developed some work on perfectionism and then I moved to Reading University where there was a new chair funded by the Charlie Waller Memorial Trust and they were interested in implementation and in training. So, then I developed that kind of trying to do evidence-based training as well as evidence-based treatment and research. So, my current job, it’s those sorts of principles have all come together, but for children and adolescents and those who are risk because they have chronic illness.

Interviewer: Do you want to tell me a little bit more about that, then? It’s developing and evaluating psychological interventions for children and young people with common mental health disorders in the context of chronic illness.

Prof Roz Shafran: Yes. So, children with chronic illness are more likely to have a mental health problem and I’ve known Isabel Heyman for many, many years because of our connection with obsessive-compulsive disorder. She and Rachel Bryant-Waugh were very keen to really make sure that this group of children were not overlooked. So, when a child has a chronic illness and particularly at Great Ormond Street, it can be easy to notice their physical health problems as opposed to their mental health problems. The hospital does have a very large and great psychological services department, but they’re very busy implementing and doing the therapy.

So, actually, to have someone in that broader team to do some of the research aspects of it to help psychological services with their research because it’s a fantastic opportunity to do research at the hospital. Since that time, so that was about six years ago, we’ve done a range of different projects. One of which was Isabel Heyman’s vision that every child in the hospital should have access to mental health treatment, that they should be identified early and that, ideally there should be some sort of screening.

We’ve received funding from the Beryl Alexander Charity and, in connection with Great Ormond Street children’s charity, and we have (it looks like a photo booth) but it’s a drop-in center in the middle of the hospital where parents, carers can come to meet their mental health needs when they’re very stressed, where young people can come and where, in fact, we can refer them and tell them about the psychological services and the support that is available within the hospital. It’s also supported by the volunteer service. So, the hospital has a great volunteer service who are helping us. So, it’s sort of a whole hospital approach to the early identification and early intervention for young people with chronic illness and sometimes they don’t need very much. Sometimes they might need signposting to adult mental health services for the parents so that they get the support that they need. Particularly because it’s such a stressful time, and sometimes it might be that they need an intervention as part of a stepped care approach. We’ve introduced psychogical wellbeing practitioners to the hospital where they’re delivering what we call low intensity psychological treatments. So, brief, but evidence-based psychological interventions, and if there’s not sufficient progress made with that brief intervention, then they can be stepped up to a more intensive intervention. But some of those interventions can be delivered over the telephone, which is important because children are missing a lot of school from their chronic illness. It’s difficult to travel to all of the appointments. Our work with young people and their families really does indicate that they appreciate the checking in of having a telephone call sometimes, rather than traveling down. We’re in the process of trying to establish that.

Interviewer: What types of interventions have been shown to be successful with this group?

Prof Roz Shafran: So there’s been an NIHR HTA-funded Evidence Synthesis led by the University of Exeter. We did one a few years before, about what psychological interventions are appropriate for young people with chronic illness. As with many of these reviews, it concludes with more research is needed, it needs to be more robust. But all the indications are that the psychological treatments that are shown to work in young people without chronic illness should work in children with chronic illness because you may be anxious because of bullying at school, may be anxious because of a neurological problem. It could be a whole range of different reasons that you feel anxious. Yet the intervention is still exposure-based type of interventions and the same with behavioural sort of interventions and parenting interventions. There’s no reason that these interventions should not work in children with chronic illness. Having said that, you do need to be a good clinician. So, you need to listen to your patients and understand their needs and understand maybe, that they might require information delivered in a different way.

The examples that you give if you’re following a manual or a protocol need to be relevant to them and that you would need to modify and shape your therapy to match the patient in front of you. And for me, I’ve always regarded that as good clinical practice rather than you need to adapt an intervention. So, I think you do need to understand the principles that you’re trying to do that apply to young people with chronic illness, who have mental health problems, but also just be really sensitive to their particular situation. What we’re trying to do is to take an evidence-based intervention. This is a modular intervention in particular and we are trying to make sure that it provides information that is relevant to the population that we’re treating. But yet the core intervention really remains unchanged.

Interviewer: Roz, you also have a particular expertise in obsessive compulsive disorder, anxiety disorders, eating disorders and perfectionism, as you mentioned and you co-authored the self-help guide Overcoming Perfectionism. I’m wondering what factors might mean a child or young person has a propensity towards perfectionism and why is perfectionism such a problem?

Prof Roz Shafran: I think a range of factors are likely to make a young person vulnerable to perfectionism in the same way as you would answer that in relation to many other mental health problems. Although perfectionism, per sae is not a mental health problem, but dysfunctional perfectionism that really interferes with progress that is associated with mental health problems, that means that they can’t complete education. Those kinds of… Due to a range of things. So, it’s going to be genetic contribution and environmental contribution. Some people will say they were just born like that, always been perfectionist. They’re perfectionist in everything that they do and parents will say, I tell them that they shouldn’t be working so much. I tell them to ease off but they’ve always been very hard on themselves and very self-critical. So, you do get that group, but you’d also get a group where the parents are quite perfectionist and have quite high expectations. That’s, you know, everybody else in my family has done this. So, there’s a perceived sort of internalisation of pressure. I don’t think can talk about perfectionism without thinking about social media now, and the issue of it being very visible in terms of popularity, in terms of comparisons with others. So, there are lots of factors and perfectionism has been shown to be on the increase.

Interviewer: So, at what point does perfectionism tip over into clinical perfectionism?

Prof Roz Shafran: When we were thinking about this, we really wanted to think about… I was sitting in the Center for Eating Disorders in Oxford. We had lots of people from Oxford around, being very successful and saying, well, actually I’m a perfectionist but that’s a good thing. I think trying to distinguish between healthy striving for excellence versus clinical perfectionism is really quite important.

So, if you’ve got a healthy striving for excellence, we might take Usain Bolt as an example of healthy striving where a person’s clearly got a natural talent. But you see him and if he doesn’t do well in a race, he’s described how he would learn from that, it wouldn’t paralyze him. He wouldn’t go over and over it. He wouldn’t dwell on it, but he would be able to be objective and learn from that and therefore, improve. Whereas somebody that has more of that sort of clinical perfectionsim is really very self-critical and it affects how they view themselves as a person so that they’re less able to be objective. They’re less able to learn from their mistakes. They have a lot of anxiety and anger and guilt. It becomes quite a complex experience and those same sorts of people, when they do well, are unable to congratulate themselves. Typically, they feel relief but that relief is very temporary and then, they often discount it. So well, I might have… Andy Murray might have won the Olympics, but it was easy that year. So, it gets discounted in some way, in terms of an achievement and the bar gets raised. Not in every case, but in many cases. Whereas somebody with healthy striving for excellence can go out and you know, say I did really well. It has adverse consequences that interfere with functioning because I think that’s really the key, isn’t it? Between anything that is functional and when it becomes dysfunctional, is when it interferes with functioning. I think that’s part of it.

Interviewer: Clinical perfectionism has been implicated in the maintenance of psychopathology. In particular, in eating disorders, as you’ve mentioned. How can professionals help a young person who presents with clinical perfectionism and what interventions are known to be helpful?

Prof Roz Shafran: So, there’s been very little research in children and young people. Almost all of it has been in adults, and even in adults, it’s really only been in the last 15 years that we’ve had an evidence-based kind of conceptualisation and treatment intervention. So, it’s relatively early stages but what we do know has been shown to work in adults, is having a sort of a cognitive behavioural approach where you look at some of the dysfunctional behaviours as well as the cognitions that are going on around it. So for example, if somebody is doing lots behaviours such as repeated checking… So, if you’re writing an essay at school, you might now have your laptop open and you might have your reading list. You have to read everything on your reading list if you’re a perfectionist and you might have to have all your PDFs open and then you’d write something. Then you might want to check all your different PDFs to make sure they’re not in there and then you could write your sentence but then you might read something else. You’d have to go back and check that first thing. So, you get very stuck because you get overwhelmed with this sort of mass of information. So, one of the treatment techniques that we try and do would be to do a behavioural experiment where you would try things a different way. It does help to have school involved or if it’s too big a risk to do it at school, then to do it with a newspaper article or something where they did an academic piece of work so they could summarize it. They might have a time limit to do that or they might have a limit on the number of PDFs they could have open to do that. You’d compare that with summarising an article where they did it their usual kind of perfectionist way. Ideally, you’d get somebody in school to mark it, blind. So which one of these is better and what have you? What you’d like to happen is they say, oh the one that they spent ten minutes on was so… But typically, that doesn’t happen. They’ll either say there’s just no difference because you can’t really tell or they might say well, this one was a bit better. But you know, how much longer did it take you and was it really worth it to you? So, you then have some sort of discussion about where you want to set the bar for you and there’s there’s some psycho education around some beliefs. So, I don’t know if you believe this but many people believe the harder you work, the better you’ll do. Do you believe that?

Interviewer: Me, personally?

Prof Roz Shafran: Yeah.

Interviewer: Not necessarily, actually.

Prof Roz Shafran: No. So, it’s not true. I mean you do no work, that’s not good. But you work excessively and you’re up all night and you don’t eat and you don’t look after yourself and you don’t sleep, that’s not good. There is a sort of a zone of optimum performance. So part of the interventionism is educating about zone of optimum performance in terms of the ratio between how well you do and the effort you put in. Effort and output ratio. So, some sort of psycho education about where you fit in there, surveys about what other people do because you can have beliefs. I think especially at school, other people are doing all this revision and I just heard it last night for revision for my daughter’s GCSE. Oh, well, I haven’t done much. I’ve only done, you know, I’ve only spent four or five hours on it today. So, really getting some information by doing surveys and then, doing these sorts of experiments to try and help people get the information to decide what is the best way for them.

Interviewer: Do kids get access to that kind of support?

Prof Roz Shafran: Typically, I think you don’t get referrals to the NHS for perfectionism. It comes up at… University counselors say they get a lot of students in that transition from school to university when maybe, their parents have helped them get through it and then, they’re on their own and they’re stuck. But typically, the kind of referrals that you would get would be for anxiety, depression and those kinds of things. Then, it’s when you start to address those, you realize the perfectionism is a problem.

Interviewer: Roz, you’re Chair in Translational Psychology. Can you say something about how one translates research into practice?

Prof Roz Shafran: I think there are many different ways to try and do it. So, I think the field of implementation science is very interesting. So. it’s about how you can implement these research findings in clinical settings. It’s quite complicated because there’s changes at an individual level, there are changes that are service level, changes at an organizational level. And I think if you don’t have buy-in at every level, you can get really stuck but getting that organizational buy-in is challenging because for an organization to change, is tricky. Quite a good example I heard was about the QWERTY keyboards. So, our keyboards now, are based on the fact that on old typewriters, the keys that were most often used were put further apart so that they didn’t stick to each other. But, obviously, many of us do not use typewriters, most of us don’t use typewriters. Apparently somebody invented a much more sensible keyboard, where the letters that you use are closer together because they’re more frequently used but it didn’t take off. So, even though it would make sense to do it, actually, everybody’s used to the keyboards that we have. Trying to get people to change is tricky and I think that’s always stuck with me as an example. It just does demonstrate the challenge that there is. Just because something is a good idea does not mean people will automatically change. I do think that the improving access to psychological therapies program is a good example of how things can change because I think the whole area of psychological treatment really has changed. Stepped care really has changed. Bringing mental health into schools in an evidence-based way has changed and that’s changed because there are government buy-in. It comes from the top and there’s money behind it. So, I think having that support is essential. Trying to be a lone person saying the QWERTY keyboard’s not very good, often doesn’t work.

Interviewer: In terms of those type of barriers, I mean, you may have answered this already. I’m just going to ask how you break them down.

Prof Roz Shafran: I think the increasing emphasis on patient public involvement and co-production and codesign is really important because I think it’s easy for researchers to say, oh, I’ve got this fantastic intervention and you should be doing it. But actually, sometimes the intervention isn’t fit for purpose. They don’t understand the clinical setting. I think having patient public involvement and having people from the organization, right from the beginning in terms of the design, really helps answer the questions that are important. So, for example, for psychological treatment, we know that a vast majority of people will have multiple mental health problems. It may not even meet diagnostic threshold, but you might be anxious but have a little bit of low mood, maybe because you’re anxious. Well, you maybe have low mood and you’ll have a bit of anxiety. So, we do know that there’s a lot of co-occurrence and yet, the mental health interventions have been for anxiety, for depression. Certainly, the beginning of the research, there wasn’t that focus on that sort of comorbidity and research is catching up. There’s transdiagnostic approaches are more common and more investigated because people are beginning to recognize the potential use of them. But equally, you could have a specific intervention that has a benefit on all those other things. So, I think the onus is on researchers to make their research clinically relevant as well, as clinicians and organizations to implement research findings. It’s got to be a two-way street.

Interviewer: What are your own successes? So, perhaps some examples of where research has made a real difference.

Prof Roz Shafran: I mean, I think I would say… We call it the ‘Lucy Booth’ because it’s after the character in peanuts who had a… those she’s quite grumpy. As her psychiatric drop-in center. I think that has been a real success and I think it’s been a real success because of our partnership with the rest of the hospital. I do think that there are families that have accessed mental health services because of the research that they wouldn’t have done otherwise. I think it’s hard not to be moved when you get the thank you letters from people and some of it has really only been getting involved with CAMHS and giving a computerized, detailed assessment of what’s gone on. Some of it’s been us, more actively doing the work and some of it’s been partnership working with other people. So, I think that for me, has been a real success story in that way, but I think we… Previous role, we set up the Charlie Waller Institute of Evidence-based Psychological Treatment and I would hope that by training the clinicians in evidence-based treatments, that we are actually therefore, making a difference and providing supervision and evaluating it. All of that’s helpful.

Interviewer: I was going to ask what are the ways one can help promote best practice? I was thinking of things like professional training and continuous professional development. I don’t know if you want to say anything more on that.

Prof Roz Shafran: When I went to Reading and started looking into it, reading the articles that say, you know, people will go in a workshop and they will say they are very satisfied. The chances of them actually using that in their clinical practice, it’s not very high. So, I guess the people listening to this podcast are a select group. They must be, you guys must be really motivated to be listening to a podcast… Whether it’s on your way to work. There are lots of other things other demands on your time and I think that actually understanding what needs to happen in terms of getting the right supervision… It’s not just training the therapist but training the supervisor so that actually, when you get stuck you can make progress. Those are the things that really make a difference to clinical practice because on a workshop, it’s general isn’t it? And it’s usually a success story and don’t tell you about the clinical reality of when it’s not a success story or when things happen that you haven’t read about in the textbook and that’s when you need that guidance from someone who understands where you’re coming from, understands the principles of the interventions that you’re doing and can support you through that. So, I think good supervision is really helpful. I think it’s so easy for CPD to get lost for time to prepare for supervision properly. So, bringing your tapes to supervision and playing where you get stuck. All of those things, easy not to do. In our hospital, we have the good fortune that some cases are videotaped live, if they agree to it or videod live and then there’s a room where people can watch and discuss. Again, just think that’s an incredible way to learn and I think all too often, because of targets, the luxury of doing sessions together goes and so you you don’t learn. You don’t interact. Whereas, if you’ve got two therapists together, dealing with the family, coming back, having time afterwards to reflect and discuss, not forgetting your outcome measures. Because I think that is a big thing that has changed in psychological treatment, which is the use of routine outcome monitoring and it’s pretty clear that it improves outcome. Yet, there’s a lot of reticence and particularly for children and young people therapists, to use those outcome measurements.

Interviewer: Why, do you think?

Prof Rz Shafran: I think there’s a whole range of reasons. Some of it maybe, are valid ones in the sense of they’re not fit for purpose. They’re not seen as fit for purpose. They’re not seen as relevant. Sometimes services think that clients won’t like to fill them out and particularly if they’re not relevant, they don’t like to fill them out. But I think not wanting to label, not wanting to diagnose, all of all of those things. I’m sure there are lots of others. Thinking of it as a tick box exercise. You know, I’m only doing this because they tell me I have to do it rather than thinking I’m going to use this to guide my clinical practice, but I think just that principle is really important. So, I think goal based outcomes are very helpful, I do because they are regular measurements that’s asking families what they want. It’s keeping track of it and it’s personalized to the individual. So, those are used in child services and I think they’re good.

Interviewer: So how do you encourage those changes?

Prof Roz Shafran: Well, I think some of it is also about then, what are you doing it for? Are you doing it because you have to return your data and then somebody has to enter it into a computer and nobody’s got the time for that? Thank you. That’s one problem but actually, are you just going to use it clinically? And if you’re just going to be using it clinically, I would say the best way to encourage that is for people to try it and see. So, what’s their experience of using gold based outcomes? It’s a bit like that whole principle of behavioral experiments and perfectionism. You can talk about it. You can go to a workshop on it but when you’ve actually got the experience of a family going actually, that’s really helpful and focusing on that, then I think you’re encouraged to use it more in your own clinical practice. And I think that some sort of practice based evidence as well as evidence based practice is important.

Interviewer: Right. Roz, what else is in the pipeline that interests you?

Prof Roz Shafran: Loneliness is interesting at the moment. So UCL has a loneliness and mental health network and slightly accidentally got involved in doing an evidence synthesis for the campaign to end loneliness. I think probably because of the work with children with developmental disabilities and seeing their families who are so impressive. I just, you know, I’m amazed every day by how families manage but it’s very isolating. The children feel different, parents feel different. It is hard to be friends, I think, with somebody that completely doesn’t have the same life as you or understand your difficulties. I think there’s different sorts of loneliness and I think young people who have social skills deficits, they want a friend. So, I think of it as bit like being in love. Everyone wants to be in love, it makes you happy to be in love. They see other people having this thing, a friendship and they do and they don’t. They don’t know how to get it and some people are very… Not everyone but some people are made very sad by that and I think that trying to understand that and the kind of social contact that people want and loneliness in the children and the parents and the differences between them, I think is important. So, that, I’m finding interesting but also interested in internet support groups. So, I work very closely with Dr. Sophie Bennett, who is a [inaudible 00:28:05] scholar and her work is around internet-based support groups and they will often talk about how they have been frustrated by CAMHS and where do you turn to? Well, you turn to the internet and you turn to support groups and it has the potential for a great good, I think and trying to understand the good that it can do, but it could also have the potential for harm because it may make people feel that they don’t need that help or they may be getting poor advice. So, understanding people’s reality. I mean, if I’ve got a problem, I go on the internet and so, understanding the real lives of people and the function of these groups and how to optimize them, I think is really an important area. I’m interested in understanding more about that and using that to… Again, you can see it as part of that whole stepped care approach. Before you even get anywhere, people may have been on Mumsnet. They may have been on these sorts of fora and so, understanding those fora, even before they get to more of the low intensity formal interventions.

Interviewer: Finally, is there anything you’d like to add that I haven’t asked or as a takeaway message for those listening to this podcast?

Prof Roz Shafran: I suppose I feel very fortunate from the people that I’ve worked with, all the way through. So, since having children, I’ve worked part-time and that’s only really been possible because I’m part of a multidisciplinary team. So, right from my mentors that were inspiring, down to the people that do the everyday kind of help you move the tables in preparation for your meeting. I mean, everybody is really an important part of the team and I’m just incredibly grateful to all of the people that I’ve been fortunate enough to work with but I’m also really pleased it’s been multidisciplinary. I think it just gives you a really different kind of perspective but not so multidisciplinary that I can’t understand what they’re saying. So, I think you know, there’s quite a buzzword on multidisciplinarity. But you do have to have a common language and a common goal. So, I just feel really, really fortunate for the people that I’ve worked with and the kind of different perspectives that people bring, that allow that room for creativity and curiosity, that actually does make a difference to clinical practice. I think the takeaway message for clinicians, I think badger the researchers to do the research that you think is relevant because that’s the one that’s most likely to make a difference. Clinicians know what’s needed.

Interviewer: Brilliant. Thank you, Roz. To learn more about Dr. Roz Shafran, visit the ACAMH website www.ACAMH.org and Twitter at ACAMH. ACAMH is spelt A-C-A-M-H.

ENDS

I am Chair in Translational Psychology at the UCL Great Ormond Street Institute of Child Health. I am an honorary Consultant Clinical Psychologist, a member of the Health Professions Council and an accredited therapist with the British Association of Behavioural and Cognitive Psychotherapy. I founded the Charlie Waller Institute of Evidenced Based Psychological Treatment in 2007 at the University of Reading and was its director until 2012. I am a Trustee of the Charlie Waller Memorial Trust, Patron of ‘No Panic’ and recipient of prizes such as the Positive Practice ‘Making a Difference’ Award, British Psychological Society Award for Distinguished Contributions to Psychology in Practice and Marsh Award for Mental Health for research that has made a difference to clinical practice. I am a former associate editor of ‘Behaviour Research and Therapy’ and currently serve on the NIHR HTA Mental Health panel and am a NICE Expert Advisor. (Bio via UCL Greet Ormond Street Insitute of Child Health)